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Human Exceptionalism

Life and dignity with Wesley J. Smith.

Don’t Bureaucratize Death Conversations



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I wrote at some length a few weeks ago in the Weekly Standard about a Senate bill to pay doctors to discuss end-of-life care with patients. I pointed out that to get the government involved in such matters is to bureaucratize it. Besides, such discussions are a normal part of a doctor’s job. I am not sure why it requires a special pay category.

But, there are those who think no one will do anything without instructions from the government, or its providing financial incentives. Such seems to be the case in a NYT blog, The New Old Age, by Paula Span. From, “A Renewed Push for End-of-Life Decisions:”

Yes, it was [Rep. Earl] Blumenauer who, as part of the effort to overhaul health care, introduced into the legislation an unremarkable provision requiring Medicare to cover voluntary discussions with a physician about advance directives and treatment preferences at the end of life. These consultations would take place every five years, more often if a patient’s health declined substantially. Critics of our health care system frequently lament that providers are paid to do things — order tests, perform procedures — but not simply to talk with patients.

Advocates for this approach often make false promises–in much the same way that President Obama did Obamacare:

Advance directives, he pointed out, protect “someone who wants the full range of medical science to give them one more minute of life,” as well as those who want to prevent aggressive end-of-life medical treatment. His bill also provides grants to help develop P.O.L.S.T. programs, which require patients’ advance care plans to be included in their electronic health records and makes such directives portable across states.

Except, that isn’t true. Futile Care Theory policies allow doctors/bioethics committees to override a patient’s wish to have life extended through medical means, but never to have it ended. Moreover, some states permit POLST orders to conflict with advance directives and prevail, and moreover, imposed DNRs without consent.

I also want to bring out a few more points about this.

1. These kind of conversations are not one-time deals. Rather, they are processes, with thoughts, emotions, and desired approaches changing over time to meet new circumstances or patient preferences. The House bill would pay every 5 years. The Senate bill (applies to Medicaid and Medicare) about I wrote, permits payment once-a-year.

Do these time limits disincentivize a continuing discourse? I say no, because I believe that most doctors are professionals. But the ideological thrust of these bills would say yes, because it implies doctors won’t do their jobs without being paid via a specific pay code.

2. Doctors don’t write advance directives. Each state has its own legal requirements for advance directives. Thus, lawyers write these documents, or patients sign standard forms that have been reviewed by lawyers. Are we going to have a government pay code for those legal discussions too?

3. Government can’t micro manage all our professional relationships. If doctors haven’t been trained to discuss these matters properly, a pay code isn’t going to mean the job is done well.

I believe in end-of-life conversations. I just don’t believe we need the government telling us when and how to have them. 



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