As our country faces the "fiscal cliff", the debate centers on raising revenues versus reducing benefits, especially in Medicare and Medicaid. Everyone wants to control health care spending, yet one critical low-cost approach is being overlooked.
Approximately thirty per cent of Medicare dollars are spent in the last six months of a patient's life, yet efforts to address this fact have proved politically problematic.
The term "death panels" was coined by Sarah Palin to disparage the proposal in the Affordable Care Act (aka Obamacare) to encourage doctors to discuss end-of-life choices with their Medicare patients. As a result, the proposal was dropped from the final legislation, and the topic was tabled.
While it's important to encourage physicians to have those discussions, there is no need to wait for legislation. Advance directives, legal in every state, provide a way for people to make known the values and choices that should inform their care. Advance directives protect individual rights and cost little or nothing to carry out. They also support families by easing decision-making during what is often a stressful time. And what is particularly relevant to the federal budget is that in most cases advance directives reduce expenditures. And they do so not by cutting services at the direction of government or insurance companies, but by respecting patients' individual rights and wishes.
As an emergency medicine doctor, I've seen what happens when there is no advance planning or discussion about end of life care. A frequent scenario is a frail elderly nursing home patient brought in by ambulance with shortness of breath, irregular heartbeat, and plunging blood pressure. The wasted and contracted limbs indicate years of incapacitation, and the medical record reveals a long history of dementia. As we work to restore stability, the patient suddenly goes into cardiac arrest.
Because there is no record of an advance directive or a "Do Not Resuscitate" (DNR) order, the ER team jumps into full cardiopulmonary resuscitation (CPR) mode. If "successful," the patient will endure pain and confusion that may last for hours, days, weeks, or a few months before dying. Whether the patient recovers from this episode or not, one thing is clear: this will be costly, both in human and financial terms.
The only ethical and legal way to avoid this situation is when patients have made their wishes known beforehand, appointed someone they trust to make decisions when they are no longer able to, and made that information readily available to health care providers.
We Americans cherish the right to make our own decisions. In light of this ardent individualism, it's puzzling that so few of us exercise this right when it comes to something almost all of us will face: medical care at the end of our lives.
Studies show that only about one-third of Americans have completed advance directive forms, and the rate of completion is even lower among minorities and the poor.
What if ninety per cent of Americans had advance directives? What if completing these forms were as routine as renewing a driver's license or paying taxes? Doctors and nurses would begin to utilize them as a standard part of every medical record, and care would be more personalized and humane. And because most people choose not to undergo heroic treatment for every conceivable condition, billions of dollars would be saved. And for those who opt for those heroic treatments, their choices would be honored as well.
Respecting individual rights is the best way to reduce health care costs, and perhaps this is one area where our political leaders can find common ground. One way to start might be a high visibility national effort, beginning with President and Mrs. Obama publicly signing their advance directives at the White House.
The tools are there; we just need to use them.