The health-care-reform bill the U.S. House of Representatives will debate when it returns from recess next month contains a provision that would have Medicare reimburse doctors for counseling patients on end-of-life care every five years. Opponents of health-care reform have latched onto the provision, claiming it would lead to forced euthanasia or "death panels" to decide whether lifesaving care for the elderly is cost-effective despite the fact that the bill says nothing about either of these frightening issues. In fact, geriatricians doctors trained specifically to care for the elderly support the provision, arguing that it will encourage patients to express their own preferences rather than leave doctors and family members to guess what they want once they're no longer able to say so themselves. There are only about 7,500 geriatricians in the U.S., and one of them is Dr. Laurie Jacobs, vice chairman of the Department of Medicine at Albert Einstein College of Medicine and Montefiore Medical Center in New York City. Jacobs, who has been a practicing geriatrician since 1988, talked to TIME about why end-of-life counseling is important, when it should start and how to talk to patients and families about planning for death.
Does this House provision for funding end-of-life counseling concern you?
This provision says that people should talk about what their goals of care are and what they want at the end of life. That could be anything. This is an opportunity for patients and physicians to share information with each other and come up with a plan. It is one of the special things about being a physician. You get to know your patient and what matters to them, and their inner thoughts, and their lives, and that's a very special role that most physicians value and that patients appreciate.
How important is Medicare reimbursement for doctors counseling patients about end-of-life care?
For some people one conversation is enough, and you get the whole picture and they tell you exactly what they want. For other people, 10 conversations in 10 weeks won't suffice. Coverage for this is expensive, but I think offering it is a wonderful first step in highlighting the importance of it by paying for it.
What kind of end-of-life-care counseling do you provide to your patients? How does it work?
Many patients have chronic illness and some disability or medical issue, and part of providing care is to speak with them about what to expect with their illness, what alternatives exist, and to have a conversation about what their preferences are. This shouldn't just happen at the end of life. You should get to know people and have these conversations throughout providing care. I like to talk individually with the patient if they are comfortable with that. If they are more comfortable with having family members there at the time, then I do it with the group. What I need to know from the patients is how they view their illness in the context of their life. Did they know somebody else with the same condition and therefore they have some [preconceived] idea about this? What are their values? How to they want to live their life? I also talk to them about whether there is someone who could make decisions for them if they are unable in the future.
How often do you provide end-of-life counseling?
It comes up very frequently in our practice, either with new patients who present very ill, or patients we have known for a very long time that have encountered a new serious condition that may be life-threatening. Death is not an option. Everyone is going to die at some point.
How important is for you to talk with people about options like hospice or do-not-resuscitate orders? This must be really stressful for patients and their families.
That's why it's so important to talk about values and preferences long before you are at the moment of having to do an intervention. If I have a patient who has early dementia, they still may be able to participate in a conversation about what matters to them, how they want to live their life, who they want to make decisions, and it may be 10 years before the point at which an illness happens and an intervention may be required. So, it enables me to get a sense of who they are and what's important to them. When you talk to family members when a patient cannot participate in the conversation, it's even more difficult. If it was for themselves, they might say, "Gee, I don't want to go through that," but they are afraid to limit options for family members, and I can understand that. If a proxy knows that the patient always said, "This is how I want to live my life, this is how I want my life to end," they feel very much more comfortable in making those decisions. So I think the fact that there is some national conversation about this is good in that it starts people talking to their friends and family about what is important to them.
How often does money come up with families or patients when you are talking about end-of-life care?
This is a question that medical students often ask. Health-care finance and social issues regarding health-care expenditures nationally are policy issues, and they are never to be decided at the bedside.