Today’s Wall Street Journal opinion page included a terrific op-ed on how physicians approach their own end of life care planning differently than most of their patients do, primarily because they actually understand the limitations of American medicine in prolonging life, and because they actually plan for the end.
The author, Dr. Ken Murray, a professor of family medicine at USC, wrote: “It’s not something that we like to talk about, but doctors die, too. What’s unusual about them is not how much treatment they get compared with most Americans, but how little. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care that they could want. But they tend to go serenely and gently. Doctors don’t want to die any more than anyone else does. But they usually have talked about the limits of modern medicine with their families. They want to make sure that, when the time comes, no heroic measures are taken.”
“Unlike previous eras, when doctors simply did what they thought was best, our system is now based on what patients choose. Physicians really try to honor their patients’ wishes, but when patients ask “What would you do?,” we often avoid answering. We don’t want to impose our views on the vulnerable. The result is that more people receive futile “lifesaving” care, and fewer people die at home than did, say, 60 years ago. Nursing professor Karen Kehl, in an article called “Moving Toward Peace: An Analysis of the Concept of a Good Death,” ranked the attributes of a graceful death, among them: being comfortable and in control, having a sense of closure, making the most of relationships and having family involved in care. Hospitals today provide few of these qualities. Written directives can give patients far more control over how their lives end. But while most of us accept that taxes are inescapable, death is a much harder pill to swallow, which keeps the vast majority of Americans from making proper arrangements.”
I come from a family of doctors, and my Mom is an accomplished family physician specializing in palliative and end-of-life care. This is an issue we’re passionate about in our family, and one I’ve pontificated on. And Dr. Murray nails the point here: those who know plan for the end, as we all need to.
But in the sudden resurgence of the culture wars during this GOP primary season, and the fact that at least two of the leading candidates — Rick Santorum and Newt Gingrich — had starring roles in the Terri Schiavo circus, it seems unlikely we’ll get a meaningful discussion of end-of-life care as part of Medicare reform anytime soon. We live in an age of distortions like ”Death Panels,” where open dialogue on end of life is politicized and limits on what Medicare will cover are demogogued as rationing.
As I said back in October, Medicare Advantage plans are uniquely positioned to advance the cause of professional counseling for beneficiaries on their last wishes, preventing unnecessary surgeries based on the patient’s preferences and likely clinical outcomes, and promoting the enthusiastic use of palliative care. A number of plans are leading quietly in this area, like UPMC in Pittsburgh, Excellus Blue Cross/Blue Shield in upstate New York (which actually has dedicated medical directors for end of life and palliative care), and any PACE site like On Lok in San Francisco.
We have much to learn from these end-of-life pioneers — they should be applauded and emulated for their courage in the face of the politics of end of life care.