So Who Can You Talk To?

We all heard the outcry over end-of-life counseling described in earlier versions of legislation that ultimately became The Affordable Care Act.  The drafters wanted private insurance and Medicare to pay for a doctor’s visit for the purpose of discussing end-of-life issues. Patients could then make informed decisions about what medical care they would or would not want should they be diagnosed as terminally ill and unable to communicate for themselves.

These are big decisions that are multi-faceted and variable. For example, you might want every possible effort undertaken to revive you if you had a car accident on the way to work, but you might feel differently about what should be done if you slipped into a coma following a long and painful illness.

In addition, the terminology is not always easily understood or well defined. What is a terminal condition? Who is unlikely to recover? Even if it is a chronic condition with no known cure, what is the prognosis for long-term quality of life? Does artificial feeding and hydration mean a feeding tube, or does it just mean that someone has to feed me? Is the thickening of liquids that I drink considered “artificial”?

These are all legitimate medical questions. And since the average doctor’s appointment is about seven minutes, the drafters of the Affordable Care Act wanted to allow for at least one appointment when this type of discussion was not squeezed onto the end of a physical exam. Unfortunately, opponents of the law characterized these appointments as “death panels,” during which the doctor would determine that care would somehow not be given to someone who is old or terminally ill, and it was dropped from the final bill.

While this meant that insurers were not required to cover an exam exclusively for this purpose, I continued to believe that a person could schedule an appointment for this purpose at his own expense. Unfortunately, this may not be true. 

A client told me last week that he and his wife, who are both in their 60s and currently in good health, knew they needed to get their advance directives in place. They obtained appropriate forms and called to schedule an appointment with their family doctor to discuss the meaning of the various provisions contained in them. However, after consulting with the physician, the scheduler informed the couple that he would not make an appointment for this purpose. Instead, they should make their own decisions, and then bring the completed forms in for their file.

Apparently, this physician finds it easier to sleep at night when he refuses to answer his patients’ legitimate questions than he would if he thought he had in some way contributed to a decision for which he might be held accountable.

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