Sunday, August 23, 2009

Krauthammer on "The Truth About Death Counseling"

May_30_Health_Care_Rally_NP (453)Image by seiuhealthcare775nw via Flickr

The Pulitzer prize winning columnist Charles Krauthammer (MD*) wrote an intriguing op-ed the day after the NY Times piece on palliative care and breaking bad news we discussed last week. The article is behind a sign up free wall although you can also connect with your Facebook account.

The column starts by a request for civility. No death panel talk here. But also don't claim that HR3200 is benign since:
'government reimbursement to any doctor who gives end-of-life counseling -- whether or not the patient asked for it -- is to create an incentive for such a chat.'
First to correct this statement, doctors are already paid to discuss goals of care with patients. The payment structure utilizes time-based visits where 'greater than 50% of the time was spent face to face (or floor time)** with patient and family in education and counseling.' But the reimbursement for time based billing is minimal compared to regular visits and time-based billing has been reported to be more likely to be denied or coded wrong and there for not be paid. If I could see 4 inpatients in one hour and make lots of complex changes and bill at the highest code 233 for each (x4), the reimbursement would be less*** more than two 30 minute family meetings which would each get a 232. So the system already incentives heavily towards testing, adding medications and procedures versus cognitive/communication activities.

But the point he does indirectly raise is what would this 'new' reimbursement look like? Does anyone know? I am guessing if it is being considered to be part of Pay 4 Performance it is likely to be minimal and many physicians may not even think it is worth it to learn a new billing code (which would likely be required) which they would use infrequently.
"Do you think the doctor will go on and on about the fantastic new million-dollar high-tech gizmo that can prolong the patient's otherwise hopeless condition for another six months?"
The language in the bill does not determine the outcome of

Dr NickImage via Wikipedia

the conversation. If this is the argument, the assumption is you are working with Dr. Julius Hibbert or Dr. Nick Riviera who are in it for the money, then why wouldn't the greedy doctor offer the advance care planning counseling (get paid for it) and encourage/nudge the patient towards the hope giving procedure/surgery/medication (and get paid for that too?) So basically this logic falls flat with a better understanding of the whole system.
"Then consider the actual efficacy of a living will. When you are old, infirm and lying in the ICU...the doctor will ask you at that time what you want for yourself -- no matter what piece of paper you signed five years earlier."
I am glad to see someone bringing up the efficacy of living wills as I have seen a trend in the palliative care community to start shying away from the actual living will but rather focus on the conversations. I think this is a fair point but to pretend a patient will always be able to make a decision when doctors start thinking mortality risk is rising and goals need to be clarified is a little optimistic. Often times it is not until a patient is unconscious or delirious that everyone (family and medical staff) start wondering if things are heading in the right direction. Pallimed has covered advance care planning impotency here, here, here, here, here and here for starters.

"Well, as pain and diminishment (sic?) enter your life as you age, your calculations change and your tolerance for suffering increases. In the ICU, you might have a new way of looking at things."

Excellent point about the dynamic nature of goals when related to one's health and symptom burden. I bring this point up often when teaching residents and fellows as well as discussing goals with other medical staff, families and patients. This doesn't make the living will or the advance care planning process inadequate, just imperfect and why these documents should reviewed upon every hospitalization or major health change to make sure they reflect the values and goals of the most current 'you.'
"And if I'm totally out of it, my family will decide, with little or no reference to my living will. Why? I'll give you an example. When my father was dying, my mother and brother and I had to decide how much treatment to pursue. What was a better way to ascertain my father's wishes: What he checked off on a form one fine summer's day years before being stricken; or what we, who had known him intimately for decades, thought he would want? The answer is obvious."
But without a 'living will' or at least a conversation about your wishes and values these decisions are some of the most difficult things to do for families. Imagine trying to buy someone a birthday present without having any clue what their hobbies or interests are? You might buy them something you like or something generic, giving you have a much higher risk of an unappreciated 'gift.' Now multiply the birthday gift decision x infinity minus one and you get an idea of the difficulty of these decisions.
"The one time (a living will) really is essential is if you think your fractious family will be only too happy to hasten your demise to get your money."
If only life were a soap opera since money is rarely the basis of any of these decisions. After several hundred (more?) family meetings I have rarely seen this be an issue. Maybe a handful of times. Families get fractured over many many more things than money. Emotions, relationships, jealousy, mis-communication, distance, willingness to assist in care, religion, politics, you name it and I have seen it at least 50x more often than money being the cause of family tension in critical illness.
"But it is subtle pressure applied by society through your doctor. And when you include it in a health-care reform whose major objective is to bend the cost curve downward, you have to be a fool or a knave to deny that it's intended to gently point the patient in a certain direction, toward the corner of the sickroom where stands a ghostly figure, scythe in hand, offering release. "
The hyperbolic and unnecessary accusation of care at the end of life being about pushing someone into a corner where it is implied they will be neglected, forgotten, dirty, and be left without dignity is an affront to hospice and palliative care. And again the idea that end of life care is always cheap is going to really surprise people when they realize there will probably not be a huge cost savings from more people choosing hospice earlier. The high quality care given by hospices and palliative care teams has a lot more to do with increased human capital and not as much technology.

* Yes Charles Krauthammer is an MD, although he doesn't flaunt it or reference as far as I can see. Thanks Wikipedia for the first source which I backed up with a quick PubMed search to find his Archives of General Psychiatry article.
**See this CAPC forum for more discussion of the particulars
*** Late night writing and editing fixed after pointed out by a studious reader. 8/24
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