Death Panels return! (Not).

It was reported Sun., Dec. 26, in the New York Times, that the Centers for Medicare and Medicaid (CMS) released new rules that allow physicians to counsel Medicare beneficiaries about end-of-life issues. That's not a very accurate description of what happened.
What actually happened was that CMS, as required by the Patient Protection and Affordable Care Act (hereafter referred to as PPACA), instituted coverage for annual wellness visits for Medicare beneficiaries, covered at 100%. Furthermore, part of that annual wellness visit may include a discussion between the patient and the physician about the patient's desires regarding end-of-life care.
Now this is important, so read carefully and slowly: PPACA only annualizes the "Welcome to Medicare" wellness visit instituted by CMS under George W. Bush. Permission to discuss end-of-life care (and be paid for it) was instituted under the Bush presidency. All PPACA did was to provide that opportunity annually, rather than just once, when the beneficiary first becomes entitled to Medicare.
Unlike the ill-fated "death panel" provision of the health reform bill, which was edited out in the final version of PPACA, these new CMS regs do not prescribe the content of the conversation between the physician and patient. And, to quell the fears of Libertarians everywhere, if you knew what Medicare pays a doctor to do an annual physical, you wouldn't waste the first bead of sweat worrying about wholesale efforts by physicians to lead seniors to slaughter. It's just not worth the doctor's time to hold extended discussions about living wills and withdrawal of care.
What I can tell you, from my personal experience, is that, contrary to the ravings of Betsy McCaughey, Rush Limbaugh and Sarah Palin, neither physicians nor the government are interested in pressuring seniors to die quickly to save Medicare's money. In fact, most physicians don't seem to want to have the end-of-life conversation at all.
Think about it. How comfortable would you be discussing death and dying with all of your clients or customers? Our reticence to have these discussions probably do cost the taxpayer money that could have been saved if better decisions were made. But much more importantly, our unwillingness to have those discussions results in untold pain and suffering that could have been avoided otherwise.
Here is what I've seen with my own eyes, in my job, at my hospital:

• patients spending the last three weeks (or three months) of their lives on a respirator, sedated to dull the pain and paralyzed with drugs to overcome the instinctual struggle to yank foreign objects out of their throats.
• patients sweating from fever, yellow from jaundice, swollen like footballs, with every pore of their skin weeping lymphatic fluid, their skin tearing in places and bruising in others, their fingers and toes becoming gangrenous.
• patients with their ribs broken and their lungs punctured from multiple attempts to revive them with CPR, only to last a couple more weeks virtually brain dead before their organs finally shut down.
• families torn apart - sometimes not speaking with each other for years - because of conflict about decisions made at the bedside in the absence of the patient's clearly expressed wishes.
• husbands and wives feeling guilty - feeling like they killed their loved one - because they were asked to make to decide to "pull the plug," without knowing the patient's wishes.

Situations like these can be avoided if only a physician and a patient can sit down, as signs start to point toward impending mortality, and have an open, frank, supportive discussion about the patient's beliefs and wishes before there is a crisis.
In my next article, I'll tell you what we talk about when we have these "death panel" discussions with patients.