Monday, December 27, 2010

Compensating Physicians for End of Life Decisions - not Ending Life

Once again those who oppose Presidents Obama's initiative to improve our health system are creating anxiety and fear by crassly labeling as "death panels" time spent by patients and their physicians discussing 'end of life decisions'. Such conversations, for primary care physicians such as myself, are part and parcel of our practice. Longitudinal care is particularly unique to our specialty. It is appropriate and expected that people whom we have cared for years, sometimes decades, while they were enjoying good health, and death was a nebulous abstract, look to us to coach them thru the maze of complex, trying, and uncomfortable efforts to ‘treat’ their untreatable illnesses. They look to the physician they have trusted their health for years to decide when treatment no longer is beneficial or desired.

These conversations cannot be complete if postponed until the final hospital admission. There is not enough time. By then the patient who is too ill to express wishes for the care they want, and too weak to articulate their choices to the unfamiliar physicians whose priority is selecting treatments to retard or control, but rarely cure, the illness. Under these circumstances, patients have little choice but to defer choices of treatment to doctors whom they barely know.

To equate these intimate conversations to death panels is to extract all dignity from the process of dying. Those who suggest that physicians who have these conversations with their patients are ‘death panels’ not only disparages the physicians and the medical community, but more importantly, negates patients their right to decide the manner in which they wish to have their life end.

Re-embursing physicians for time spent in these discussions will encourage physicians to allocate their time and resources to assist their patients with these most difficulty medical decisions. It is only when a patient encounter is specifically committed to this most personal issue that the patient has the opportunity to express his/her desires and the physician has the necessary time to listen. Without these opportunities, patients will be committed to a death that is too frequently postponed to a time when there is no honor to life or dignity in death.

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