Globe Editorial

Doctors shouldn’t shy from straight talk about death

August 15, 2009

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WHEN key senators decided Thursday not to seek Medicare reimbursement for doctors who discuss end-of-life choices with their patients, it was a dispiriting defeat for political discourse in this country. A House bill would reimburse doctors for time spent advising patients on living wills and other options, but in the fevered imaginations of Sarah Palin and other diehard opponents of health reform this became a blueprint for a “death panel’’ that would pull the plug on ailing seniors. Unwilling to defend in raucous town halls a perfectly reasonable proposal to help Americans plan for their last days, senators are giving Palin an undeserved victory.

Almost as discouraging as this retreat in the face of willful misinformation about the House bill is the fact that a specific law authorizing Medicare reimbursement for such conversations is necessary in the first place. Ideally, doctors with the best interests of their patients at heart would find time to talk over options in the event a patient is no longer able to decide between life-extending interventions and palliative care. It is a sad commentary on the fee-for-service system and the time constraints on primary-care doctors that some feel they cannot conduct end-of-life discussions without Medicare paying for the consultations.

Experts in the care of seniors say the real barrier is not the lack of reimbursement but the reluctance of doctors, patients, and patients’ families to discuss death. Patients might want to talk about it, but worry about upsetting their loved ones, and vice versa. Often doctors and nurses lack the skills to do it well. “The only way to get good at having these conversations is having these conversations,’’ said Dr. Lachlan Forrow, director of palliative care programs at Beth Israel Deaconess Medical Center.

James Conway of the Institute for Healthcare Improvement says a major reason that doctors hesitate to broach end-of-life options with patients is physicians’ desire to come up with one more possibility of a cure, one more new-generation treatment. Doctors tell him, he said, “Jim, we’re in the business of hope, not death.’’

The result, as palliative care specialist Dr. Muriel Gillick noted in the Globe recently, can be seen in a 2005 AARP study of its Massachusetts members. While 89 percent of AARP members rated having honest answers from their doctors about end-of-life choices as very important, only 17 percent had actually discussed their preferences with their physicians. Medicare reimbursement for such consultations would make them somewhat more likely, but the greater deterrent is the unease that hushes all parties. Irresponsible talk about “death panels’’ can only deepen that silence.

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