The Lynx Group

Healthcare Reform and End-of-Life Care Myths versus Reality

July 2013, Vol 4, No 6

Hollywood, FL—End-of-life issues have advanced in a positive direction since the so-called death panel controversy of 2009, but health plans still need to promote these discussions, said J. Russell Hoverman, MD, PhD, Vice President, Quality Programs, Texas Oncology, at the Third Annual Conference of the Association for Value-Based Cancer Care.

“Death panel” is a term famously popularized by Sara Palin in 2009 after Rep John Boehner suggested that the provision for end-of-life counseling in the Affordable Care Act (ACA) could “start us toward government-encouraged euthanasia.” The statement won the PolitiFact “Lie of the Year” award.

The amendment involving end-of-life care was stricken from the final ACA, but the coverage of end-of-life discussions has been written into the regulations pertaining to the law starting on January 1, 2011. The death panel debate had a serious effect on the American public:

  • 35% of older Americans said that the ACA would allow a government panel to make decisions about end-of-life care for people in Medicare (Kaiser Family Foundation.
  • 47% of Republicans thought that death panels existed (Pew Research Center. 08/20/health-care-reform-closely-followed-much-discussed/)
  • 59% of Republicans either thought that death panels were part of the ACA or were unsure (Regence Foun­dation.

The Regence Foundation survey also showed that 78% of the public still believes that palliative care and end-of-life issues should be in the public discourse; 93% say that advance care planning and end-of-life decisions should be a top priority for the US healthcare system; 70% agree that “it is more important to enhance the quality of life for seriously ill patients, even if it means a shorter life”; and only 33% of Americans expressed trust in elected officials for delivering accurate information.

With such a gap between myth and reality, and when the political system “is not to be trusted,” the US healthcare system has a responsibility to be a source for accurate information, Dr Hoverman emphasized.

Rationing in Healthcare

The concept of death panels does have some historical basis. In the mid-1960s, hemodialysis was apportioned to individuals deemed by a committee to be most worthy. Today, society is being called on to determine how to manage expensive treatments. Arizona has responded, for example, by cutting Medicaid coverage for previously covered organ transplants, creating a subclass of people without access to critical medical treatment.

“To the extent that death panels, of a sort, do exist, they are composed of state officials who must decide whether each state’s version of Medicaid will cover certain expensive, potentially life-saving treatments,” Dr Hoverman said. It is possible that this could extend beyond transplants to pharmaceuticals.

Meeting Patients’ Needs at the End of Life

It does not take a death panel to decipher and provide what patients want at the end of life, especially for patients with cancer; this includes not receiving nonbeneficial treatments, not suffering, and avoiding “financial waste,” as well as receiving “honest information and truthful prognostic disclosure, which does not destroy hope,” Dr Hoverman said.

Studies show that 86% of patients would prefer to spend their last days at home, 87% would not be put on a ventilator to gain 1 week of life, and 77% would not want a ventilator to gain 1 month of life. Seriously ill patients do want freedom from pain, peace with God, presence of family, and mental awareness. They want to have their treatment choices followed and their finances in order. They want to feel that life was meaningful. They want to resolve conflicts and die at home. “The list does not include more chemotherapy,” Dr Hoverman emphasized.

Advance Care Planning Improves End-of-Life Care, Reduces Waste

End-of-life conversations result in increased use of hospice services and in less pain. Patients with cancer who have advance care planning are:

  • 3 times less likely to enter the intensive care unit (ICU)
  • 7 times less likely to have mechanical ventilation
  • 8 times less likely to undergo cardiopulmonary resuscitation (CPR), with no difference in mortality rate.

When nursing home patients engage in advance care planning, hospitalization rates are reduced and the global cost of care is reduced by 33%, with the mortality rate again unchanged. Good pain control is far more likely to occur when patients die in hospice care than in the hospital.

Patients who have advance care planning are more likely to die amid family, and their family members report significantly less stress, anxiety, and depression, as well as higher satisfaction with care. By contrast, in the absence of advance care planning, families demand more futile treatments and more CPR and ICU services, and undergo more stress overall.

Suboptimal end-of-life care is very expensive. The United States spends $142 billion on medical care in the last year of life, and $71 billion in the last 2 months, Dr Hoverman noted.

Facilitating the Patient–Provider Discussion

“Multiple studies show that patients receive better care after advance care planning. The question is, how do we begin these conversations? How can we make it easier for physicians?” Dr Hoverman asked.

A simple intervention has helped Texas Oncology’s physicians in the Innovent Oncology program. The program involves a 10-item quiz aimed at determining a patient’s wishes for end-of-life care. The list contains such statements as, “It is important for me to be told by my physician when I am dying,” he noted.

“These simple questions serve as a bridge to having these conversations,” Dr Hoverman stated. “The take-home message is that honoring people’s choices with informed decision-making leads to better, less aggressive end-of-life care. The challenge is to build that into a healthcare system so this is the thing that every patient receives.”

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