Medicare needs to change to serve those at the end of life

Reforming Medicare enrollment and simplifying Advance Directives are passions for Dr. Kevin Haselhorst. In this podcast he argues that most Advance Directives are confusing for caregivers and families and he cites well-documented research to substantiate that point. Dr. Haselhorst does believe Advance Directives are a critical tool for patients and healthcare, however, they need to be simplified. He suggests two strategies for simplification.

First, have a patient select one of three treat options for end-of-life care:

• Proactive inpatient hospitalization

• Comfort care in the home

• Palliative care in the outpatient setting

Second, make completing an advanced directive mandatory at enrollment with Medicare and require Medicare recipients to review the directive annually as part of the annual Medicare Wellness visit.

The podcast provides several patient care examples to illustrate why Dr. Haselhort’s recommendations are advisable. He invites patients to assume much greater responsibility for their own end-of-life care. In essence, he is suggesting we need to engage individuals into becoming more informed about their end-of-life choices. Making the three simple choices he suggests would be powerful, but these choices are only feasible if the individual understands the implications of those choices.

My book, The Journey’s End, makes similar recommendations. The book outlines many of the challenges making the implementation of these recommendations feasible. As Dr. Haselhorst acknowledges, one of the biggest challenges is that the vocabulary for all these choices is confusing and inconsistent. The Medicare insurance world, the clinical world and the legal world each contribute to this confusion.

The Journey’s End helps patients become informed about these choices and offers health reform recommendations to make their implementation feasible. If you’re interested in reading more on this topic, my book is available for pre-order. Use code RLFANDF30 for 30% off.

We need to change the way we think about death

This episode of The Doctor's Art is an excellent overview of Dr. Shoshana Ungerleider's impressive work advocating for improved end-of-life (EOL) care in the United States.

Dr. Ungerleider has created the End Well Foundation to promote this vital work. One point she emphasizes in this podcast is the importance of changing views on death and dying. Changing our perspectives on death and dying is a serious challenge, and the road to this change is uncharted.

So how do we help society and individuals look at the end of life differently? I believe that the journey begins by educating individuals about what to expect from healthcare at the end. Our current EOL expectations are unrealistic and uniformed. Too often, families make desperate care choices because patients and families fear death but do not understand that ICU cannot save a frail elderly dying patient.

Advance education is the key to helping patients and families not panic and pursue unrealistic care options in the end. Such education requires time and thoughtful communication. Time for individuals to digest the reality of the end. Unfortunately, there are numerous forces - economics being the most significant that discourage these conversations.

My book The Journey’s End offers patients and families a compassionate education on EOL care.

We need to talk

While they are necessary, end-of-life conversations are seldom discussed. Such silence is understandable when it comes to the general public, but it's outright puzzling in terms of public health policy.

That is why this Advisory Board article is so important. It sheds light on the need for end-of-life conversations, which are in many ways the key to improving healthcare. The article points patients toward the information they need and outlines how they can better understand their care choices.

Helping patients get informed is at the core of these conversations -- and it's at the core of improving healthcare, too. Of course, most patients (and physicians) are not eager to have an end-of-life (EOL) conversation. Part of that is due to human nature, but part of that is also due to how the health system operates.

Few realize that our healthcare system is designed to keep patients in the dark about their care options. In other words, ignorance is a feature of the system, not a flaw.

Just look at the incentive structure. The health system does not reward physicians for having such discussions. Similarly, palliative care and hospice -- which are crucial alternatives for EOL care -- are difficult to access and often off the table. And while these options may be available at the very end, at that point their value is limited.

In sum, we need to pay much greater attention to EOL care. My forthcoming book, The Journey’s End, makes the case for this because these critical conversations cannot wait.