End of Life Care Discussions with our Patients:  Are Doctors Ready?

Medicare is now reimbursing end of life care in the form of advance care planning.  The question is: are doctors ready to have serious end of life conversations with their patients?

A recent poll commissioned by The John A. Hartford Foundation, the California Health Care Foundation and Cambia Health Foundation of 736 primary care doctors and specialists suggests that more education and training is necessary.  A Kaiser Health News report on the poll explains:

• “While 75 percent of doctors said Medicare reimbursement makes it more likely they’d have advance care planning discussions, only about 14 percent said they had actually billed Medicare for those visits.”
• “Fewer than one-third reported any formal training on end-of-life discussions with patients and their families.”
• “More than half said they had not discussed end-of-life care with their own physicians.”

But end of life care is not just the responsibility of the individual physician.  As  Dr Karl Lorenz writes in the Washington Post:

“Many health-care systems are emphasizing “patient-reported outcomes” communications from patients about their own health, on their own terms. Just as important is the idea of giving patients and families a direct voice. Why aren’t they included when we deliberate budgets for hospital improvements? Does the C-suite hear the stories that patients and families tell at end of life?”

Even with systemic changes, the individual conversations are often hard for doctors.  The Conversation Project website has many stories and suggestions about how to have the end of life conversation. Dr Ravi Parikh, a resident at Brigham and Women’s Children Hospital, writes about his transition from having end of life conversations from the perspective of a resident doctor to end of life conversations based on the patient ‘s needs .  At first he explains the conversations were based on his clinical needs:

“As a resident, I approach most end-of-life conversations with a narrow focus: Confirm a code status and get the name of an emergency contact person. “Do you want to be resuscitated if you lost your pulse?” “Do you want to have a breathing tube if you were unable to breathe on your own?” “Whom should we contact in case of an emergency?” I needed to document answers to those questions to finish my patient-chart note. With my pager ringing and admissions arriving, I usually didn’t have time for anything else. “

But eventually he learned to have the conversation from the patient’s perspective. He writes,  “So at my next meeting with my patient, rather than beginning the discussion around his code status, I asked what mattered most to him (emphasis added).”

Clearly this is an area that doctors need more education, training and experience in.  What are your thoughts- both as a doctor and a potential patient (or your family as potential patients)?