The New End-of-Life Counseling Benefit

By Greg Scandlen

The New York Times article by Robert Pear (who, by the way, is the best health care writer in the nation, notwithstanding his employer) that alerted the world to the latest sneaky Obama deal, said the following —

“Advance care planning improves end-of-life care and patient and family satisfaction and reduces stress, anxiety and depression in surviving relatives,” the administration said in the preamble to the Medicare regulation, quoting research published this year in the British Medical Journal.

Well, let’s take a look at that research. As the Times reports, it was published in the British Medical Journal. It is all of one – ONE – study conducted in Australia at one – ONE – location and involved patients that were aged 80 or older. Twenty-nine patients (that is – 29) got the intervention and another 27 were a control group (no intervention), and all 56 patients died within six months. The people who got the intervention and their families were more satisfied with the care and had their wishes followed better than the control group.

But that isn’t saying much. These folks got more attention in the last six months of life, so of course they were more satisfied. And they were asked what their wishes were, so of course those preferences were more likely to be followed. Decent research would have tested the particular intervention against a “placebo,” not against no intervention at all.

That is how drug trials are conducted. One group gets the drug being tested and the other group gets a placebo. The placebo group usually does better, too, but not as well as the test group. Honest research would have given each group the same amount of attention, but provided a particular set of interventions to one but not the other.

This research in no way supports providing everyone on Medicare with annual “advance planning counseling.” Most people on Medicare are relatively healthy and their wishes at age 65 may be far different than at six months before their death.

The Australian research was also notable for all of the things it left out. No one asked the patients if they had a will, for instance. There was no mention of assigning a durable power of attorney to anyone. In fact, there were no legal or estate issues involved whatsoever.

Even more shocking is that there was no mention of clergy involvement and the patients were not even asked about their religious affiliation. There were no hospital chaplains involved, no prayers, no last rites for Catholics, no discussion of funeral arrangements.

How can you have end-of-life counseling without dealing with these critical issues?

More importantly, how can Obama’s little Czars and Czarinas use the experience of 56 patients at a single hospital in Australia as a justification for a new benefit for 45 million Americans? And a benefit that has already been considered and rejected by the Congress of the United States?

If this is what is considered “evidence-based decision making” by this administration, we are in deeper trouble than I realized.

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3 Responses

  1. I understand agree with your concern about one study being used to justify a policy. However, it would help if you would state your problem with the policy itself. Is end-of-life counseling by a physcian a bad thing? Shjould physicians avoid the subject? I’m not clear on your critique, other than your statement that only one study was the basis for the policy.

    Right now, at age 65, when I get my annual check-up we (my doctor an I) discuss things like exercise, weight control, alcohol consumption, and the like, but we skipped the end of life stuff. If the issue had been front and center, I would want such a discussion, and want my PCP to be paid for the discussion rather than to feel he had to rush on to the next patient.

    Can you explain your critique beyond your allegation of a lack of studies.

    • This. My father passed away at age 87 last year. My wife, a medical doc, suggested we bring in Hospice as early as possible. They made a fantastic difference in my father’s sense of control over his own death. He was prepared, relaxed, nurtured, and pain-free when he died.

      None of his many doctors EVER broached the important conversations in the years they treated him.

  2. Thanks, John. It is an important question. A friend (a retired surgeon) sent this:
    —-

    My wife and I have had advance planning and power of attorney for years. It’s only implemented if one of us is unable to make that decision and there is no hope of cure.

    This is a legal issue. We payed our attorney to draw it up. Most physicians would have trouble drawing up such a plan properly, and it should be done beforehand, not when the crisis occurs. I told numerous patients they should do this. It can really save problems, when one is incapacitated suddenly. If there is no previous arrangement, the doctors and hospitals don’t have much choice but to continue treatment until the legal people can give us some help. Payment to physicians for that kind of “counseling” is ridiculous, but God knows we are going to end up with a perfect system. As usual, a government comes up with a stupid solution for a practical problem requiring a practical solution. How would the physician prove they gave counseling or that it was any good? Keep the government out of the examination room.
    —-
    That is what my wife and I did, also. Our physician was not involved. If my doctor wanted a copy of our living will I would be happy to provide it to him. But I fail to see how he would be helpful to me in deciding when I would want a DNR invoked.

    Greg

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