Modern medicine is good at staving off death with aggressive interventions—and bad at knowing when to focus, instead, on improving the days that terminal patients have left.
—Atul Gawande
The healthcare reform debate that produced the Affordable Care Act included missed opportunities along with meaningful gains. The tone of the debate was disappointing and contributed to one of the greatest of those misses: a meaningful discussion on end-of-life care. Headlines mischaracterizing end-of-life discussions as “death panels” charged with deciding who lives and who dies left policy watchers, patients, and families reeling. As pundits delivered sound bites, their ghoulish rhetoric killed provisions that would have allowed providers to be reimbursed by Medicare for talking with patients about advanced care planning, promoting good communication, and honoring patients' care preferences. Lost, too, was the chance for meaningful progress on one of healthcare's most vexing and expensive gaps. Last year alone, Medicare spent $50 billion on doctor and hospital care for patients who were in the last two months of life. That means 25 percent of all Medicare spending is for the five percent of patients in the final stages of life. Worse, an estimated 20 to 30 percent of these expenditures may have had no meaningful impact (CBS News 2010). These estimates do not capture whether the patients even wanted the care.
Although the potential to better serve patients while saving money would seem to have obvious bipartisan appeal, in this political environment it instead became an explosive issue. This country badly needs a rational, meaningful discussion on end-of-life care.
