The Secret of a Good Life

Paulie Brading

Representative Earl Blumenauer understands the secret to a good life for loved ones involves planning.

Usually we wake up to that responsibility when the first child is born. We make provisions for who will care for our children should anything happen to both parents.

Right around the time our parents slide closer to 65 years of age some of us wonder how we will take of them while managing a full time job and parenting. Then a Great Aunt in her 80's becomes very ill with no end-of-life directives. You watch her die.

You start to think about your loved ones surrounding you in your last days. Do you want to be at home in your bed with a hospice worker or two at the ready for the last days? Do you want to be hooked up to machines and tubes in the ICU unit? Do you want oxygen or water or a feeding tube? Do you want to understand the options you have at the end of life? My mother understood this.

My mother was in the ICU when she whispered to her eldest child, me, "Get the folder in my filing cabinet and do everything it says." I dashed to my parents home and pulled the folder with my mother's name on it with the tag reading "My Death Wishes." I read a long list of very specific directives. She had consulted her doctor and met with the family lawyer. It felt like I was reading a cook book with all the ingredients listed.

1 cup water, 8 tablespoons of unsalted butter, 1 & 1/2 cups all-purpose flour, 5 eggs, 1 cup diced Gruyere cheese, Pepper to taste, 1/2 cup grated Gruyere cheese.

I showed her end-of-life directives to my family members and the nurse in charge of her. Without my mother's forethought our family was heading for a cliff. I loved her for taking care of us. I loved her generosity. We knew exactly what to do. Death is like one glorious and terrible five-hour meal. Every taste and emotion flies through with a trajectory that is terrifying.

There were no family arguments or second guessing one another.

My father is nearly 87. He too has his plan for the end of his life. His children are truly grateful. It's like carrying around a thick comforting soup in your belly knowing we will do exactly as he has asked. Someday in the future we will honor his wishes.

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    Amen, Paulie. The greatest gift my mother and stepfather gave me was to spell out their end of life wishes.

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    My mom's planning also was of great help when she passed away. However, she didn't need any Medicare inducement to accomplish this.

    not a huge deal either way, there is lots to not like about HCR, end of life planning is not one of them.

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      There is no "inducement".

      Here's the deal. It's really very simple. When doctors talk to patients about end-of-life planning, there's no "billing code" for that. The doctors that do it basically do that service for free. And as a result, some doctors don't do it -- and others keep the conversations extremely brief (like a sentence or two.)

      Instead, by making sure that doctors get compensated for taking 15 minutes to have a more in-depth discussion, we make sure that more doctors do it.

      The fact that this turned into some kind of "death promotion" thing -- or worse, "government death panels" -- is utterly bizarre.

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    Get ready for the rabid right to promote the "death panel" lies all over again. Their alternative to end of life measures is to remove the consent of the patient, and have doctors decide everything to protect their own ass from litigation.

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    It's really amazing. The same people that scream about keeping the government out of the dr-patient relationship want the government to prevent doctors from discussing end of life with patients.

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      If I'm not mistaken, these are generally the same people who advocate that the government should strictly regulate doctors in the way they discuss pregnancy options (including abortion) with patients.

      Being a conservative is so complicated!

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    Kari, I did a poor job of agreeing. The brief discussion a Medicare/Medicaid doctor has with any patient regarding end-of-life decisions has nothing to do with death panels. It is a chimera.

    However, the circumstances and planning mentioned in Paulie Brading's fine piece had nothing to do with a Medicare/Medicaid doctor's discussion. The planning and decisions can and should be done ahead of time and for those of us who have been through this with our parents it is a blessing.

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    My 81 year old mother's nightmare was that she would have a stroke and linger disabled for months. Still, she was always going "to get around to it" when the family urged her to prep her end of life instructions. The strokes hit her 11 years ago this week and there were no instructions so they used extraordinary measures to keep her alive.

    Working with a very enlightened doctor in Southern Illinois, after two weeks we chose to remove the feeding tube... only to have a born-again evangelical "Christian" nurse sneak into her room against orders and spoon some melted ice cream into her mouth. That meant we were legally required to keep her alive- unable to communicate or control her movements- for another 5 months. We buried her on Mother's Day.

    Had Medicare offered these end of life services, I'm pretty sure my frugal mother would actually have gotten around to it, and while our pain would not have been less, it would not have lasted so long.

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    Larry I am sorry for your mother's last few months and the pain caused your family. The nurse violated basic patient care standards and hospital policy. She should have been terminated and your family has a legal cause against her and the hospital.

    Medicare does not need to offer a digagnostic reimbursement code (DRG) for a DNR, ppoa for medical decisions and durable living will. Those are all items that are handled between family members on a regular basis.

    I am in favor of the new change allowing this discussion billing code, but find it hard to believe the lack of such a code keeps anyone from taking reasonable steps as outlined above.

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      We'll never know what her reluctance was. She wrote her will by hand within the law, but her end of life decisions were made after considerable family debate and recrimination. I envy and admire Paulie's family... and I will note that everyone in our extended family learned a valuable lesson and only one of the dozen of us has failed to take care of our own instructions.

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      (full disclosure: I work for Compassion & Choices, an advocacy organization for end-of-life choice)

      The regulation in question with Medicare does not create a new billing code for the end-of-life conversation. It allows for physicians to reimburse for the conversation as part of the regular initial and annual wellness exams already covered by Medicare.

      The new change is to encourage these voluntary conversations--which frankly, aren't happening to this point in an effective way. Only about 20-30% of Americans have advance directives.

      Whether a patient doesn't wish to be on life support under certain circumstances or they want every medical procedure possible, their treatment ought to be managed according to their values and wishes. Without an advance directive, it's extremely difficult to do this.

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    I always scratched my head at the use of 'death panels' in refering to end-of-life planning. If anything that term should have been used to describe the practice of many current health insurance companies who determine what kind of care they cover (i.e. Gleevac vs. bone marrow).

    However, I see many problems with setting up a cost code for 15 minute consults. What is the bill rate of the cost code? A friend of mine from OHSU said that average bill rate for specialists is around $550/hr, and GP around $250/hr. What would Medicare be charged?

    Let's assume ($250/hr)x (0.25hr) x 50 million people on Medicare. This comes to a total cost of $3.125 billion? Assuming cost share over 10 years, that's still over $300 million a year to fund this. Is there any evidence that 15 minutes with a doctor will cause people to get their affairs in order if they have had the whole rest of their life to do so? I think what would make more sense if there was a bill code set up for counseling services at a bill rate of $50/hr. Docs could just use less than a minute to inform patients of the service that is available. Then you could have an hour long appointment with a counselor specifically trained to deal with these matters rather than a catch-all doctor who is in a hurry to see the next patient and put out the next fire. (plus you'd save 20% program cost)

    Just my $0.02

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