ADVANCED CARE PLANNING PROVISIONS MUST NOT PRESSURE PATIENTS TO REJECT LIFE-SAVING CARE
National Right to Life strongly encourages the execution of a pro-life advance directive, the Will to Live (See http://www.nrlc.org/MedEthics/WilltoLiveProject.html). However, the pro-life fear is that efforts to push patients and prospective patients to prepare advance directives may in practice become a means of persuading or pressuring them to agree to less treatment as a means of saving money.
Central to the Health Care reform bills is the concept that cost cutting measures will be sufficient to make up for financing shortfalls. One of these measures is the promotion of advance directives.
There have been several recent studies showing how advance directives and end of life conversations generally yield cost savings.
A 2009 Archives of Internal Medicine study concluded, “Patient-physician discussions about [end of life] wishes are associated with lower rates of intensive interventions.”[i] The mean cost of care was 35.7% less for patients who reported having end-of-life discussions compared with for patients who did not in their final week of life. “We refer to the end-of-life discussion as the multimillion-dollar conversation because it is associated with shifting costs away from expensive, …., to less costly comfort care….” noted Dana-Farber's Holly Prigerson PhD[ii].
A recent JAMA study reaches a similar conclusion that, "On the other hand, patients who reported having end-of-life discussions received less aggressive medical care and were more likely to receive hospice services for more than a week."[iii]
Aside from the many stand-alone bills related to advance directives this term in both houses, there are three separate provisions dealing with advance directives in the House legislation. 1) There is the main 1233 provision.[iv] There are also two other amendments, one requiring private and public health care plans to give potential enrollees the option to establish advance directive; [v] and the other to empower the Secretary to spearhead a public education campaign, toll-free telephone hotline, and clearinghouse to promote advance directives and other advance care planning. [vi]
What is particularly disturbing about this “cost-savings” provision of the bill is that it appears to follow President Obama’s call this past spring for “a very difficult democratic conversation” about “those toward the end of their lives [who] are accounting for potentially 80 percent of the total health care bill out here.”[vii]
It is also extremely troubling that Compassion and Choices, the principal group that promotes physician assisted suicide throughout the country[viii] is not only aggressively promoting these provisions, but claims responsibility for the inclusion of the main provision.[ix]
 This provision allows assisted suicide and euthanasia to be promoted as an option in the places where it is legal (Washington, Oregon, and Montana).
[i] Health Care Costs in the Last Week of Life Associations With End-of-Life Conversations. Arch Intern Med. 2009;169(5):480-488.
[ii] Dr. Prigerson was the senior author of the study.
[iii] Wright AA, Zhang B, et al. Associations Between End-of-Life Discussions, Patient Mental Health, Medical Care Near Death, and Caregiver Bereavement Adjustment. JAMA. 2008;300(14):1665-1673.
[iv] Section1233 of H.R 3200, “America’s Affordable Health Choices Act of 2009” provides for Medicare reimbursement for consultations about “advance care planning” between health care providers and their patients when they enter Medicare, every five years thereafter, and if they become seriously ill.
[v] Amendment offered by Mr. Hill in Energy and Commerce titled “Information on End-of-Life Planning.” offered July 31, 2009.
[vi] Amendment offered by Ms. Baldwin in Energy and Commerce titled “Programs to increase awareness of advance care planning issues: part S—programs to increase awareness of advance care planning issues.” offered July 31, 2009.
[vii] April 14 interview, published in the New York Times Magazine April 29, 2009.
Jennifer Popik, J.D.
Robert Powell Center for Medical Ethics - NRLC
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