Physicians should be compensated for counseling patients on end-of-life planning, according to recommendations from the Institute of Medicine, and the health care delivery and payment system should be realigned to encourage and financially reward higher-quality, more comprehensive, more efficient, and more humane care for those with serious illnesses.
“Individuals should have time with their doctors to talk about end-of-life issues, and clinicians should receive the training and financial incentives for such discussions,” said David Walker, the former comptroller general of the United States, who was the cochair of the IOM committee that created the report published Sept. 17.
Dying in America calls on health care providers, payers, policy makers, and the American public to have a more open discourse about death and dying.
End-of-life care was caught up in a political firestorm in 2009 when the Obama administration proposed to pay for advanced care conversations under the Affordable Care Act, Dr. Harvey Fineberg, former IOM president, noted in a video message at a briefing to release the report. Such efforts were construed as “death panels,” and the administration withdrew its proposal within days of it going into effect in 2011, said Dr. Fineberg, who is now at the University of California, San Francisco.
“The controversy on this topic and the political desire to avoid it do not alter the fact that every person will face the end of life one day, and many have had hard experience with the final days of a parent, a spouse, a child, a sibling, another relative, or a dear friend,” Dr. Fineberg said.
The report focuses on three areas: what individuals and their families can do to take more control over their own life and their health care throughout their life; what clinicians and other professionals can do; and what policy makers and payers need to do to try to effectuate change. The 21-member IOM committee spent 2 years developing the consensus report, Mr. Walker said.
“For most people, death does not come suddenly,” said Dr. Philip Pizzo, committee cochair. “Instead, dying is a result of one or more diseases that must be managed carefully and compassionately over weeks, months, or even years, through many ups and downs,” said Dr. Pizzo of Stanford (Calif.) University.
The committee made five broad recommendations:
• Comprehensive care for patients with advanced, serious illness who are nearing the end of life should be covered by public and private payers.
• Evidence-based standards for clinician-patient communication and advanced care planning should be developed by professional societies; such standards should be used as measures for payment, licensing, and credentialing.
• Standardized training and requirements should be developed and implemented.
• Care standards should seek to avoid unnecessary emergency department or acute care services; care should be coordinated across settings and providers by using tools such as interoperable electronic health records and physician orders for life-sustaining treatment programs.
• Fact-based information on end-of-life care planning should be developed and disseminated broadly through public health and other governmental agencies, community-based organizations, and faith-based organizations, as well as through health care providers and payers.
More needs to be done to educate physicians, other health care providers, and patients about the differences between hospice care and palliative care, and the potential they have for improving quality of life and reducing potentially unnecessary – and costly – medical services, according to the committee report.
Dr. Pizzo noted that many physicians, when asked in surveys, have said that they would personally prefer less-aggressive care at the end of life, and if possible, having the patient receive care at home. Yet, when it comes to their patients, they tend to pull out the stops.
He said that was being driven by a lack of understanding of patients’ individual needs and preferences, and by what he and the committee called the “perverse incentives” of the health care system.
The system rewards more care, not less, and acute care more so than palliative or supportive care, Mr. Walker noted. “Our current system is broken. It does not result in the honoring of individual preferences as much as it should.”
The IOM report was financed by an anonymous donor, Dr. Fineberg said.
The donor made money available for the IOM to continue for at least a year, disseminating the findings and encouraging adoption of its recommendations, Mr. Walker said.
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