All patients have at least two choices when it comes to end-of-life care: curative care and palliative care. But a handful of states have moved forward to give patients greater control over how they end their lives as well.
According to the Death with Dignity National Center in Portland, Oregon, whose mission is to promote Death with Dignity laws based on the Oregon Death with Dignity Act, a legal prescription for life-ending medications is only available in states with Death with Dignity laws.
At press time, California, Colorado, the District of Columbia, Oregon, Vermont, and Washington have such statutes. Life-ending prescriptions are also legal in Montana, due to a 2009 State Supreme Court ruling. “It is hard to generalize about state-based trends because only a relatively small number of states have adopted Death with Dignity laws thus far,” says Tricia Neuman, senior vice president of the Henry J. Kaiser Family Foundation. “But it is fair to say that discussions about end-of-life care are receiving more attention. There may even be growing interest among health plans and medical schools in providing health professionals with the skills they need to have difficult but important conversations with their patients about their end-of-life wishes.”
Driving the trend
This greater focus on end-of-life care is partially due to the aging of the population and concerns that people may not be receiving the care they desire. “As individuals reach advanced stages of their lives, they may not have had an opportunity to discuss their preferences with their family or doctors,” Neuman says.
According to a recent Kaiser Family Foundation survey, only 25% of older adults say they have shared with their doctor their written wishes about end-of-life care.
End-of-life care has also garnered attention because of the high cost associated with medical care in the last year of life, particularly impacting Medicare and to a lesser extent Medicaid, according to Neuman, director of the foundation’s program on Medicare policy.
“When people in Medicare HMOs and PPOs elect hospice, they disenroll from their Medicare Advantage plan to get hospice care under traditional Medicare,” Neuman says. “Medicare Advantage Plans cover Medicare-covered services, but not hospice.”
Neuman says end-of-life discussions between patients and their physicians are difficult, yet have less to do with policy than culture. “Medicare recently modified its payment rules to allow doctors to bill Medicare for visits which are exclusively focused on end-of-life discussions,” she states.
There is also a trend to help patients avoid ending their lives in a manner that is inconsistent with their wishes; for example, with feeding tubes or in an intensive care unit rather than at home with supportive services.
“Even with greater interest in improving end-of-life care, about four in ten older adults do not have advance directives and many say they have not had conversations about their preferences with their doctors,” Neuman says. “Often, these decisions are made at a time when individuals are unable to make decisions for themselves.”