November is National Hospice and Palliative Care Month. In a major shift in policy, the federal government announced last week that Medicare will begin to cover visits with healthcare providers to discuss end of life care and advance care planning. This represents a big change in the practice, policy, and process of discussing end of life care in the United States.
What does this mean for patients with Medicare? Beginning in 2016, you can schedule an appointment with your physician to talk about your goals of care and advance care planning needs. Your physician can now be paid for assisting you with completion of advance directives, talking with you and your family about your care needs, and answering questions about important topics like if you desire CPR, intubation, artificial nutrition and hydration, and what these interventions may do to prolong your life (and in many cases to prolong suffering).
Why is making healthcare decisions in advance so important? Because despite the fact that some 71% of Americans have thought about their end of life preferences (Pew Charitable Trusts, 2006), very few have actually put them in writing or discussed with their family, healthcare providers, and other caregivers what those preferences might be in the event that the individual cannot speak for him/herself. I always tell my patients, let’s have a conversation about this BEFORE we have a crisis.
While this discussion with your medical team is purely voluntary, it provides the opportunity for you to have some control over what happens to you when you cannot speak for yourself. At the same time, it makes the making of these decisions easier for your loved ones during a very stressful time.
What about for people who have another type of insurance? Many private plans are already reimbursing physicians for this care, and others tend to follow the example of Medicare—so this represents a huge improvement in facilitating conversations between patients and their healthcare providers.
So what do you need to know about this?
1. What is advance care planning?
Advance care planning is a larger umbrella term for a process that involves (a) learning about health care and treatment options, (b) thinking about personal values, wishes, and definitions of quality of life, and how these interplay with treatment options and goals of care; and (c) communicating these thoughts, wishes, and plans with both your healthcare team and your family and friends who are involved in caregiving. These directives are driven by and completed by YOU.
Typically, these wishes are communicated via the advance directive or living will and the health care power of attorney or proxy. These documents DO NOT require an attorney for completion. Free, state specific advance directive forms are available through www.caringinfo.org.
You may also hear other terms from your healthcare team when talking about advance care planning including “DNR,” “DNR,” or “POLST.” These are PHYSICIAN driven orders for medical care.
2. How do I ask for this type of visit and what if my healthcare provider declines to offer this type of care?
Beginning in 2016, all Medicare providers can bill for advance care planning, as a separate service. Talk with your healthcare team about scheduling a visit for this purpose. They now can bill for this service. If you provider refuses, contact the Center for Medicare and Medicaid Services (CMS).
3. What is hospice? What is palliative care?
Hospice care is a service provided to patients/families when their illness has reached a terminal phase and is expected to result in death in six months or less. Hospice care can happen at home, at an inpatient hospice facility, and in nursing homes. It is delivered by a team of hospice practitioners who focus on quality of life, managing of symptoms, including pain, anxiety, insomnia, and depression, and support of the family/caregivers. Hospice care also provides bereavement support to families/caregivers after the patient has died. Hospice is covered by Medicare and most other insurance providers.
Palliative care is a type of healthcare service that focuses on the relief of symptoms and stress associated with series illness. The focus of palliative care is improving quality of life. Certainly palliation is part of hospice, but hospice is not always a part of palliative care. Like hospice, it is provided by a team of healthcare professionals and offers added support and resources to manage illness. ou can receive palliative care at any point in your illness and while receiving curative treatment.
4. If I complete advance care planning documents does that mean I’m on hospice or palliative care?
No, these are entirely separate. Completing advance care planning documents does not mean you will no longer be able to receive aggressive, curative treatments. These documents exist to help guide your family and healthcare professionals about your wishes for ongoing care, should you be unable to make these decisions on your own. You are also not required to have advance care planning documents to receive hospice or palliative care.
5. I don’t have a life threatening illness, can I still talk to my doctor about my advance care planning wishes?
Yes. One underlying goal of this policy is to normalize discussions about end of life and encourage these discussions before there is a need to utilize them. Accidents happen. Illness happens. Usually these things are beyond our control. However, we can control the conversations before a crisis. This policy encourages us to do so.
For more information on this policy change: