End-of-Life Care Issues

A Personal, Economic, Public Policy, and Public Health Crisis

Dan K. Morhaim, MD; Keshia M. Pollack, PhD, MPH


Am J Public Health. 2013;103(6):e8-e10. 

In This Article

Implications for Policy

Increasing the low rate of completion of advance directives in the United States needs to become part of the public health agenda. The prime reason to do this is humanitarian: empowering individuals and families to be actively involved in care decisions at a critical time. In addition, reducing needless or unwanted end-of-life care expenses would allow those funds to be diverted to other pressing public health needs.

There are policies that might address this. Physicians, nurses, social workers, and other key providers should obtain fair reimbursement for having end-oflife care discussions with patients. The rate of completion of advance directives should be a routine part of patient encounters and used as a metric of quality care. Advance directive registries should be universally available, and the information presented, with proper access, in electronic format. The role of advance directives should be part of medical education and training and incorporated as an aspect of cultural competency. End-of-life care issues could be discussed, as appropriate, at other venues such as the workplace or at faith-based institutions. We would like to see our political and cultural leaders be part of a coordinated campaign effort to promote use of advance directives. For these ideas and others, we believe that the public health community is a critical stakeholder, and efforts should be made to update the American Public Health Association policy statement related to advance directives.[19]

Though we Americans strive to control nearly every aspect of our lives, many of us abandon control of life's final passage. But the realities of 21st-century medicine will allow most of us to have a say in how, when, and where we die. We are the first generation in human history afforded this unique circumstance, and the implications are far-reaching.

As public health professionals, our job is to find the best, positive, and most effective ways to empower Americans to take full advantage of their options. In the final analysis, it is a matter of individual responsibility, and we hope that having an advance directive on file becomes as routine as getting a driver's license or a Social Security number. The cost is small, but the payoff is substantial. These complex issues involve personal, spiritual, and cultural values combined with family dynamics and health care economics. Addressing this must become part of the public health agenda.