COMMENTARY

'Death Panels': Moving Beyond the Rhetoric

Kenneth W. Lin, MD, MPH

Disclosures

September 10, 2015

Editorial Collaboration

Medscape &

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I'm Dr Kenny Lin. I am a family physician at Georgetown University School of Medicine, and I blog at Common Sense Family Doctor.

Physicians and health policy makers have increasingly recognized that we too often provide unnecessary or harmful medical interventions to patients near the end of life. Little seems to have changed since I was a medical student 15 years ago and placed a chest tube in a near-comatose patient within days of his death, and also participated in the failed cardiopulmonary resuscitation of an elderly woman with metastatic colorectal cancer.

To prevent these sorts of pointless interventions from occurring, the American College of Physicians (ACP) has published a statement of best practices[1] for communicating with patients about serious-illness care goals. In patients with potentially life-limiting conditions, the authors recommend that primary care physicians address patients' understanding of their prognosis; their wishes, goals and fears; decision-making and information-disclosure preferences; acceptable levels of function; trade-offs; and family involvement.

And in a move that hopefully signals that we have finally moved beyond politically overheated "death panel" rhetoric, Medicare has announced plans to pay doctors for counseling patients about end-of-life care options[2] beginning on January 1, 2016. A final decision about the proposal will be made on November 1, 2015.

However, one remaining obstacle to improving end-of-life care is that most family physicians, myself included, no longer personally care for our patients when they are admitted to the hospital. My experience is that patients are more comfortable having these difficult discussions with their longtime personal physicians than with compassionate strangers.

For example, a friend and family physician colleague, Dr Jennifer DeVoe, recently wrote in JAMA Internal Medicine[3] about how her knowledge of her father and her primary care expertise allowed her to coordinate end-of-life care for him that was consistent with his priorities and preferences. She observed that since the rise of hospitalists has made in-person, primary care consultations in the hospital less common, payment incentives to utilize telehealth technology could restore the family physician's traditional role in protecting patients from unwanted interventions near the end of life.

In the past few years, payers and health systems have invested a lot into improving transitions of care from hospital-based teams to primary care physicians,[4] and I am starting to see evidence of this in my own practice in the form of more timely admission notifications and discharge summaries. I agree with Dr DeVoe that more attention now needs to be paid to integrating family physicians meaningfully into hospital care when geography or practice circumstances do not allow us to round on our patients personally.

This has been Dr Kenny Lin for Medscape Family Medicine. Thank you for listening.

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