What Physicians and Other Healthcare Providers Need to Know Today About End-of-Life Care

Robert Glatter, MD; Ferdinando L. Mirarchi, DO


October 22, 2015

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End-of-Life Care: New CMS Reimbursement Rules

Robert Glatter, MD: This past summer, the federal government announced a proposal to reimburse healthcare providers for talking to Medicare beneficiaries about end-of-life care.[1] This move comes after increasing calls for a better approach to conversations about dying, which can ultimately improve patient care and reduce healthcare expenditures. The proposal will be finalized in November 2015, with the goal to begin reimbursement for such discussions on January 1, 2016.

The rule, announced in July of 2015, would allow doctors, nurses, nurse practitioners (NPs), and physician assistants (PAs) to bill for discussions about end-of-life care, which was supported by a September 2014 report[2] by the Institute of Medicine (IOM) titled, Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life.

End-of-life care has changed considerably since the IOM last reported on this issue in 1998.[3] To begin with, palliative care is now well established in medicine, nursing, and social work. Yet there is considerable room for improvement. Americans have strong preferences and feelings about the type of care they would like to receive at the end of life. They generally prefer to die at home and with the ability to maintain control over healthcare decisions, according to the recent report.[2] As of now, however, there is minimal or no planning really put in place.

The report details findings about more than a quarter of adults, including those aged 75 years and older, who have not given thought to specifics regarding end-of-life care. Many more have not written down their preferences or spoken with their families about their true wishes, according to the report. Because our healthcare system is often focused on curative care rather than supportive and comfort care, such discussions are vital to support the preferences of dying patients and their families.

In 2009, efforts to reimburse medical providers for having such discussions ran into opposition after mostly Republican opponents of the Affordable Care Act (ACA) believed that the law would lead to death panels that aim to produce cost savings by rationing care. A provision to pay physicians for such end-of-life counseling was actually stripped from the final bill. Physicians who counsel newly enrolled Medicare beneficiaries, however, are currently reimbursed under the ACA, but this reimbursement does not apply to those patients who are currently enrolled in Medicare.

Many medical providers believe that we are not having these conversations often and soon enough. Family members, trying to do the right thing, may end up feeling guilty and uncertain without having had this kind of conversation. Also, the approach to a proper conversation regarding end-of-life care should not only focus on the existence of advance directives such as do-not-resuscitate (DNR) orders, or whether a living will exists, but more recently there is a significant push to generate a document known as a physician orders for life-sustaining treatment (POLST). Ideally, a POLST or a living will should be in place well before a catastrophic event occurs that may require care in an emergency department (ED).

A POLST clarifies and spells out instructions for medical providers to follow after a catastrophic event, such as a cardiac arrest, or when caring for patients who might be entering the last stages of a terminal disease. One expert who is well qualified to discuss aspects of end-of-life care and POLST documents is Dr Ferdinando Mirarchi, medical director in the department of emergency medicine at University of Pittsburgh Medical Center-Hamot in Erie, Pennsylvania. He is also the principal investigator of The Realistic Interpretation of Advanced Directives (TRIAD) studies.[4] Welcome back, Dr Mirarchi.

Can you explain what a POLST document is? How is it different from a living will or other advance directives?

What Makes A POLST Different

Ferdinando L. Mirarchi, DO: Great point! It is really important to clarify the difference between the POLST document and an advance directive. POLST is a medical order set that is supposed to go into place, just like any other physician order set, and that other medical professionals like nurses follow. The point of it is to create an order set that would encompass a patient's care spectrum when in cardiac arrest and when not in cardiac arrest, as well as to address other issues, etc.

It is very important to clarify that POLST is an "immediately actionable document"—an order set—whereas a living will is not an immediately actionable order set. The POLST is a document that comes into play when a patient is frail, elderly, or expected to die within 6 months to 1 year. A living will comes into play when a patient cannot speak for themselves and has entered an end-stage medical condition or a persistent vegetative state. Although a living will can be helpful in creating a POLST document, the two are not the same. A living will declining treatment is not the same as a POLST specifying DNR with comfort measure only. Again, one is actionable (POLST), while the other one (living will) is not actionable.

Dr Glatter: To clarify, a DNR only refers to a condition when the patient has no pulse and is not breathing. Would you agree with that?

Dr Mirarchi: That is correct. A DNR does not equate with end-of-life care or do-not-treat orders. That is a misnomer that has developed over the years, which we in the healthcare community have allowed to happen. DNR orders only come into play when a patient is found in cardiac arrest.

Dr Glatter: In terms of a checklist or a resuscitation pause (what we would call an advance directive pause), where do you see this concept in terms of implementation into care? Do you see that happening in the near future?

Dr Mirarchi: I think it is imperative that it happens in the near future. In fact, the Joint Commission[5] recently came out with a statement about the whole issue of safety surrounding end-of-life care. We know from Atul Gawande's work[6] on surgical pauses that checklists have extreme benefit in preventing errors. At this point in time, I think a patient safety checklist is going to become imperative to making sure that we have safe, balanced discussions that will provide the patient with the ability to have informed consent. We have discussed the importance of checklists in previous conversations on Medscape.

Talking About End-of-Life

Dr Glatter: Getting to the discussions themselves, there have been several current procedural terminology (CPT) codes created for these types of discussions, though they have obviously not been activated. The codes are for coding of discussions of up to 30 minutes and even beyond. Certainly these discussions take time, and I think with the average amount of time that most medical physicians, PAs, and NPs have to care for patients, 30 minutes and even beyond is a significant amount of time. Do you see the time factor being an issue?

Dr Mirarchi: Yes and no. This is going to be new, so essentially physicians are going to have to figure out how they are going to go about having this discussion. If you are involved in a system today—and most of us are, because of all of the flux happening in medicine right now with increasing numbers of clinicians employed by big healthcare systems—that system is going to determine what resources clinicians will be utilizing to have these discussions based on the merits of compliance with the rule, so they can bill out for that first half-hour and second half-hour. There is going to be a lot of variable practice out there, ranging from the paternalistic approach of some organizations to the more patient-centered approaches of others. In order to ensure informed consent, it is important that these conversations be a balanced and not a leading discussion.

Dr Glatter: Another important question is whether the documents will be legally binding and official, assuming there is informed consent in these types of conversations.

Dr Mirarchi: I think they will be binding, and that is where the POLST is gaining ground as they are enacted into statutes across the states. There are states where there is physician or provider immunity. There are states where there is not provider immunity. If POLST documents are to really become embraced, there is going to have to be some immunity that comes with them. I think that when physicians do this, they are more than likely going to be creating POLST documents for people rather than attorneys. In contrast, patients might see their attorney to create a living will or go to a site like and create a digitally created living will.

Dr Glatter: Anecdotally, I have seen social workers create these documents for patients in the throes of resuscitations. Nonmedical people are certainly informed, but they cannot give the type of advice a physician necessarily could give. Often a group discussion takes place with the family member and the social worker, and then the document is created. We need to be aware of that.

Dr Mirarchi: That is a great point. And to expand on it, to date there are numerous healthcare payer systems out there that essentially incentivize the completion of forms with quality financial bonuses for the institutions. What is happening there, as you said, is that a social worker—who may not have as in-depth knowledge as we do—is essentially looking at a living will and then pulling out a POLST form, checking off a box that says, "DNR comfort measures only," and having the patient sign it. That is a very dangerous thing to do outside of an informed conversation because the end result is an actionable order set. As you have seen with the current DNR forms, we are getting very good at scanning documents into our electronic health records and setting up banner bars. It is not uncommon for patients to return to the hospital with a critical illness and for clinicians to look in the system to see that patient's code status, advance directive, or POLST information. If it is incorrect, it is a pretty serious patient safety risk.

A Call for Education

Dr Glatter: How can we educate all kinds of providers—from NPs to physicians to PAs—about how to read these documents and create them? How can we standardize this process? Where do we start?

Dr Mirarchi: My views might be skewed, but personally I think this has to become part of the curricula of all the professional schools—including medical, nursing, PA, and NP. Every facet of healthcare has to be educated and brought up to speed quickly. For those who are currently in practice, it needs to come back down to some degree of a continuing medical education (CME) activity—CME that is made mandatory by the institution or the state. As we go to the next American College of Emergency Physicians Assembly, it is very interesting that some states have requirements that physicians earn some number of CME credits on the topic of end of life. At this point in time, we are going to need to look at that education, standardize it, and then really begin to enforce the requirements for physicians and providers of all sorts to get that education because it is going to be vital.

Dr Glatter: Do you see this as one criterion to meet for renewing a medical license or even passing a 10-year exam, with the maintenance of certification (MOC) such a current issue?

Dr Mirarchi: That's my hope and dream—that eventually this kind of education becomes a medical licensure requirement. Remember, our TRIAD research showed that the existing education out there today is either ineffective or flawed because those who receive education perform no differently from those who did not receive the education. That was a very surprising finding to us.

Dr Glatter: It almost begs the question of whether physicians should have some sort of legal course in how to decipher these documents.

Dr Mirarchi: Yes, and remember, this is a new realm for physicians. These kind of documents are only maybe 20-30 years old at best. The POLST is a very effective document. It is good at limiting resources utilized at the end of life. However, if a clinician does not know what to do with it, it becomes a patient safety risk, just as has been previously shown with advance directives. Standardizing the approach to education about these documents and getting out ahead of their widespread use is going to be very important. But the horse is already out of the gate here: POLST documents are already approved—or in the process of being approved—in 46 states to at least some degree. We need physicians to become aware that they really need to question these documents and orders.

Dr Glatter: Do you think we should be educating the public as well about the POLST document? Is it something they should be aware of as much as we should?

Dr Mirarchi: I might have a skewed approach, but I think that there should be efforts geared towards educating the public about what a DNR order is, a living will is, and a POLST, and when it's appropriate to have each of those. At this point in time, this is all new to medicine, and we do not know who is actually going to receive reimbursement yet for end-of-life care counseling and at what point in time a patient's care becomes end-of-life care. In the situation of a critical illness, there are paternalistic providers who seem to think that is the time to essentially withdraw care, treatment, or life-supporting measures. Then there are others who are more patient-centered who feel that you give the treatment and then allow the family to make the decision. I do not know which one is going to win out there, but I have the feeling it is going to be financially based to some degree.

Timing an End-of-Life Talk

Dr Glatter: When should this discussion ideally take place? Should it be when someone is just 50 years old? Sixty years old? Or only when they are on the cusp, or the throes, of a terminal illness? Oftentimes it happens in the ED, right before resuscitation is to take place. If Medicare sees this as a process that requires 30 minutes for this discussion, it is certainly not going to happen in the ED. It's going to be somewhere in an office, well away from the frenetic pace of the ED.

Dr Mirarchi: Yes, that is correct. The ED is a disconnected setting. The primary care office is very disconnected from the hospital these days, and in an emergency, because of different on-call systems, ED clinicians may have no way to contact a physician who might know the patient. So, unfortunately, even though the patient may have created these documents, we might not be able to talk to the physician who advised them or assisted with the creation of the document to get clarification as to what the patient's instructions mean and what we are supposed to be doing in terms of treatment. As far as when these discussions should occur, it would make sense that it would happen in the primary care physician's office and ideally as soon as possible. But in reality, I do not know if that is the most effective way to do it anymore because, with the birth of hospitalist physicians, primary care physicians are often not coming to the ED or hospitals anymore.

Dr Glatter: I think you bring up a good point about the separate nature of the office vs the hospital and the hospitalists because the hospitalist or intensivist is increasingly the provider who delivers medical care during a hospital stay—the time and place where there's a chance to intervene and really make clear changes in a patient's wishes and address these changes at that point.

Dr Mirarchi: I completely agree with you.

Dr Glatter: There was a recent article by Stub and colleagues[7] that looked at how resuscitation following out-of-hospital cardiac arrest occurs in hospitals and whether or not certain goals for resuscitation, including use of recommended interventions and amount of time per intervention, are met. I wonder if you could comment on this study and how it relates to our discussion.

Dr Mirarchi: In emergency medicine we are faced with this clinical scenario every day. Right now, with increased focus on public reporting, surgeons, emergency physicians, and interventional cardiologists are very concerned about the information, specifically mortality rates, that is publically reported. When you look at that study, it showed that our cardiac centers are actually following the guidelines on withdrawing life-sustaining treatment only 50% of the time.

The guidelines actually say that, for patients who have cardiac arrest either in or out of hospital (especially if there's hypothermia), healthcare professionals should wait at least 72 hours before withdrawing life-sustaining treatment. The most common reason for this decision is perceived neurologic damage that is expected to progress and be long term. In reality, we know that these patients need to be cooled, they need to go to the catheterization laboratory, and they need to have their artery opened up.

But what is happening, instead, is that centers and physicians are using these documents and orders to bypass that 72-hour period and withdrawing care too soon. We really need to look at this process and make sure that we are compliant with the guidelines for out-of-hospital cardiac arrest, whether it is a stroke or an intracerebral hemorrhage. There is a lot that we need to research still, and unfortunately this move towards payment for end-of-life care may precipitate some safety issues that we have not thought about.

Dr Glatter: I think that now that Medicare will be watching and possibly reporting on hospitals in terms of these issues, hospitals are going to be attentive to such data, assuming it does get incorporated into patient care.

I want to thank you so much for your time, and I appreciate your input into this important discussion about end-of-life care.

Dr Mirarchi: Thank you, Dr Glatter. Remember, above all else, just stick to a patient safety checklist and make the conversation balanced.


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