Planning for your health care

By U.S. Sen. Susan Collins

    Noted health economist Uwe Reinhardt once observed that “Americans are the only people on earth who believe that death is negotiable.” Advancements in medicine, public health, and technology have enabled more and more of us to live longer and healthier lives. When medical treatment can no longer promise a continuation of life, however, patients and their families should not have to fear that the process of dying will be marked by preventable pain, avoidable distress, or care that is inconsistent with their values and needs.

    Unfortunately, most patients and their physicians do not currently discuss death or routinely make advance plans for their end-of-life care. As a consequence, about one-fourth of Medicare funds are spent on care at the end of life that is geared toward expensive, high-tech interventions and “rescue” care. 
    While most Americans say that they would prefer to die at home, studies show that the vast majority still die in institutions where they may be in pain, and where they may be subjected to high-tech treatments that merely prolong suffering.
    We are making some progress in meeting the wishes of those at the end of their lives. More people over 65 are dying at home and in hospice care, and fewer are dying in hospitals. At the same time, however, a recent study published in the “Journal of the American Medical Association” found that end-of-life care continues to be characterized by aggressive interventions. Increasing numbers of patients are receiving care in an intensive care unit in their last month of life, and a growing number are shifted back and forth between different care sites in their final three months. Moreover, while the study found that hospice use has increased, more than 28 percent of hospice patients were enrolled for three days or less.
    Clearly there is more that we can do in this country to improve the way that we care for people at the end of their lives. Advance care planning has been shown to increase satisfaction and improve health outcomes because people with advance directives are more likely to get the care that they want, in the setting they prefer, and avoid the care that they don’t want. Still, while 93 percent of Americans say that advance care planning should be a priority, only about a third of the adult population has completed an advance directive.
    I serve as Ranking Member of the Senate Special Committee on Aging. We recently held a hearing to discuss the importance of advance care planning and examine ways to improve how we care for people at the end of their lives.
    One of the first bills that I worked on after being elected to the Senate was the Advanced Planning and Compassionate Care Act, which I introduced with Sen. Jay Rockefeller (D-West Virginia). Our bill, which we went on to introduce in subsequent Congresses, was intended to facilitate appropriate discussions about end-of-life issues and encourage advance care planning. It required that every Medicare beneficiary receiving care in a hospital, nursing home, or other health care facility be given the opportunity to discuss end-of-life care and the preparation of an advance directive with an appropriately trained professional within the health institution. It also required that, if the patient had an advance directive, it must be displayed in a prominent place in the medical record, so that all of the doctors and nurses could clearly see it. 
    Our legislation also established a telephone hotline and information clearinghouse to provide consumer information and advice about advance directives, end-of-life issues, and medical decision-making. And, last but certainly not least, it provided Medicare coverage for advance planning consultations between patients and their doctors.
    End of life care is a critical issue that, at some point, will confront each and every one of us. Patients and their families should be able to trust that the care they receive in their final days is not only of high quality, but also respects their values and desire for dignity and autonomy.

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