End-of-life care

One of the healthiest debates beginning in the United States these days is about dying: How and under what conditions the terminally ill will end their lives. A bill recently introduced in Congress gives Medicare and Medicaid recipients more information in this debate and deserves support.

The Advance Planning and Compassionate Care Act, sponsored by Sens. Susan Collins and Jay Rockefeller of West Virginia, would distribute information on advance directives — the documents in which patients describe the level of care they want, ensure that advance directives will be honored in all states, fund pilot projects to help improve the quality of the end of life and provide for coverage of a greater range of pain medications. The bill is important because even as some people have become aware in recent years of death-with-dignity options, many others have not.

This is important because the level and type of care a patient receives varies widely across the country. A recent study at Dartmouth Medical School, reported in The New York Times, showed, for instance, that Medicare enrollees in Miami received twice as many surgical procedures and tests as enrollees in Minneapolis, even after adjusting for differences in the incidence of illness between the cities. The differences were found across the country, with one region offering three times as many coronary bypass grafts than another and patients in one region five times more likely to use hospital intensive care at the end of life than another region.

The Dartmouth study, conducted by John Wennberg, is reported to have found no medical necessity for these disparities — geography dictated care. Surveys have shown similar results on selected operations within Maine. While managed care is supposed to eliminate some of these disparities, the more patients know about their options, the better they will fare. The Senate bill provides Medicare and Medicaid patients and their doctors with help in making difficult decisions about end-of-life care. Currently only about 20 percent of patients use advance directives, yet even with these patients doctors report that approximately half the time they do not learn about these directives until after care has begun.

The Collins-Rockefeller bill is a welcome response and balance to the medical community’s wondrous discoveries that keep people living long beyond what could have been expected even a few years ago, perhaps even longer than is desirable. Patients more than ever need information about their care, and the Senate bill should help them get it.