Talk about the end

July 20, 2015
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Six years after the idea was scuttled by Sarah Palin’s talk of “death panels,” Medicare announced that it plans to reimburse doctors for conversations with patients about care at the end of life. Perhaps this time around, Americans are ready to acknowledge the wisdom of having these conversations.

As it is, 80 percent of Americans say they want to discuss end-of-life treatment with their doctors, but only 7 percent of seriously ill patients ever do. Medicare’s proposal is a modest move toward encouraging a crucial discussion, serving people’s wishes, and improving the quality of care.

Though many people say they would prefer to avoid fruitless medical procedures and want to die at home rather than in a hospital attached to tubes and machines, intervention remains the health system’s default mode. Medicare is often more likely to pay for open-heart surgery on a dying patient than for hospice care. Medicare spends 28 percent of its budget on patients’ last six months of life, and it’s been estimated that up to 30 percent of these expenses have no meaningful impact—except, in many cases, to prolong and increase suffering.

Several years ago, California doctor Ken Murray noticed that his fellow doctors tended to die differently from most people: swiftly, peacefully, and at home. Those who know the most about medicine know the most about its limits, and they are most likely to refuse its treatments. Doctors have seen up close what cutting-edge technology does to people at the end of life, and they want no part of it.

For those of us without firsthand knowledge of medicine, the next best thing is a relationship with a doctor and honest conversations about last things and final wishes. Doctors need to know our hopes and fears. They also need to know that, when it comes to interventions at the end of life, we want to know what they know.

“Death with dignity” is a slogan everyone embraces. The phrase is most often associated these days with the campaign for legalizing physician-assisted suicide—a burgeoning movement, with bills under consideration in California and 19 other states. The popularity of these bills surely reflects people’s fears of dying in unbearable suffering, at the hands of a relentless, uncaring medical system.

Improved medical care—featuring more conversations with doctors, fewer futile interventions, more-effective palliative care—would alleviate many of those fears. The possibility of such humane care, more than any provision for assisted suicide, will determine whether the vast majority of people are able to die with dignity.



response to Aug. 5 editorial: “Talk about the end"

People want to talk about their unique, values-centered wishes for care through the end of life with their loved one and doctors. Where we get stalled is knowing just how to do it. And, if the first time we reflect carefully on the reality of our mortality is in the doctor’s office or ICU, it’s going to be harder to articulate what is most important to us about living and dying.

The Conversation Project website has a free, user-friendly guide for talking to your doctor. Filling out this Starter Kit before your next appointment can help you hone the key ideas you want to share during a short office visit.

Clergy have a special role in encouraging people to express their wishes sooner rather than later. Preaching our faith’s teachings nurtures the kind of spiritual courage and compassion needed to begin talking about “the end.”

This November, dozens of congregations in Greater Boston and beyond are unifying around these themes by celebrating “Conversation Sabbath” and committing to teaching or preaching about this critical topic during a two-week event and celebration of life. Our readiness to have The Conversation will support our health care professionals, and help ensure that our wishes will be respected.

Letter from Pacia Vamvas

This article had some fine points, but the onus was put on the family to initiate the conversation. As a hospice chaplain, I ob­served that it was often the doctor who did not want to discuss hospice. Doctors are trained to “fix it”—so stopping treatment and placing the patient on hospice means the doctor has failed. I’ve seen too many families miss out on the supportive services of hospice until the patient’s very last days on earth. In the statement “Doc­tors won’t know what their patients want unless they discuss it,” they should refer to the doctors as well as the patients.

Pacia Vamvas
Cobleskill, N.Y.