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After many teasers and disappointments for doctors and patients, an important change is in the cards. Medicare will start compensating physicians for end-of-life dialogues with their patients effective Jan. 1, 2016. No longer will these urgent appointments be scheduled under the guise of addressing some other issue. Without payment, doctors have resisted such talks: They are difficult and lengthy and have traditionally incurred lost income for the physicians. The fact that they were not compensated also subtly gave the impression that the talks were not really regarded as all that important.

January will mark a dramatic change. Doctors won’t have to rush through their comments and their listening on the run, concerned about their bottom line, utilizing their time only in “other” talks that pay.

Patients need now to openly and boldly request a dialogue to help clarify and share their final wishes and options, so that when the time comes, there’s no guessing, especially when the patient is unable to speak for him or herself. Included is the patient’s entire philosophy about whether they want everything reasonable done — even if the chance of keeping them alive

is tiny — or whether they’d prefer an exit from extreme suffering. Specifics would be documented: A preference for dying at home rather than in the hospital; the use of a ventilator for breathing and/or a feeding tube for nourishment; the repercussions of each; and the mortality statistics.

A state-specific, concise document will help you decide in advance what you will accept or what procedures are out of the question for you. Doctors can tell you your personal odds for the success of each option, so that you can make more informed decisions.

These conversations must take place before a crisis happens. Without them, the health-care system can easily go on autopilot, undertaking invasive and sometimes painful procedures that often prolong death rather than improve the quality of a patient’s life — what Atul Gawande calls the “overmedicalization” of dying.

Envisioning one’s end makes for hard conversations on the patients’ part, and the same for many physicians. Add the tough subject matter and a frightened patient, and the results could include awkward silences, questions not asked and information not volunteered. Some physicians, skilled and confident, handle such interviews with sensitivity and compassion. Others are poorly trained or just more introverted, and find themselves in over their heads.

At those times maybe the patient would find confidence enough to jump in, seize the initiative and lead the session, making it easier for a doctor by asking lots of really tough questions (jotted down in advance), probing into vague answers and speaking as clearly as possible. Reticent doctors would likely be relieved. Remember that they, like their patients, are on unfamiliar ground.

Be prepared to learn what “no” sounds like, emerging from your or your proxy’s mouth, even in response to a routine procedure like a blood test — which may be painful to you and could be phony posturing, as if the staff is professing to look for “cures” though you are terminal.

The relationship between a patient and a physician is somewhat like feet and shoes. Not all shoes fit all feet. So depending upon how your conversation goes, you may find you need to go shopping for new shoes. ¦

2 Responses to “Having conversations about the end of life”

  1. cherry says:

    I have a question. I mistakenly removed an aluminum seal from a bottle of n. it was in the cupboard for one day and then I put it in the fridge. do you think it will degenerate in potency and should not be trusted or used? How long could I keep it? do I have to replace it? do you have some information/answer on this? thanks

  2. ergo says:

    Cherry: Your n. (Nembutal) is almost certainly useless now. Taking the lid off was a mistake, then putting it in the fridge compounded that error. Trash it.

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