Many years ago patients had primarily one family doctor who knew them well. Today with all of the many specialists and often there is a resultant lack of coordination of care, there can be a feeling of confusion and brokenness in the doctor-patient relationship. One doctor who attempted to bring a deeper level of caring to his patients found it to be cost prohibitive. Dr. Sandeep Jauhar author of the book Doctored says that “insurance companies don’t pay enough for spending time with patients. But they do for CT scans and stress tests.” Dr. Jauhar says“ It is a comedown from most doctors initial ideals of wanting to help people .” According to figures in the book, a 2008 doctor survey showed that only 6% of physicians reported positive morale. Although a doctor should strive towards compassion with all patients, this ability to be fully present and caring with a terminal patient is especially important.
Sadly, this lack of patient compassion often has its genesis in the medical training that has not accentuated the need for development of courses on the emotional and spiritual care for the patients. Normally the coursework is focused on the disease process and the various specialty rotations. The impact of how the disease process affects the patient from an emotional, psychological and spiritual perspective is not addressed. Rarely is there any coursework in the areas of how to deliver a terminal diagnosis or death and dying in general, even though the mortality rate is100%. A survey we did for the book Soul Service: A Hospice Guide to the Emotional and Spiritual Care for the Dying (Balboa Press, 2013) www.soulservice.info showed that only eight of the 122 medical and nursing schools contacted had courses offered related to psychological,emotional or spiritual care of the dying. Yet most doctors of all specialties will ultimately work with patients who are in terminal situations.
A recent report released last week and featured in a New York Times article on September 17,found the American system of providing end-of-life care is badly in need of an overhaul. Appointed by the Institute of Medicine, a 21-member nonpartisan committee called for sweeping changes. “The bottom line is the health care system is poorly designed to meet the needs of patients near the end of life,” said David M. Walker, a Republican and former U.S. comptroller general, who was chairman of the panel. Advocating against futile care the panel finds that “The current system is geared towards doing more, more, more and that system by definition is not necessarily consistent with what patients want and is also more costly.”
Additionally, the panel recommends that palliative care skills should be required to be taught extensively in medical and nursing schools. This is something that one of the panel members, Dr. Meier said “would require a revolution in health care education.”
On the positive side of recent developments, the issue of paying doctors to talk to their patients about end-of-life care is making a comeback, and these patient talks may be covered by Medicare as early as next year. Bypassing the political process, private insurance companies have started reimbursing physicians for these “advanced care planning” talks. As the population is aging in America these end-of-life talks will gain in popularity. According to the New York Times article, the American Medical Association, the country’s largest association of physicians and medical students requested that these talks become standard and is the process of creating billing codes for these discussions.
There are two recent bipartisan bills being introduced into congress which will have Medicare cover such conversations. A third introduced by Sen. Tom Coburn, R-Okla., would pay Medicare patients for completing advanced directives. But few think these bills can pass, as Dr. Philip Rogers, co-chair of public policy for the American Academy of Hospice and Palliative Medicine states that “ people are so careful about getting anywhere close to the idea that somebody might deny lifesaving care.”
Let’s hope these bills pass and Americans can come into the level of consciousness that supports a more open discussion of end-of-life care. Maybe then this can foster a shift in the concept of service so that medical practitioners can more freely offer their time, emotional support and empathy to those the service. A medical system that puts profits first and patient centered care last will not promote the doctor-patient level of trust and respect that is essential to quality care. We as a nation need to insist that the pendulum begins to swing more towards the holistic incorporation of treating the whole person, mind, body and spirit in patient care.