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The One Certainty
How to Plan Better for Death

A new report has kicked off a vigorous debate over how we provide and pay for end-of-life care, but a crucial cultural dimension to the coming crisis is being largely overlooked. The Institute of Medicine (part of the National Academy of Sciences) warned in its report “Dying in America” that current end-of-life health care practices are unsustainable, because many practitioners assume that patients with terminal illness prefer medical intervention to palliative care—in part because few people think seriously about and inform doctors of their preferences while still healthy. As the Baby Boomers enter old age and put more stress on the system, this unsustainability will become even more acute.

As the New York Times reports, the IoM’s recommendations include reimbursing providers for advance care conversations and using Medicare to fund more palliative home visits instead of expensive, treatment-heavy hospital stays. These are good ideas, in part because many people would rather die in their homes than expire in hospitals, hooked up to all sorts of tubes and unable to say a proper goodbye.

However, the natural human fear and denial of death makes it hard to encourage patients to have these conversations, as WaPo points out:

When the federal Agency for Healthcare Research and Quality studied the issue about a decade ago, it found that medical records for more than half of severely or terminally ill patients didn’t include an “advance directive” with instructions for care if they became incapacitated. Strikingly, just 12 percent of patients with an advance directive said they had actually consulted with a doctor when they formed it.

The decline of institutional structures that can help us face, become reconciled with, and think well about death plays a big part in our inability to discuss these matters. Until we grapple with death as a personal reality, we are not likely to get much better at planning ahead for it—no matter how much Medicare tinkers with its reimbursements.

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  • ShadrachSmith

    Who grows up wanting to be on a Death Panel? Even a strictly advisory Death Panel is still not a dream job.

    • Fat_Man

      Hint: they belong to ISIS.

  • qet

    The last paragraph states the truth of the matter. Death and dying–at least in the normal course–are not matters for public policy or public accountancy. The attempt by modern secularists (people who believe that faith, religion, metaphysics have no place in public life) to substitute financial calculations for faith and metaphysics as the ethical underpinning of our practices towards the dead and the dying is repugnant even to confirmed agnostics like myself.

  • Tempus Fugit

    …one of the grandest lies that we Americans have been taught in our schools, is that the founding fathers were “CHRISTIAN”! LIES, LIES & more LIES! The founding fathers were NOT Christians!…at least not the more prolific ones!
    “Jesus Christ and the twelve apostles are a parody of the Sun God and the twelve signs of the Zodiac” “THE RELIGIOUS COMPILATIONS OF THOMAS PAINE”
    … other words……….Jesus NEVER existed!

    • Fred

      Since it is both pointless and impossible to argue with someone of your obvious combination of ignorance and dogmatism, I won’t even try. I will, however, point out that it is off topic. If it is helpful, there are many blogs that cater to gnu atheist fundamentalists. Jerry Coyne’s comes to mind. I suggest relocating your ranting to one of those blogs more congenial to it.

  • DiogenesDespairs

    Medicare “tinkering” with end-of-life reimbursements. Does anyone realize how short a step that is to “You’re too old; no more insulin for you.” And then to a Medicare Lois Lerner “Oh, you’re a registered (fill in name of party here); NOTHING AT ALL FOR YOU!”

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