Elderly schedule talks once labeled 'death panels'

HACKENSACK, N.J. -- The doctor got down to business after Herbert Diamond bounded in. A single green form before her, she had some questions for the agile 88-year-old: about comas and ventilators, about feeding tubes and CPR, about intense and irreversible suffering.

"You want treatments as long as you are going to have good quality of life?" Dr. Manisha Parulekar asked.

The retired accountant nodded.

"And at that point," she continued, "you would like to focus more on comfort, right?"

There was no hesitation before his soft-spoken reply: "Right."

Scenes such as this have been spreading across the U.S. in the months since Medicare started paying for conversations on end-of-life planning.

Seven years after that idea spurred fears of "death panels," supporters hope lingering doubts will fade.

"The more and more that that happens, the more patients, families and doctors will become comfortable with it," said Dr. Joe Rotella, chief medical officer of the American Academy of Hospice and Palliative Medicine.

"Any distrust people have about, 'What is this?' really disappears when patients sit down and find out this is about empowering them."

The Centers for Medicare and Medicaid Services quietly tucked the change allowing for payment for end-of-life counseling into a massive package of regulations last summer, with billing permissible as of Jan. 1.

To date, CMS has not released data on how many people have taken part in the sessions, but a survey released last month suggests it may be off to a slow start.

Three not-for-profits -- the California Health Care Foundation, Cambia Health Foundation and John A. Hartford Foundation -- fielded a poll of 736 doctors who see patients 65 and older.

Only 14 percent said they had billed Medicare for the new counseling, though the survey was conducted Feb. 18 through March 7, meaning the earliest participants only had about six weeks from the start of the benefit.

Altogether, 95 percent of doctors in the poll expressed support for the Medicare benefit, and a big majority considered such conversations important.

Some doctors had incorporated end-of-life planning into regular visits, and certain private insurers began offering reimbursement for it before Medicare announced its change.

But because Medicare is the single largest payer of health care in the U.S., this could stand to be one of the most significant developments in end-of-life care seen in the country.

It also gives Americans a glimpse into something many only knew through the lens of controversy.

Diamond arrived for his appointment at Hackensack University Medical Center on a mundane day in which he had reviewed investments, had a dentist appointment and ate a couple of slices of pizza for lunch.

In his last visit with Parulekar, she gave him a copy of "practitioner orders for life-sustaining treatment," or POLST, a doctor-signed document that makes end-of-life preferences known.

"Did you have a chance to look at the form?" she asked.

He had, and they set out to review it as Parulekar filled it out.

"I wish to live a full and long life, but not at all costs," she wrote as a goal of care, repeating language common in living wills, something Diamond long ago completed.

This document will go further in its specificity and authoritativeness.

It serves as a medical order to dictate the response to a health crisis if patients no longer are able to make their decisions known.

The doctor calmly addressed questions as she moved through the document with Diamond: How long would he feel comfortable being on a feeding tube?

If hope seems lost, should CPR be performed?

Would you want to be put on a respirator?

"I wouldn't want to be on a machine for the rest of my life, that's for sure," Diamond told her.

All told, it was only about 20 minutes before Diamond's white sneakers shuffled out of the room and the appointment was over.

Medicare reimbursements for the appointments vary by region and the type of facility, but on average, an initial 30-minute session in a doctor's office costs $86.

As those experiences proliferate, the topic of discussing end-of-life care may return to the relatively uncontentious mantle it once enjoyed.