End-of-life care and psychologists, and other behavioral professionals

The Aug. 30, ‘14, edition of the New York Times included an article, CoverageforEnd-of-LifeTalksGainingGround, about paying doctors, and potentially other medical providers, to talk to patients about end of life care issues and treatment options, and to help with with the very challenging and complex decisions that they are facing.

The article notes that this service had been caught up in intense politics, with Conservatives categorizing it as “death panels.” It also notes that the American Medical Association has developed billing codes for this service (“end of life care consultations”, not “death panels”) and recommended that CMS, the Federal body the runs Medicare, to cover it. CMS is the agency which runs “public” medical insurance programs, Medicare and Medicaid, but CMS decisions are often the blueprint for policy and procedure decisions by “private,” or commercial, insurance plans. Many f these plans have contracts with CMS, or State agencies, to mange public plans (e.g., in MInnesota we have PMAP plans managed by the major local insurance plans), and CMS guidelines usually are incorporated by commercial plans.

The article also notes that end of life counseling had been initially part of the Affordable Care Act, but Conservatives rallied around the concept of “death panels” and for political reasons it was dropped from the Act. Some commercial plans have, however, understood the benefits of this service and have begun to cover it. Therefore, while the service may be a political causality, it is in the process of being resurrected by insurance companies and the AMA.

There are two reasons for commercial companies to be interested in this service. Of course, one – perhaps the primary one- is that is often will save them money. The article discusses this in detail. The reason that is perhaps more of interest to behavioral professionals, and focuses on compassion for the patient and family facing end of life decisions. The article provides some real-life illustrations of these situations.

The article raises a question about whether non-physician professionals would be reimbursed for this service, and includes psychologists as professionals who could potentially provide this important service. 

I recently provided an inpatient consultation that I believe illustrates that psychologists can, and should be involved in end of life care services. I was on call to provide weekend coverage for psychiatric consultations at Fairview Ridges Hospital (discussing this service, with psychologists backing up a psychiatrist like this is another blog posting). I was asked to see a patient to help his medical team manage “depression.” This is a standard inpatient consultation “order,” but it turned out to be a bit more complicated than that.

The pateint was 89 years old, very frail, and had been admitted from a long term care center (what used to be called a nursing home) due to increasing weakness and pain. I noted, while reviewing the EHR, that the family complained to the hospital staff that the care center staff was refusing to let the patient use his walker, which is unusual as usually the care center staff are pushing the patient to walk and want the family to encourage him to get out of bed, use the walker and otherwise be more physically active.

I also noted thorough documentation of the patient’s complex and chronic health problems, with many references to the fact that he has “life-shortening,” or “terminal” illnesses. There was no mention consideration of referral for hospice care.

When I met with the patient he was sitting in a chair and looking at the TV, but did not appear to be tracking the show. He had obvious cognitive impairments – had trouble finding words, did not know his age or the year, and when a friend arrived to visit my patient did not recognize him. He complained that he was miserable and in chronic pain. Near the end of my interview I asked him whether he had considered plans for end of life care, such as criteria for when he would begin receiving hospice services. He stated that he has strong religious beliefs and has hope for “help from God.” When asked what we, the hospital team, could do to best help him, he said that he wanted “relief from my pain.” I asked if anyone has discussed hospice care, and he first said, “That would mean that the end is near for me,” but also quickly went on to say that he would be willing to talk to hospice staff, particularly in regard to managing his pain.

I talked to his wife by phone. She emphasized that she and their children are deeply religious and “are hoping for a miracle.” I pointed out that he has several chronic health problems and his symptoms are worsening, and “maybe it is time to consider hospice care.” Her response: “nobody has suggested that. It is very hard to face that, but I think you are right.” We agreed that she will follow up with further discussion of whether hospice care is indicated with his hospitalist.

The outcome of my consultation, in regard to my role as a member of his medical team, was to recommend that the team that the follow up with talking more with the family about hospice care. I also, diplomatically I hope, suggested that the focus should be not on viewing him as “depressed” but as “chronically ill, in pain, and nearing the end of his life.”

Given the demographic bulge of aging baby boomers, I suspect that health care teams will be dealing with this type of situation more frequently. Hopefully CMS will follow the AMAs recommendation and expand upon it to include us for payment.

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