Last year, the Institute of Medicine issued a special report called Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. The 500-page document called for major reform in the way care is provided to patients who are near death. Surveys show that the majority of people state their preference is to die at home, and that they would choose a higher quality of life over life-extending measures when those two things are at odds. Yet according to the CDC, nearly 70 percent of Americans die in a hospital, nursing home or long-term-care facility. The IOM study suggests that advance care planning can not only ensure that the patient’s wishes are honored, but can reduce overall health spending by avoiding undesired and unnecessary interventions.
Often, the problem is that patients and their families have little guidance when it comes to navigating end-of-life choices. Let’s face it, doctors have had very little incentive to sit down and go over all the options with their patients in detail, taking into consideration the patient’s preferences and goals. This past summer, Medicare proposed a new rule that could be a game-changer in end-of-life care, by reimbursing physicians and nurse practitioners for time spent counseling Medicare patients about the end-of-life choices available to them, including hospice, do-not-resuscitate orders, and palliative care. The proposal acknowledges that paying doctors for this service will increase the likelihood that these conversations actually happen when they are needed.
At this point, the idea is still just a proposal, in the public comment stage. If approved, it could become official policy early in 2016. But we’ve been here before—in 2009, opponents of healthcare reform fabricated claims about a similar proposal, falsely stating it was a way to set up “death panels” and mandatory euthanasia. It may or may not be the case that the times are now more favorable to this type of policy.
So what does this all mean for nurses?
If the proposal becomes policy, many or most private insurers are likely to follow suit. And if our current system moves away from aggressive and futile treatment at the end of life, this could expand opportunities for nurses working in hospice, home health, and palliative care—all of which are recognized nursing specialties with certification available. Critical care and acute care nurses might also be less prone to the moral distress and burnout that result from having to provide inappropriate care to the terminally ill. It’s also possible that nurses working in case management will be trained to counsel the elderly or terminally ill about end-of-life choices.
A 2010 position statement from the American Nurses Association says:
Academic preparation and continuing education should prepare nurses to provide comprehensive and compassionate end-of-life care, so they can serve as advocates and resources for the patient and patient’s family. Expression of the patient’s fullest autonomy in end-of-life decision making is best honored by addressing such questions in the primary care setting and throughout the lifespan, not only when a life-threatening condition arises. End-of-life patient counseling and education are “best practices” in all health care settings, and should be encouraged systemically through rigorous practice standards and appropriate reimbursement.
So the ANA is solidly behind the idea of a healthcare system that supports end-of-life counseling. It also states that nurses have an ethical and preparation obligation to “provide comprehensive and compassionate end-of-life care, including the promotion of comfort, relief of pain, and support for patients, families, and their surrogates when a decision has been made to forgo life-sustaining treatments.”
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