One of the major reasons for our excess spending is how we presently use advanced directives. They were created by The Patient Self Determination Act of 1990 in response to the Karen Ann Quinlan and Nancy Cruzan cases and were created to give patients choices as to their preferences in end-of-life situations. Although created with the best of intentions at the time, there are many unforeseen consequences. Patients cannot possibly predict their health situation years in advance. What may be appropriate for someone in their fifties may not be appropriate for the same person in their eighties. Most patients who have advanced directives do not discuss them in detail with their physician or their designated proxy. Many patients, perhaps most, are not aware of the technical issues involved with specific choices. An inappropriate choice in light of the patient’s overall condition, i.e. terminal cancer, puts the physician in the position of ordering therapies while knowing they cannot succeed rather than focusing on pain relief and comfort care. An overwhelming majority of patients never create an advanced directive, leaving the hospital and medical team no choice but to press on while knowing it will not be beneficial. Alternatively, an advance directive gives patients the sense of more control than is realistic in many situations. Families, often when emotionally distraught, are frequently put in the position of making very difficult choices in extremely complex situations. The net effect of all this is a great deal of non-beneficial even detrimental care causing increased suffering at alarmingly increased costs.
Although these issues have been discussed and written about for years, the Congress is either unaware of these problems or has chosen not to address them. This post is intended for the public to be aware of this very serious problem. It could be solved with relatively simple Congressional action, an amendment to The Patient Self Determination Act stating, “Within the bounds of evidence based beneficial care tailored to the individual.” This would in effect cause the patient and the physician to collaborate creating a rational advanced directive with each hospital admission.