The Centers for Medicare & Medicaid Services are proposing rule changes that could make conversations about end-of-life care preferences more common, requiring hospitals to report whether those conversations are documented.
Not having end-of-life conversations is a disservice to patients, said Dr. Ian Neel, a geriatrician at UC San Diego Health.
“I cannot count the number of times when I was working in an ICU, and a discussion hadn't been had about 'should we really be doing this?'” Neel said. “And making those decisions at the moment are impossible, and it ultimately leads to more negative outcomes for patients."
Only about 1 in 3 U.S. adults have documented their end-of-life care wishes. Doctors said the gap reflects how late these conversations are happening.
“Unfortunately, these conversations are not happening early enough, and honestly, anyone who's 18 and above should really be having a conversation about what they would want regarding their health and types of treatments that they would want,” said Dr. Vishva Lakshman, who runs the palliative care department at Scripps Health.
The new Medicare requirement would begin in 2028. It would include advance directives, do-not-resuscitate orders and medical power of attorney forms.
The change could help make those conversations more consistent, Neel said.
“The hope would be that it's more streamlined, because it really is different hospital to hospital, and even provider to provider,” he said. “That's why I'm cautiously optimistic about changes at the federal level kind of mandating this. Every provider that admits somebody to a hospital should be having a discussion with them about their wishes were the worst come to pass.”
Both physicians said the goal isn't simply to document a patient's wishes; it's to make sure those conversations are meaningful.
“That's always the caution when we have something that becomes a new policy,” Neel said. “Are we doing it just to complete the policy, or are we doing it for the good of the patient? And that's what we really hope, is that with the policy, that it doesn't just become another box to check.”
Patients don't have to make every decision all at once, Lakshman said.
“It is a scary conversation to have,” she said. “I think having patients understand that what they say today is not set in stone but could be an evolving conversation over time,” she said.
The Centers for Medicare and Medicaid Services is expected to make a final decision on the proposal later this summer.
