Why mid-life is the time to start talking about the end


I'm about halfway through reading Being Mortal: Medicine and What Matters in the End, by Atul Gawande, M.D. It's requiring that I pace myself, for emotional reasons. My parents are in their 70s. I have lost a 40-year-old sibling to cancer. The question of what matters in the end is one that matters to me all the time.

The more I learn about the topic, the more I realize that I've been guilty of looking at it backwards--in terms of details such as the use of artificial life support--rather than the joys, goals and sense of purpose that make a life.

Examining these fundamentals of what we truly need and want most in our lives, and figuring out the means to attain or keep them, is a complicated exercise to do for ourselves. To do so with or on behalf of someone else? Someone who may have already been accumulating mental and physical deficits for years?

That's so much more than a 30- or 60-minute conversation. It's hardly a discrete, codable event. Nonetheless, the Centers for Medicare & Medicaid Services announced last week that you can soon be reimbursed up to about $160 for CPT code 99497 plus the add-on 99498. It's sure more than the $0 you've gotten to date, and hopefully won't come with the hoops that have made last year's addition of codes for chronic care management so difficult to use.

It's too soon to know whether formal reimbursement for advance care planning will spur more conversations about patients' end-of-life wishes early enough for physicians to try to grant them. I suspect that society's growing consciousness of these issues will open a far bigger can of worms than codes 99497 and 99498 can begin to account for--and sincerely hope that doesn't become a dialogue deterrent.

The dialogue simply needs to start sooner, in my opinion. Not sooner as in hundreds of days before death than it typically does now. Sooner as in middle life, when a majority of patients admittedly put lackluster effort into taking care of themselves-and have the gall to say it's doctors' job to kick them in the pants to change behaviors that will inevitably catch up with them, if they haven't already, in the form of chronic disease. A study reported in the New York Times just yesterday revealed that mortality rates are actually rising for middle-aged white Americans, not due to the usual suspects of diabetes and heart disease, but to suicides and afflictions stemming from substance abuse.

Physicians are not responsible for motivating patients to take care of themselves, physically or emotionally. It is not possible for a doctor to physically get into another human being's head and make him or her care about anything. Closer integration of medical and mental health services may help reduce this frustration. But eventually, it's the healthcare industry that is charged with managing the medical consequences of patient behavior and simple old age. And although reimbursement systems are evolving to account for the behind-the-scenes work that goes into doing so, the math may never truly work in your favor.

If you're going to put in unpaid overtime, to extend yourself to forging a relationship and communicating a message that gets people's attention, the ideal time to do so is not when you believe they have years or months to live, but when everyone involved assumes they have decades.

For lack of better terminology, what would happen if physicians prescribed midlife crises? By this I don't mean to tell Mr. Jones to go out and buy a convertible, but rather to induce a wake-up call. What if people put some serious thought now into what really mattered as though they were terminally ill?

After all, as Aaron Keriaty, M.D., recently put it, "The human mortality rate continues to hold steady at 100 percent and shows no signs of changing." - Deb (@PracticeMgt)