The 'advance directive' for what's to be done at death's door

Joseph C. d'Oronzio

June 23, 1993|By Joseph C. d'Oronzio

AMERICANS have embraced our individual right to limit heroic but futile medical treatment at life's end with such documents as an advance directive, living will and health- care proxy.

How can we combine this ethical consensus with the economics of rationing care?

The coming reform of our health-care system may provide an opportunity.

First, current law should be amended to require all registrants for federal entitlement programs -- Medicare, Medicaid and Social Security benefits -- to consider and complete an advance directive.

Second, employers and the new cooperative purchasers of health-care insurance should reduce the premiums for individuals who consider and complete an advance directive.

An advance directive, ideally, is written well before the patient becomes ill, informing families and physicians what life-support technology is acceptable should illness hinder the patient's ability to make a decision. This is also an economic choice, since by limiting these unusually expensive activities, health-care resources are conserved.

Under current law, patients are encouraged to consider advance directives when they are admitted to a hospital. This system is not working. Illness and anxiety keep many patients from making an informed decision at that moment.

While most of us want to limit the futile over-treatment that still dominates end-of-life health care, only 5 percent to 10 percent of Americans have these documents.

We need a new point of entry for informed consent: Patients should consider an advance directive when enrolling in a health insurance policy or federal program, free of the pressures of hospital admission.

Here they will have the opportunity to discuss it in detail with their physician and family and to name someone they trust as a health care proxy. Linked to universal health insurance, advance directives would become more standard.

The cost of the last 60 days of Medicare is about $32 billion per year. Additional billions are paid out-of-pocket, out of savings and by private insurers. These estimates are no more exact than the clinical prediction of death.

Yet physicians understand that a day comes when further treatment is futile. Philosophers and health economists can help us understand the toll it takes.

In the end, however, only we individually can resolve to do something about it.

Joseph C. d'Oronzio is assistant professor of social medicine at Columbia University.

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