Moving Away From Death Panels: Health Reform for the Way We Die

Regrettably, however, the dominant mindset of American medicine has become "more is better." Newer and more sophisticated treatments or medical devices are better still. If a treatment might work, why not try it?

It's worth pausing to recall that we have yet to make even one person immortal. Instead, we have made dying a lot harder than it has to be. In the course of a progressive illness, there almost always comes a point when more treatment is not better care.

Real reform can start from a base of good intentions and widely held values -- including reverence for life -- that are shared by people of all religions and by social conservatives and progressives alike.

When someone we love is seriously ill, we all want the best care possible. For most people, that includes effective treatments to enable them to live longer along with skillful attention to comfort to enable them to live well. When it comes their time to leave this life, most people want to die gently.

Naturally, one size does not fit all. Ethnicity, culture, religion, family, and personal history all influence an individual's choices. What is best for one person would be wrong for another. And the best care for someone at an early stage of illness might well not be the best care later on.

Working as a physician within a palliative care team at an academic medical center, much of my practice focuses on helping seriously ill people and their families clarify their values and preferences, and apply them to their particular medical condition and circumstances. Often, that entails helping people weigh the potential benefits of a treatment against the known and potential burdens.

This process of shared decision-making is an example of patient-centered practice that is advanced by the Affordable Care Act. Most importantly, key provisions of the law make local health systems -- comprised of doctors, hospitals, clinics, laboratories, and imaging facilities -- responsible for both quality and costs. The new approach, called accountable care, also makes health systems' performance data freely available to the public.

This new way of doing business amounts to a sea change that can move our health care system toward personalized, safer, and more effective care. Suddenly, things like care planning, thorough communication and coordination of care, ongoing monitoring, meticulous medication management, prevention and early response to problems, and shared decision-making -- all of which are currently reimbursed poorly, if at all -- acquire substantial economic value. Higher quality and lower costs are aligned.

It's time to dampen the culture war rhetoric and acknowledge broad agreement on the basics of what constitutes optimal care. Working together, across cultural and political spectrums, we can ensure that people reliably receive care that responds to their individual needs and honors their personal preferences. We must accept no less. But we need not be constrained to clinical and ethical fundamentals. Americans are a caring people. If we have the will, whatever the Supreme Court decides and whoever is elected president in 2012, we have the wherewithal to enable people to feel wanted, worthy, and dignified through their final days.

Presented by

Ira Byock

Ira Byock is director of palliative care at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., and author of The Best Care Possible: A Physician’s Quest to Transform Care Through the End of Life.

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