There are many unique features doctors need to consider when caring for geriatric patients--multiple chronic illnesses, increasing rates of cognitive impairment, the need to focus on maintaining function, and of course the undeniable proximity of death. This last feature modifies schedules for testing and the value of treatments to reduce long-term risks. Advanced age requires that treatments focus on advancing the values and choices of patients. This is of course true at any age, but conflicting guidelines and increasing side effects of treatments, as well as possibly reduced potential treatment benefits, make patient centeredness the essential organizational principle of health care late in life. Limited remaining life span makes having good conversations about desires and preferences for end-of-life care essential to getting people all the care they want and none of the care they don’t.
So I am very disappointed that within a mere week the “Voluntary Advanced Care Planning” component of the new Medicare Annual Wellness Visit came and went. On Tuesday, I lampooned what I saw as the “pseudo” controversy around this aspect of the new wellness visit while trying to highlight the potential value of the many other required components of the visit--such as depression and cognitive screening and planning for health promotion interventions. Never could I believe that by Wednesday the White House would actually overrule HHS and its new CMS administrator, Don Berwick, over a rerun of the death panel canard.
I don’t pretend to be a political insider, but I don’t see how this behavior will make anyone confident that the administration will stand by its commitments when the road gets rough. The abandoned policy was entirely defensible, and many advocates for care of older Americans would have been glad to say so. Doing such an abrupt about-face is bad policy and bad policymaking, and it does nothing to advance clear and open discussion of the care of older Americans.