Dr. Levine is a nationally recognized expert in wound care and pressure ulceration. and has published and spoken widely on this topic. He is a Board Member of the National Pressure Ulcer Advisory Panel (NPUAP). Dr. Levine's Pocket Guide to Pressure Ulcers co-authored by Elizabeth Ayello RN and published by the New Jersey Hospital Association is in its 4th printing and has sold over 30,000 copies.

In a recent blog post I pointed out some legislative initiatives that essentially make certain principles of geriatric practice required by law.  I noted how these laws can be interpreted as an effort to make up for the scarcity of practicing geriatricians, and the lack of geriatrics training for most physicians in America.   President Obama has continued this trend by signing a new Medicare regulation which provides reimbursement to physicians who advise patients on options for end-of-life care, effective January 1st.  End-of-life decision making may include advance directives such as living wills and health care proxies, palliative care or hospice programs, and choices about life sustaining technologies such as ventilators, feeding tubes, defibrillation, and others. 

In America, our healthcare system is sometimes in denial about the processes of aging and death. An unfortunate byproduct is lack of education regarding reasonable options for end-of-life decision making.  The result is application of aggressive and advanced technology to prolong life, often in the setting of a hopeless prognosis.  This can result in needless suffering and monetary expense, and death without dignity or consideration of the patient’s preferences.  A basic principal of geriatrics is to discuss advance directives and counsel patients on reasonable end-of-life choices, with the goal of dignity, autonomy, and curtailment of unnecessary suffering. 

Geriatrics is a subject that does not have substantial emphasis during the medical undergraduate curriculum, despite the fact that the over 85 age group is the most rapidly growing sector of American society.  In the face of a growing elderly population there are diminishing numbers of graduating physicians entering the field of geriatrics.  The processes of aging are often not recognized in clinical practice, and end-of-life choices are frequently not addressed by physicians.  The results can translate into needless surgical procedures, ICU and hospital stays, and inter-institutional transfers that increase the chances of medically induced illness. 

Section 1233 was the component of the Health Care Reform legislation that allowed reimbursement for end-of-life counseling.  This issue became politically charged with some conservatives mischaracterizing the legislation as “death panels,” and claiming that it encouraged euthanasia.   As a result Section 1233 was dropped from the Health Care Reform bill.  Provisions of this deleted clause were essentially resurrected and incorporated into a service covered under the Medicare wellness benefit, allowing doctors to discuss end-of-life options as part of the regular yearly visit.  This was signed by President Obama and goes into effect January 1, 2011. 

With the medical establishment often removed from implementing principles of geriatric care, the government has turned to legislation to make up the practice gap.  The results include financial incentives to promote reasonable care, financial penalties for poor care (see my post on pressure ulcers in hospitals), and complex laws that govern medical assessments of nursing home patients.  Given the limited progress that geriatrics has made in penetrating the mainstream of healthcare, legislative incentives to enforce reasonable practices for care of the elderly will continue as our population ages.  The challenge remains to educate physicians about the nature of advance directives and reasonable choices for care at the end of life.  Physicians may also need training on how to provide this counseling – something which is often uncomfortable for families and patients as well as caregivers. 

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Read the New York Times article on this topic.

Similar posts:

Geriatrics by Legislation: The Trend of the Future?

Retooling for an Aging America: The Thud that Should Have Been a Bang.





  • Penny Mulder
    12/30/2010, 10:05 pm  Reply

    I can believe that these circumstances still exist. I have been in these very difficult positions. With family consultations, education and support, sometimes these things just happen… I too have been a RN in Hospice. I always thought, so presumptuously that I could teach people to find the “right ” choices. These right choices meant something that the families could live with, but sometimes, even the best of time and education cannot change these things. I have suffered the consequences of such decisions, for the people I have cared for. We do it despite the believes of some. These decisions are painful to watch knowing what the patient may have “wanted”.

    It has nothing to do with us. It still is left to be a decision of bereaved families at the most difficult time of their lives, which leaves emotion to make decisions. This is why these conversations must take place at the doctor’s office so all people know about it. Empower the people and the loving staff that care for them.

  • karin Pantel RN MSN CNE
    12/29/2010, 9:55 pm  Reply

    I am not in full agreement with the Health Reform Policy set forth by President Obama, but I certainly support the intention of Section 1233.
    Nursing professionals were instrumental in lobbying support for advanced directives decades ago and anticipated their achieved implementation as a means to restore dignity and the right to choice to all of our adult patients, young and old when contemplating end-of-life decisions.

    I was a practicing RN for 35 years prior to transitioning to academia 7 years ago. Advance directives and the inception of Hospice programs appeared to act in a significant way in establishing acceptance of the patient’s right to choice in end-of-life issues. In my role as a clinical instructor this semester I have witnessed total abuse and non-adherence of the patients’ decisions at end-of-life. Despite a signed health care proxy and the presence of the proxy, a daughter, the second daughter insisted on ignoring the proxy and her Dad’s transfer to pre-arranged Hospice care at home. The physician accommodated the second daughter. A travesty indeed, and a heart wrenching experience for my students, as they cared for the patient,who was essentially alone, unable to verbalize, with sores deteriorating more greatly each day, until finally weak and with fever he passed away, alone.

    I don’t know whether to view the conservative view of the legislation as ignorant or simply politically self-serving and stupid. We heed the findings of the IOM and the initiatives of Healthy People 2020, but in essence we ignore the power of education, in this instance end-of-life counseling serves much as Informed Consent does, allowing all elements of the issue to be explored, discussed, and finally decided upon by the patient, with experts facilitating the discussion. Discussion can also include family or significant others. Teach a man to fish…
    By law, prior to HIV testing, a teaching/counseling session MUST occur to ensure participant cognition. Are end-of-life issues any less critical?

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Dr. Jeffrey M. Levine has authored numerous articles on topics related to healthcare of the elderly. These include medical history, prevention and treatment of chronic wounds such as pressure ulcers, elder neglect and abuse, and physical restraints. He has also edited a book on legal and regulatory aspects of nursing homes.