Advance care planning must safeguard patients

An Obama administration proposal to pay doctors for “advance care planning” for Medicare patients is fraught with dangers for the elderly and those facing serious illnesses, and Congress needs to act quickly to protect those patients from making uniformed decisions about their care, the National Right to Life Committee (NRLC) said July 9 at its annual convention in New Orleans.

Burke Balch, director of the NRLC’s Powell Center for Medical Ethics, said an Obama administration proposal to institute “advance care planning” is designed to “nudge” patients to forego life-saving treatment and even assisted feeding by giving them “unbalanced, distorted and even inaccurate information” about their condition and the effectiveness of treatment options.

A cost-benefit analysis
Citing a 2013 Health Affairs article entitled “Decision Aids: When ‘Nudging’ Patients to Make a Particular Choice is More Ethical Than Balanced, Nondirective Content,” Balch said advance care planning is touted as a means of drastically cutting health care costs.

Balch said the NRLC favors advance medical directives – it has developed its own “Will to Live” document – and supports alternatives that “provide truly informed consent to decisions about medical treatment.”

The 2013 Health Affairs article offered advice on how doctors could persuade men with prostate cancer to agree not to undergo expensive surgery.

“If incontinence and impotence are presented as plainly stated – that is, with no detailed description of these risks – men with early-stage prostate cancer may be swayed toward the option of surgery,” the article said. “If instead those possible side effects of surgery are presented vividly via personal stories, men may be swayed away from the surgery option.”

The Powell Center report – available at – cited other widely available advance care planning materials that violate the principle of informed consent by presenting unbalanced facts so that patients might be convinced to forego cardio-pulmonary resuscitation (CPR), IV fluids and medically assisted feeding. Other materials paint disabilities and illnesses in such “an inaccurately repugnant way” they may convince people that a low “quality of life” is not worth living, Balch said.

Balch said Aetna hired the “Center to Advance Palliative Care” in preparing its advance care planning program. The center reported that its program had resulted in a $12,000 average annual reduction in medical benefits.

Balch said using taxpayer money for Medicare advance care planning was so controversial in the original House bill for Obamacare that the proposal eventually was dropped. But on July 9, the Obama administration opened a “notice and comment” period in order to re-establish the proposal.

“We are concerned about the rationing of health care through government action,” Balch said. “We support advance directives. We believe patients ought to have the right to make decisions about what medical care they receive. Our ‘Will to Live’ starts with a presumption for treatment, although an individual can indicate specific treatments that he doesn’t want. Tragically, however, there is considerable evidence that in practice, advance care planning is being used deliberately to nudge patients toward accepting a denial of life-saving treatment.”

Balch said many private insurance companies have hired organizations to “cold call” beneficiaries “in order to talk them into rejecting treatment,” and they usually “report how much money they are saving per beneficiary.”

“In this context, we greatly fear that this advance care planning will not be balanced,” Balch said. “Despite giving lip service to balance, it will be used deliberately to try to reduce health care spending. We are calling on Congress to block this rule.”

Peter Finney Jr. can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it. .

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