New Final Rule: Conversations with Patients Matter

November 13, 2015

Last month, the Center for Medicare and Medicaid (CMS) issued a final rule updating payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule.

It included a separate payment and a payment rate for clinicians to conduct advance care planning conversations with patients who are seriously ill.  In other words, Medicare will now pay doctors to talk with patients about end-of-life care planning.

Now, it’s not clear as to where these conversations with patients need to take place, but we can assume that they will happen either in a physician’s office or in the hospital. Still, the “where” is not defined in a way that facilitates a meaningful dialogue about very difficult issues.

Most hospitals have private consultation rooms with a table and maybe a couple of chairs. But is this really place for intimate conversations about life and death?

Place Matters

How can we create spaces that facilitate candid, personal, and challenging conversations? That help patients, families, and physicians authentically share their greatest fears and deepest desires regarding death and dying?

We know what won’t help: noise and interruptions caused by talk television, other people’s laughter and banter, cell phones, and pagers. This is the short list.

What might help: A comfortable, home-like environment that puts each person in the conversation in place where they are able to participate, or at least hear one another. This place should have:

• Appropriate background music to fill the all-too-quiet environment and reduce the stress that comes with silence
• Nature elements, through artwork, video, or other visual representation
• Lighting that makes it possible to see each person without strain and not so bright as to create glare
• Windows to the outdoors with shades that can cut bright sunlight if necessary
• A round table with comfortable seating that establishes that everyone has a stake in what happens.

What matters is the physicality of those who are in this discussion. That they can be with each other and the clinician. If at all possible, this should not be a clinical setting where the patient plays second to the physician.

The C.A.R.E. Channel is often used as a back drop for these kind of intimate conversations. It creates an environment of intention and respect. And, because the music is instrumental and non-commercial, those in the room will not be distracted by it.

Designing the environment for conversations about end-of-life decisions is just as important as having the actual discussion. It will help patients and families better comprehend and retain what the physician is saying. And, help them make the best decision.

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