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Commentary: underwriting choice at the end of life.

This case, with its focus on end-of-life care, provides an opportunity to discuss an insurance company’s responsibility in defining what constitutes compassionate and ethical care when cure is no longer possible. A distant insurance company, which views a patient as a consumer, is not in a position to define the clinical decisions made for a patient as he dies. This needs to be left to the clinicians at the bedside, who are familiar with the facts of the case and who weigh care options with the patient and family. It should be the responsibility of insurance companies to validate this plan of care, rather than impose arbitrary limitations from a distant perch. When third-party payors inappropriately deny hospice care, they undermine the therapeutic doctor–patient relationship so essential to endof-life care. Once established, this relationship allows the patient to trust and be cared for by his physician. In the present case, the doctor– patient relationship was threatened with loss of insurance company support. His vulnerability could have led him to equate loss of payment by his insurance company with loss of trust in his hospice physician. And when a terminally ill patient can no longer trust his physician to remain engaged, he becomes hopeless. Arbitrary discontinuation of hospice services after 210 days of active attention to psychosocial, spiritual, and physical needs also threatens the physician’s fiduciary obligation to the patient and the principle of nonabandonment. 1 To subject a man with a terminal condition, who already fears pain, isolation, and abandonment, with withdrawal of care and financial devastation is unethical and cruel. It is punishment for dying too slowly. Rather than terminate payment entirely, the more responsible action could have been to negotiate with the hospice for a payment schedule consistent with services provided. To maintain the integrity of end-of-life care and ensure patient trust in the systems of care upon which they rely, clinicians and reimbursement systems need to agree on what interventions have value and should be sustained. 2 This case revealed a striking lack of agreement over the primacy of the patient’s self-determination and prerogative to accept or reject any form of medical therapy offered and felt to be clinically appropriate. A referral and acceptance to a hospice program is an affirmation of the principle of self-determination. But selection of care options based on reimbursement undermines patient autonomy, free choice, and voluntariness. Reimbursement will direct patients toward choices that are reimbursed, and discourage use of those that are not. As presently constituted, reimbursement strategies lead to choices that delegitimize patient preferences for palliative care. For example, if the patient had accepted one more course or one more vial of chemotherapy, mislabeled as “hope,” his insurance company would have paid for it. If he had chosen to die in an intensive care unit connected to a ventilator, where the moment of his death was played out with the chest compressions of cardiopulmonary resuscitation and the delivery of 400 joules of electricity to his cancer-ridden body, his insurance company would have paid that bill. And they would have done so without even asking the question: “What is the quality of the life that you’ve worked so hard to save?” Current reimbursement strategies reflect broader cultural attitudes that favor efforts for cure and the prolongation of life, even when these goals are elusive. Patients and families who have the courage to forego all that technology seems to offer and opt for hospice should not have their preferences undermined by illogical and capricious reimbursement schemes. Insurers must be held accountable for the cogency and fairness of their benefit packages throughout the life cycle. Payors that accept their obligation to provide an opportunity for cure and prolongation of life should be similarly challenged to support the comfort and choices of dying patients when achieving these goals is no longer possible.