Correspondence
Health Insurance and Palliative Care
N Engl J Med 1998; 338:767March 12, 1998
- Article
To the Editor:
I recently admitted two patients to the hospital for palliative care. Reimbursement was rejected by the insurance company for the care of one patient and is under review for the second patient. The outcome was unexpected in that both patients survived, and since I did not “do anything,” acute hospitalization was deemed unwarranted.
Both patients were admitted with the expectation that death was imminent. One was 90 years old, with severe dementia, a systolic blood pressure of 60 mm Hg, and a temperature of 88°F. The second patient was in cardiogenic shock with a systolic blood pressure of 70 mm Hg and a heart rate of 40. Both patients had previously established wishes that when death was imminent, only comfort care be administered. In both cases, family members or caretakers had expressed concern about the potential for the patients to have an uncomfortable death and wished measures be taken to prevent that from occurring. Both patients were admitted with orders for comfort care as needed (e.g., morphine for dyspnea), and both spontaneously recovered.
Health insurance would have covered the costs of care for either of these patients had I prescribed life-sustaining measures. It would have paid had I prescribed a morphine drip, which was not indicated and would have effectively constituted euthanasia. What insurance did not pay for was a good-faith assessment that death was imminent, the concern of the patients' caretakers about the potential for substantial suffering, and a plan for immediate intervention should suffering occur.
The situation is akin to one in which a high-risk patient presents to the emergency department with chest pain, only to have the evaluation reveal esophageal reflux. Insurers used to reject these claims — and sometimes still do — because the patient presented with “only indigestion.” Perhaps it is time for the “prudent layperson” standard to be applied to palliative care.
Andrew M. Knoll, M.D.
Syracuse, NY 13207- Citing Articles (2)
Citing Articles
