By Randi Kahn. As many of you may have read, Evelyn Lauder, the senior corporate vice president of Estee Lauder Companies and daughter-in-law of founder Estee Lauder, a champion of breast cancer research, died of ovarian cancer at her home in Manhattan Saturday. Her death came on the same day I finally got around to watching “The Education of Dee Dee Ricks,” a documentary that follows the journey of a woman battling breast cancer while attempting to raise millions of dollars to help treat other breast cancer patients without resources, and also shares the story of a woman named Cynthia who was uninsured and ended up passing away in a hospital after her breast cancer, which was caught late, spread to her liver.

I have been unable to get these strong, Disruptive Women out of my mind, and could not help thinking about both Evelyn and Cynthia while listening to the National Journal’s “Living Well at the End of Life” event on Tuesday, wondering what their conversations about end of life care were like with their clinicians, and if there was a difference between them as a result of their insurance and financial statuses. Did Cynthia choose to live her final days in the hospital?  Did her medical situation necessitate it? Was she given proper information about her hospice and palliative options?

Although we’ll never know the answers to those questions, it is interesting to take a look at barriers that exist for clinicians in end of life care that are likely impacting potential disparities.

First, there are Medicare and Medicaid reimbursement issues. Although both programs currently provide some coverage for hospice and palliative care, there is not reimbursement for the tough conversations doctors should have with their patients about their care options at the end of life. Former Obama advisor on health reform and now chair of the National Institute for Health’s Department on Bioethics, Ezekiel Emanuel, MD, PhD, said at the National Journal event, that those consultations can take anywhere from a few minutes to several hours and that without reimbursement for them, some clinicians don’t take the time to conduct them. His statements align with a survey of 500 board certified physicians conducted by the National Journal and the Regence Foundation where 82 percent of respondents identified inadequate reimbursement from Medicare, Medicaid and private insurers for end of life consultations as a significant barrier for palliative care.

There is also the issue that some clinicians put off the conversations because they do not know enough about end of life care options, or about how to talk to a patient about the decisions that need to be made as they near death’s door. The poll data found 73 percent of physicians 39 or younger reported “a great deal or some exposure to palliative care during medical school” compared to 36 percent of those 40-49, 23 percent of those 50-59, and only 6 percent of those age 60 or older, highlighting the need for continuing medical education courses on palliative care, hospice care, and the development of an advanced care directive. The poll didn’t inquire about communications training that, according to Dr. Emanuel, would help clinicians overcome their own psychological barriers to having these discussions and enable them to better address the patient’s psychological needs to make the conversations more effective.

With entitlement reform almost inevitable, and much of continued medical education focused more on health care reform related topics like coordinating care and utilizing health IT, what will the end of life look like for women like Cynthia and Evelyn in the future?

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