A new law requiring New York physicians to discuss palliative care and end-of-life options with terminally ill patients is well intentioned, but may not do much to change clinical practice or institutional culture, according to some observers in the state.
The New York Palliative Care Information Act was signed into law by Gov. David Paterson (D) in August. Perhaps as a sign that palliative care is being embraced more readily and becoming better understood, it took just 14 months from the bill's introduction in the state Senate (S. 4498 and A. 7617) to its signing.
Even so, “whether or not it will change behavior is a bit of a black box,” said Dr. Bradley Flansbaum, director of hospitalist services at Lenox Hill Hospital in New York. “It's a nice thought, but I don't know how they're going to put it into effect.”
Under the law, physicians and nurse practitioners are required to provide a patient who has less than 6 months to live with information and counseling on palliative care and end-of-life options, including, “the range of options appropriate to the patient, the prognosis, risks and benefits of the various options, and the patient's legal rights to comprehensive pain and symptom management at the end of life.”
The physician or nurse practitioner can refer the patient to another provider who is willing to meet the legal statute or who is “professionally qualified” to offer the services.
There is no reimbursement offered for the required services.
Because it is an amendment to the state's public health law, violations of the new law could result in penalties or fines. It's not clear how it will be enforced or what might trigger the penalties; the health department has until the law's effective date (February 2011) to devise regulations, said David Leven, executive director of Compassion and Choices of New York.
That advocacy group helped devise the proposal and then shepherded it though the legislature, said Mr. Leven. California has a similar statute, but is not as strong because it does not put the onus on physicians, he said.
The organization sought the legislation because even with increased training on end-of-life issues, too few physicians are having conversations with their dying patients, Mr. Leven said. That means patients' wishes aren't being respected, to the detriment of both patients and the practice of medicine.
The organization also hoped that the law would be a catalyst to improving end-of-life education in medical school and at the professional level, he said.
Dr. Wendy Edwards, director of the palliative medicine program at Lenox Hill, said that education would be a key component, but there appeared to be no such formal requirements in the law. About 15 years ago, she was part of a group that attempted to get a bill passed to mandate the teaching of palliative care in medical schools, but it did not get anywhere.
She said she wasn't sure that the new law was the way to increase attention to palliative care, but that it had likely come about as a result of frustration and impatience on the part of palliative specialists.
The law will be positive, however, she said. Palliative care won't just be the standard of care, but will be the law, which gives some backing to hospitals that seek to implement and strengthen their quality of care, and end-of-life care in particular.
But it still will not make it easier for physicians who do not have experience in palliative care, Dr. Edwards said. “It's a very hard discussion to have; it's not something doctors are trained to do.”
A recent study in non–small cell lung cancer patients found that those who were given palliative care at the time of diagnosis had a better quality of life than did those in standard care (N. Engl. J. Med. 2010;363:733-42). This study may do more to advance the field than does the New York law, Dr. Edwards noted.
Although the Hospice and Palliative Care Association of New York State supported the law, the Medical Society of the State of New York did not. The medical society, which represents 25,000 physicians, opposed the law because of concerns that it would interfere with the way each and every doctor navigates through end-of-life situations with each individual patient, said Elizabeth C. Dears, the society's senior vice president for legislative and regulatory affairs.
Mandating that information be given on palliative care “may undermine the patient's belief and conviction in prevailing against their disease and undercut the confidence in their treating physician,” said Ms. Dears.