pay doctors who advise patients on options for end-of-life care, which may include advance directives to forgo aggressive life-sustaining treatment. Congressional supporters of the new policy, though pleased, have kept quiet. They fear provoking another furor like the one in 2009 when Republicans seized on the thought of end-of-life counseling to reason that the Democrats` bill would provide the government to cut off care for the critically ill. The last edition of the health care legislation, signed into law by President Obama in March, authorized Medicare coverage of yearly physical examinations, or wellness visits. The new rule says Medicare will cover "voluntary advance care planning," to discuss end-of-life treatment, as division of the annual visit. Under the rule, doctors can offer data to patients on how to make an "advance directive," stating how sharply they want to be treated if they are so disturbed that they cannot make health care decisions for themselves. While the new law does not mention advance care planning, the Obama administration has been capable to reach its policy goal through the regulation-writing process, a strategy that could get more rife in the following two days as the president deals with a strengthened Republican opponent in Congress. In this case, the government said research had shown the rate of end-of-life planning. "Advance care planning improves end-of-life care and patient and family satisfaction and reduces stress, anxiety and low in surviving relatives," the government said in the preamble to the Medicare regulation, quoting research published this class in the British Medical Journal. The government also cited research by Dr. Stacy M. Fischer, an adjunct professor at the University of Colorado School of Medicine, who found that "end-of-life discussions between physician and patient help assure that one gets the care one wants." In this sense, Dr. Fischer said, such consultations "protect patient autonomy." Opponents said the Obama administration was bringing back a process that could be used to justify the premature withdrawal of life-sustaining treatment from people with serious illnesses and disabilities. Section 1233 of the measure passed by the House in November 2009 - but not included in the final legislation - allowed Medicare to pay for consultations about advance care planning every 5 years. In contrast, the new rule allows annual discussions as division of the wellness visit. Elizabeth D. Wickham, executive director of LifeTree, which describes itself as "a pro-life Christian educational ministry," said she was concerned that end-of-life counseling would encourage patients to forego or curtail care, thus hastening death. "The infamous Section 1233 is even alert and kicking," Ms. Wickham said. "Patients will miss the power to control treatments at the end of life." Several Democratic members of Congress, led by Representative Earl Blumenauer of Oregon and Senator John D. Rockefeller IV of West Virginia, had urged the administration to cover end-of-life planning as a service offered under the Medicare wellness benefit. A national system of hospice care providers made the like recommendation. Mr. Blumenauer, the source of the original end-of-life proposal, praised the convention as "a footstep in the correct direction." "It will make people more mastery over the fear they receive," Mr. Blumenauer said in an interview. "It means that doctors and patients can cause these conversations in the normal form of business, as function of our health care routine, not as something put off until we are constrained to do it." After learning of the administration`s decision, Mr. Blumenauer`s office celebrated "a quiet victory," but urged supporters not to brag about it. "While we are very happy with the result, we won`t be shouting it from the rooftops because we aren`t out of the wood yet," Mr. Blumenauer`s office said in an e-mail in early November to people working with him on the issue. "This regulation could be limited or reversed, especially if Republican leaders try to use this small provision to perpetuate the `last panel` myth." Moreover, the e-mail said: "We would ask that you not broadcast this accomplishment out to any of your lists, even if they are `supporters` - e-mails can too easily be forwarded." The e-mail continued: "Thus far, it seems that no contract or blogs have observed it, but we will be holding a faithful watch and may be calling on you if we demand a rapid, targeted response. The longer this goes unnoticed, the better our chances of holding it." In the interview, Mr. Blumenauer said, "Lies can go viral if people use them for political purposes." The proposition for Medicare coverage of advance care planning was omitted from the final health care bill because of the brouhaha over unsubstantiated claims that it would encourage euthanasia. Sarah Palin, the 2008 Republican vice-presidential candidate, and Congressman John A. Boehner of Ohio, the House Republican leader, led the criticism in the summer of 2009. Ms. Palin said "Obama`s death panel" would decide who was worthy of health care. Mr. Boehner, who is in contrast to become speaker, said, "This preparation may part us down a treacherous path toward government-encouraged euthanasia." Forced onto the defensive, Mr. Obama said that zero in the charge would "force the cud on grandma." A recent poll by the Kaiser Family Foundation suggests that the mind of death panels persists. In the September poll, 30 percent of Americans 65 and old said the new health care law allowed a government panel to take decisions about end-of-life like for mass on Medicare. The law has no such provision. The new policy is included in a huge Medicare regulation setting payment rates for thousands of services including arthroscopy, mastectomy and X-rays. The formula was issued by Dr. Donald M. Berwick, administrator of the Centers for Medicare and Medicaid Services and a longtime advocate for better end-of-life care. "Using unwanted procedures in terminal illness is a form of assault," Dr. Berwick has said. "In economic terms, it is waste. Several techniques, including advance directives and interest of patients and families in decision-making, have been shown to reduce inappropriate care at the end of life, leading to both lower price and more humane care." Ellen B. Griffith, a spokeswoman for the Medicare agency, said, "The final health care reform law has no preparation for voluntary advance care planning." But Ms. Griffith added, under the new rule, such provision "may be included as an ingredient in both the 1st and subsequent annual wellness visits, providing an opportunity to periodically review and update the beneficiary`s wishes and preferences for his or her medical care." Mr. Blumenauer and Mr. Rockefeller said that advance directives would help doctors and nurses provide aid in keeping with patients` wishes. "Early advance care planning is crucial because a person`s ability to make decisions may fall over time, and he or she may suddenly lose the capacity to enter in wellness care decisions," the lawmakers said in a missive to Dr. Berwick in August. In a recent study of 3,700 people about the end of life, Dr. Maria J. Silveira of the University of Chicago found that many had "treatable, life-threatening conditions" but lacked decision-making capacity in their last days. With the new Medicare coverage, doctors can take a patient`s wishes before a crisis occurs. For example, Dr. Silveira said, she might ask a someone with heart disease, "If you take another heart attack and your heart stops beating, would you wish us to try to resume it?" A patient dying of emphysema might be asked, "Do you need to go on a breathing machine for the relief of your spirit?" And, she said, a patient with incurable cancer might be asked, "When the sentence comes, do you wish us to use technology to try and delay your death?"
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