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December 7/21, 1998

Managed Care and End-of-Life Decisions: Learning to Live Ungagged

Arch Intern Med. 1998;158(22):2424-2428. doi:10.1001/archinte.158.22.2424

WE DISCUSS a case involving end-of-life decisions in a tertiary care facility to illustrate some typical problems involving the disclosure to patients and their families of limitations in their insurance coverage. Hospitals often rely on physician disclosure of medical information to the patient but create mechanisms that monitor the care that are hidden from the patient. Furthermore, the information collected from this monitoring may not be included in the medical record. Such mechanisms may complicate communication because only some parties in the decision-making process have access to the information produced. It is clear that these mechanisms should be amended. We argue for an ethical framework for dealing with this kind of information that has 3 major tenets: (1) all financial information should be routinely disclosed and continually updated during the course of a hospitalization, (2) disclosure of financial information should not be solely or even primarily the responsibility of the attending physician but should include specialized personnel such as case managers, and (3) financial information that affects decision making should be a part of the medical record and available to all members of the health care team.