Since the Patient Right to Autonomy Act (病人自主權利法) took effect in 2019, the uptake rate for advance directives, also known as “advance decisions,” has fallen short of expectations, lower than 1 percent. That is mainly because the advance care planning (ACP) consultation costs about NT$2,000 to NT$3,500, which reduces people’s willingness to make living wills.
Although the Ministry of Health and Welfare’s Department of Health Affairs oversees the act, the ministry’s cash-strapped National Health Insurance (NHI) Administration is responsible for funding affairs related to it, and the administration has few dollars to promote ACP. The ministry should set up a separate budget for ACP promotion, to create more room for its development. It should not rely on the NHI for everything.
The NHI was expanded to cover ACP fees for people aged 65 or older with severe injuries or illnesses or multiple chronic diseases, who are now exempt from paying for the consultation fee, a change that it is estimated to benefit 1.8 million people. By doing so, the ministry is aiming to increase the number of living will signatories by 20,000 to reach its 40,000 goal this year. Still, a gap remains between that and the ministry’s original goal of covering the fees for everyone by next year.
The ACP differs from do not resuscitate (DNR) documents in that the latter does not require a consultation from a professional medical team, which makes the promotion of DNRs simpler and easier. Signing an advance decision needs to go through ACP conducted by a professional medical team, which naturally incurs costs, with people needing to pay NT$2,000 to NT$3,500 out of their own pockets for ACP first to sign an advance decision. That is why the signing rate is low.
To promote advance decision signing, the NHI Administration is now covering the ACP fees for those with mild dementia, and those older than 65 with major injuries or illnesses, who are not only hospice patients, but also included in the home-based medical integration program.
However, the number of people in that category is quite low. Even though the administration has expanded the scope of coverage to two more groups starting last month, the advance decision signing rate is unlikely to rise to a significant degree.
To promote advance decision signing, it is not enough to rely solely on NHI coverage. If the ministry is truly determined to boost the signing rate, it should make available additional funds to expand coverage, encouraging people to take an ACP and sign an advance decision.
In addition to budgetary funding, due to a labor shortage for the ACP consultation at some hospitals, people who make an appointment for the service might need to wait one to three months. Faced with staffing problems, the ministry should also come up with some incentives. Only with sufficient budget and staff for ACP can the government revitalize the advance decision signing rate.
Tsai Ming-chung is director of Fengan Polyclinic.
Translated by Eddy Chang
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