Question: My mother, 84, has been a widow for 20 years. She still lives in the home in which she raised us, has limited savings, receives Social Security, and has a Medicaid card that helps with some of her prescriptions. That’s it. She has steadfastly refused to sign a power of attorney (because she did not want to lose control over her limited finances) or a living will (for fear she would not be given appropriate treatment because she was elderly and not productive to society).

But recognizing the importance of her putting her wishes in writing, my brother and I tried to talk to her over the past several years until we were blue in the face. We took her to several lawyers, and even met with her and her physicians. Finally, last year, she agreed to sign both a power of attorney for finances and a living will, and our entire family was relieved. Then, last week, she announced that she had torn up her documents because she had heard that, in order to cut costs, the government was going to deny Medicare and Medicaid recipients needed treatment when they were the sickest.

Although my brother and I have been unable to verify what she now believes, there is no talking to her. Are there efforts to use living wills to cut health care costs for senior citizens?

Answer: Unfortunately, “slips of the tongues” – for lack of a better description -- of a number of legislators and bureaucrats at both the state and federal levels have caused concerns by the elderly and their advocates.

By way of background, before 1990, Congress was aware that a high percentage of all health care expenses were incurred during the last year of life, most within the last two months. Of the estimated 35.6 million people receiving Medicare before 1990, nearly six percent died each year and, of those, more than 50 percent died in hospitals at a cost of more than 30 percent of annual Medicare payments.

At about the same time, according to a study published in the Archives of Internal Medicine, the end-of-life costs for patients without advance directives were approximately three times those of patients who had prepared these documents. And the American Medical Association estimated that although more than 70 percent of Americans will face at least one end-of-life decision during their lifetimes, less than 15 percent of our population had signed advance health care directives such as living wills.

Given this background, Congress passed the Patient Self Determination Act in 1990 to try to bring awareness to the American public about advance health care directives such as living wills – and, of course, for cost containment should folks decide not to pursue extraordinary measures at end of life. The Patient Self Determination Act is the reason hospitals and other health care providers that accept Medicare and Medicaid are required to ask patients, on admission, whether they have advance health directives.

With budget cuts at the forefront of the governmental mindset today, there are moves afoot to reduce the cost of Medicaid and Medicare. In Wisconsin, a legislative committee is considering a requirement that all Wisconsin Medicaid recipients sign and file with the state either a living will or health care power of attorney as a cost-cutting device. The reason, according to one Wisconsin legislator, is that approximately 75 percent of the cost of health care in a person's life is spent during their last two months of life. If signed into law, each Medicaid recipient would be forced to either sign an advance directive or lose eligibility and, presumably, the state would use the choices made in these documents to gauge their Medicaid budgeting process. Under federal law, patients are not required to either sign directives or file them with the government.

And, at the federal level, in early May of this year, the Secretary of the Department of Health and Human Services encouraged seniors to sign living wills as a way in which to help reduce Medicare’s mushrooming health care costs. According to governmental statistics, one-third of the nearly $300 billion Medicare budget is used to provide care during the final year of life. The Secretary also stated that he was considering a suggestion from a congressman that would require physicians to educate and promote directives for end-of-life treatment, in part to save a large amount of Medicare money.

Taking the NextStep: While we are staunch advocates of self-determination after education, we don’t believe that seniors or anyone else should be forced to make decisions to satisfy budget-cutting legislators and bureaucrats when there is plenty of other waste out there that could be cut without scaring the dickens out of seniors. We don’t believe your mother tearing up her documents solves the problem, but we certainly understand her concerns.