Death Care Reform
Wednesday, August 12, 2009 at 11:33PM Section 1233 of the House-drafted legislation encourages health care providers to provide their Medicare patients with counseling on . . . end of life treatments, and may place seniors in situations where they feel pressured to sign end of life directives they would not otherwise sign . . . .
[T]his provision could create a slippery slope for a more permissive environment for euthanasia, mercy-killing and physician-assisted suicide because it does not clearly exclude counseling about the supposed benefits of killing oneself.
— House Republican Leader John Boehner (R-OH) and Republican Policy Committee Chairman Thaddeus McCotter (R-MI), July 23, 2009
The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama’s “death panel” so his bureaucrats can decide, based on a subjective judgment of their “level of productivity in society,” whether they are worthy of health care.
— Sarah Palin, August 7, 2009
America has been in desperate need of a serious health care debate for years. Which is why it is so disappointing to see an honest and productive public debate polluted by blatant lies, as told to us by politicians who are supposed to be informed.
As many have observed elsewhere, the myth of euthanasia and death squads stems from a single provision attached to one of the reform bills allowing doctors to bill for the time they spend counseling patients about end-of-life care. There are no provisions for death squads. In fact, as a doctor who has discussed end-of-life issues with his patients many times, I resent the implication that by talking with patients about death I am taking my place next to Dr. Kevorkian.
We cannot enact health care reform without dealing with end-of-life issues. Death is the inevitable outcome of a lifetime of medical care, an outcome that will occur no matter how good the doctors and nurses are. The best doctors eventually lose 100% of their patients, just as the worst ones do. The difference is how the end comes about.
Counseling is the cornerstone of end-of-life care. Since death is inevitable, at some point most patients and their families will have to address matters such as life support, ventilator care, and extraordinary medical treatments. The proposed provision would allow doctors to allocate time apart from a regular visit to sit and talk about fears patients and families have about the dying process, rather than having to cram the discussion in between medical complaints at an annual office visit, or worse, having to bring it up at for the first time at the bedside of a dying patient. I can hardly think of a more humane and important use of a doctor’s time.
In my work, I welcome the opportunity to give advice. Unfortunately, many patients don’t want advice — they want drugs, diagnostic tests, or a referral. They want something from me, something that often only requires my signature. And either they don’t care what I think, or they have so many concerns that I end up as an expedient ordering a drug or a test for each symptom and sending them on their way.
This is not what I spent 8 years of medical training for. All that knowledge is there to be shared, and I should be paid to share it. But I am not paid to share information; I am paid to sign things. This is the end-result of a system that rewards providers for seeing patients in large volumes and devalues old fashioned talking and listening.
What’s wrong with a Medicare provision that lets me sit down with a patient for half an hour and explain to her what CPR is, and when it is beneficial; what a ventilator is and why she might want to be on one or not; what is meant by “life support” and when life support makes sense and when it doesn't?
The most important decision a doctor makes is when to treat and when not to treat. There are times when doing something is much worse than doing nothing at all. Patients need to understand that sometimes doing nothing is the best treatment. That is what end-of-life counseling is all about.
Such explanations take time, and a great deal of experience and skill. It is one of the most challenging tasks in my work, and one every doctor ought to be paid for. When a patient knows his insurance will cover end-of-life counseling, he is more likely to feel comfortable asking his doctor to explain the dying process. Patients deserve that service, and it should be a standard part of every health plan.
Some time ago, I treated a middle aged man I’ll call George who destroyed his liver with chronic drinking. He had bleeding ulcers and esophageal varices, a condition in which a diseased liver produces massive bulging veins in the lower esophagus that are prone to catastrophic bleeding. George bled so rapidly that it took more than two dozen units of blood over the course of a week just to keep him semi-conscious. When he was awake, which wasn’t often, he asked nurses and doctors to please take all the tubes out. I wanted to, but he was too confused for me to trust his mental state.
His out-of-town family said travel was “too expensive” for them to come visit him in the hospital. After he spent a couple of weeks in intensive care on just about every medication we could pour into him, his relatives finally showed up. We carefully discussed withdrawing care. Nothing we were doing was going to save him, I observed, and we seemed to be merely prolonging his suffering. I pointed out that he expressed the desire to be taken off the ventilator, that his condition was hopeless and his liver was completely shot, and that he was not a candidate for the only procedure that had any chance of helping him — a liver transplant. I told them he might be more comfortable and die more peacefully at home, surrounded by loved ones.
After listening to my explanation, his sister said to me, “I’ll have to talk it over with my family.” Which she did, I guess. The next day she sent word that the answer was no. They wanted everything done.
Eventually we got him off the vent and moved him to a regular room. He lay there in a state of delirium for a few days, all alone, and died. I felt horribly sad for this man, and harbored mixed feelings of frustration with and pity for his relatives, who were so overwhelmed by the urgency of the situation that they were afraid to make the decision to let him die peacefully at home. Instead, they left him to die a lonely, antiseptic end.
We have to do better than this. If George had left a living will or consulted with a doctor prior to his fatal event, all this misery might have been avoided. Such conversations are not about euthanasia. They are about preparing for the inevitable. Talking to patients about end-of-life issues will no more lead to euthanasia than planning fire drills will lead to arson.
This kind of counseling is necessary. Not only should it be encouraged, it should be considered a normal a part of medical care, like mammograms and serum cholesterol checks. The people who argue otherwise don’t care about alleviating human suffering. They want to scare people into turning against health care reform.
People like Boehner, McCotter, and Palin are responsible for the fear that leads to deaths like George’s. They too will die one day, and if they succeed in their aims, their reward will be the horrors of the health care system they wrought.
I wish I could call it justice, but I can’t bring myself to wish that kind of suffering on anyone.
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Reader Comments (5)
Also, since you say you believe in intellectual honesty, especially from politicians, can you tell me that the President has been honest in his assessment of the reasons for performing, and the reimbursement costs of surgical procedures. He certainly has impugned the honesty of doctors on two separate occasions so far.
This is the response from the American College of Surgeons -
CHICAGO—The American College of Surgeons is deeply disturbed over the uninformed public comments President Obama continues to make about the high-quality care provided by surgeons in the United States. When the President makes statements that are incorrect or not based in fact, we think he does a disservice to the American people at a time when they want clear, understandable facts about health care reform. We want to set the record straight.
Yesterday during a town hall meeting, President Obama got his facts completely wrong. He stated that a surgeon gets paid $50,000 for a leg amputation when, in fact, Medicare pays a surgeon between $740 and $1,140 for a leg amputation. This payment also includes the evaluation of the patient on the day of the operation plus patient follow-up care that is provided for 90 days after the operation. Private insurers pay some variation of the Medicare reimbursement for this service.
Three weeks ago, the President suggested that a surgeon’s decision to remove a child’s tonsils is based on the desire to make a lot of money. That remark was ill-informed and dangerous, and we were dismayed by this characterization of the work surgeons do. Surgeons make decisions about recommending operations based on what’s right for the patient.
We agree with the President that the best thing for patients with diabetes is to manage the disease proactively to avoid the bad consequences that can occur, including blindness, stroke, and amputation. But as is the case for a person who has been treated for cancer and still needs to have a tumor removed, or a person who is in a terrible car crash and needs access to a trauma surgeon, there are times when even a perfectly managed diabetic patient needs a surgeon. The President’s remarks are truly alarming and run the risk of damaging the all-important trust between surgeons and their patients.
We assume that the President made these mistakes unintentionally, but we would urge him to have his facts correct before making another inflammatory and incorrect statement about surgeons and surgical care.
Actually the ACS got part of it wrong. Barack Obama didn't accuse surgeons of taking out tonsils for greedy profit. He impugned people like you --- Pediatricians, who clearly don't take out tonsils. This just shows how little this man really knows about medicine...and he is supposed to be telling us how to improve healthcare??? Please, this is the biggest joke of all.
Well, Medicare is an insurance plan, You can't bill Medicare unless you have a Medicare provider number. You have to be a doctor, or at least some kind of health care professional (nurse practitioner, psychologist, physical therapist),to bill Medicare.
There is a lot of mythology circulating about this particular provision. It was written by a Republican, and if it authorized non-medical personnel to discuss medical decisions with patients this would be a historic change in health care delivery in this country. None of us really know what is in the bill, because it is subject to daily changes, but I have seen nothing to suggest the provision will involve payouts to people who don't have Medicare provider numbers. As long is that remains the fact, there is no risk that bureaucrats will ever do end of life counseling.
Anyway, all Medicare payments are subject to a 20% copay. What patient would be stupid enough to pay a government bureaucrat who is not a doctor out if his own pocket to be counseled about ways to die? I don't see that happening. No matter what, the visits are voluntary, and I just don't see patients paying their own money to do something like that.
The other comments you make about inaccuracies Obama has made are disturbing, I will agree with you. It bothers me that Obama couldn't have found a physician to lead the charge here. Instead he has mostly surrounded himself with lawyers, the regular Ivy league kind that dominate insider politics in Washington.
To me this isn't really about Obama, though. It's about extending medical benefits to people who don't have it. I guess you don't like Obama, but whether we like him or not our health care system is in awful shape and we can't afford to wait 4-8 years until he leaves office to make changes. The changes have to be made now, and since he's the president he's the one who has to sign them into law. That's how it is; we have to leave town on the horse we rode in on.
Of course, Obama made a very common error in applying the entire cost of an amputation to a physician. The entire hospital stay for an amputation could very well be $50,000 in some cases (though $15,000 sounds more like it), but the doctor doesn't get most of that money. Doctor's fees are only a small part of health expenses. Controlling costs is not about cutting doctor's salaries, it is about reining in the cost of expensive tests.
Anyway, thanks for the comments. When Obama makes factual errors like this he needs to be corrected immediately -- and I think he usually is. As long as people combat his statements with the truth, I want them to speak out against him. What I don't what is misinformation -- and I do think it is misinformation to lead people to believe health care reform will mean politicians will be forcing patients to kill themselves.
Obama's Plan to Restore New Orleans
New York Times | August 25, 2007
By Jeff Zeleny
Washington -- On the cusp of the two-year anniversary of Hurricane Katrina, Senator Barack Obama will present a plan on Sunday aimed at hastening the rebuilding of New Orleans and restructuring how the federal government responds to future catastrophes in America.
The Gulf Coast restoration, Mr. Obama said, has been weighed down by red tape that has kept billions of dollars from reaching Louisiana communities. As president, he said, he would streamline the bureaucracy, strengthen law enforcement to curb a rise in crime and immediately close the Mississippi River Gulf Outlet in order to restore wetlands to protect against storms.
Mr. Obama also said that he would seek to lessen the influence of politics in the Federal Emergency Management Agency by giving its director a fixed term, similar to the structure of the Federal Bureau of Investigation. The FEMA director would serve a six-year term, under Mr. Obama's plan, and report directly to the president.
Mr. Obama, an Illinois Democrat, and several presidential hopefuls are scheduled to arrive in Louisiana this week to highlight how New Orleans has — and has not — recovered from Hurricane Katrina. Democrats have sought to use the city as an example of what they believe was among the Bush administration's greatest domestic failures
If elected, Mr. Obama said he would establish a Drug Enforcement Agency office in New Orleans that would be dedicated to stopping drug gangs across the region. He also would create a "COPS for Katrina” program, which would allow communities affected by the storm to hire more police officers and prosecutors to fight crime.
The city's recovery has been crippled by a shortage of doctors and the closures of hospitals and medical centers. Mr. Obama said he would create a program to forgive medical school loans in exchange for doctors agreeing to practice in New Orleans.
In his plan, Mr. Obama will call for creating a National Catastrophe Insurance Reserve, which would be paid for by private insurers contributing a portion of the premiums they collect from policy holders. Working with the industry before a disaster, he said, would create a "backstop” to protect homeowners and business owners against catastrophic loss.
Mr. Obama will also propose overhauling the levee and pumping system in New Orleans by 2011 to protect the city against a 100-year storm. To restore wetlands, marshes and barrier islands to help protect the city from a future storm, he pledges to close the Mississippi River Gulf Outlet, an old navigation channel that many scientists say destroyed wetlands and contributed to a funnel effect that increased damage from the storm.
Here is what he is DOING now....
http://www.cnn.com/2009/US/08/28/shearer.new.orleans/index.html
Since the Obama administration took office, the Corps has: announced that one part of the new "system" will be built using a "technically not superior" solution, because of funding problems; and, DEFYING A CONGRESSIONAL MANDATE, delivered a report supposed to offer a post-2011 plan for so-called Category 5 storm protection 20 months late and lacking a specific plan, offering only a menu of possible options. It's almost as if the Corps is inviting someone else to do the job.
President Obama, who has mainly limited his comments about New Orleans to feel-good boilerplate, did pledge to make good on President Bush's promise on that eerie, floodlit night in a deserted Jackson Square in 2005, to rebuild New Orleans better and stronger. But he has yet to actively intervene to make sure New Orleans gets state-of-the-art flood protection and robust and timely coastal wetland reconstruction. Like President Bush, President Obama so far seems to be acting as if just saying it makes it so.
Is this the kind of "Change you can believe in"?