Return of the ‘death panels’

Even in a health care bill that was unpopular, the panels that would make end-of-life recommendations in order to save the government on health care costs (said recommendations being passed on by paying doctors to share them with patients) were even more unpopular. Some people call these panels that make end-of-life recommendations “death panels.” Others, thought the term inaccurate and prefer terms like “end-of-life planning” and “consultation” and “directives.”

These end-of-life panels in Section 1233 of the health care legislation were so unpopular, in fact, that they were removed from the bill after outcry from folks on the left and right.

But whatever you call these panels that make end-of-life cost-cutting recommendations that doctors are paid to pass on to patients — the New York Times just broke a huge story: they’re ba-a-ck. And somehow they’re even more intense. Whereas the House had passed a version of the bill that would arrange for consults once every five years, now target populations will have these chats with incentivized doctors every year.

How? Behold the mighty, mighty power of regulation:

When a proposal to encourage end-of-life planning touched off a political storm over “death panels,” Democrats dropped it from legislation to overhaul the health care system. But the Obama administration will achieve the same goal by regulation, starting Jan. 1.

Under the new policy, outlined in a Medicare regulation, the government will 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 idea of end-of-life counseling to argue that the Democrats’ bill would allow the government to cut off care for the critically ill.

WHOA. The story is somewhat sympathetic, as you might expect, to this rule by regulatory fiat. Still, it’s the kind of article that leaves the reader speechless. Among many fascinating details, the reporter got a hold of some emails from members of Congress basically pleading with others to keep hush hush about what had happened. Representative Earl Blumenauer of Oregon found out in November that the Obama administration planned to institute this rule but purposely kept the news hidden. I assume this must have been in the Federal Register at some point, but all the reporters missed this huge news. It does make you wonder what other news we miss, doesn’t it.

Anyway, like I said, the article is rather typically sympathetic to the panels, directives, consults, what have you. And that weakness manifests itself by generally failing to get much feedback from those Americans who are less-than-elated about having the government pay doctors to do these health care cost-cutting consults. Instead the article goes out of its way to mention any interested parties that support such end-of-life consults (without noting what their financial interests might be, I might add).

Just to give you an idea of the types of objections that are out there, here’s what the health care bill-supporting liberal Charles Lane of the Washington Post wrote about the panels over a year ago:

Though not mandatory, as some on the right have claimed, the consultations envisioned in Section 1233 aren’t quite “purely voluntary,” as Rep. Sander M. Levin (D-Mich.) asserts. To me, “purely voluntary” means “not unless the patient requests one.” Section 1233, however, lets doctors initiate the chat and gives them an incentive — money — to do so. Indeed, that’s an incentive to insist.

Patients may refuse without penalty, but many will bow to white-coated authority. Once they’re in the meeting, the bill does permit “formulation” of a plug-pulling order right then and there. So when Rep. Earl Blumenauer (D-Ore.) denies that Section 1233 would “place senior citizens in situations where they feel pressured to sign end-of-life directives that they would not otherwise sign,” I don’t think he’s being realistic.

What’s more, Section 1233 dictates, at some length, the content of the consultation. The doctor “shall” discuss “advanced care planning, including key questions and considerations, important steps, and suggested people to talk to”; “an explanation of . . . living wills and durable powers of attorney, and their uses” (even though these are legal, not medical, instruments); and “a list of national and State-specific resources to assist consumers and their families.” The doctor “shall” explain that Medicare pays for hospice care (hint, hint).

Admittedly, this script is vague and possibly unenforceable. What are “key questions”? Who belongs on “a list” of helpful “resources”? The Roman Catholic Church? Jack Kevorkian?

Ideally, the delicate decisions about how to manage life’s end would be made in a setting that is neutral in both appearance and fact. Yes, it’s good to have a doctor’s perspective. But Section 1233 goes beyond facilitating doctor input to preferring it. Indeed, the measure would have an interested party — the government — recruit doctors to sell the elderly on living wills, hospice care and their associated providers, professions and organizations. You don’t have to be a right-wing wacko to question that approach.

These types of concerns — shared by liberals like Lane as well as conservatives and moderates — aren’t prevalent in the article. But among religious conservatives, there’s also not enough accurate discussion of their concerns about having a financially interested party encouraging particular end-of-life decisions for individual patients. Note the way the lone religious opponent is quoted:

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 forgo or curtail care, thus hastening death.

“The infamous Section 1233 is still alive and kicking,” Ms. Wickham said. “Patients will lose the ability to control treatments at the end of life.”

I assume the clunkiness in the description of LifeTree is about realization that the standard rewriting of “pro-life” as “anti-abortion” doesn’t work even remotely well in this case (something about which should give the copy editors general pause about the term “anti-abortion.”). But the set up of the quote also reads like the reporter didn’t exactly have a command of what Wickham and other pro-lifers’ objections are to such government-controlled counseling.

Of all the decisions we make that are haunted by religion, how we approach death has to be one of the biggest and most important. It’s almost impossible to talk about life-and-death decisions, such as end-of-life directives and hospice care, without discussing religious doctrines. I have to think that most Americans would like to make these decisions in consult with their rabbi, imam, pastor and priest at least as much as with their government-funded doctor working off a cost-saving script.

And we haven’t even gotten into other issues, such as how doctors’ religious views affect their end-of-life advice and care. What role will religion play in the advice put forth by government accounting panels? What role will religion not play?

Death and dying are intricately tied to the subjects of God, religion and faith. Stories about paying doctors to communicate the “guidance” from “end-of-life” advisory panels whose aim is to “cut costs” are haunted. As this story progresses, I hope we see stories that engage these religious ghosts. The fact is that there is a wealth of theology surrounding death and dying. How to die a good death has been a topic that theologians have given more thought to than Health and Human Services bureaucrats have. Let’s hope the New York Times and other outlets remember that in their coverage in days to come.

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  • Jeffrey

    Let’s also hope the NYT and others can explain that there are no “panels,” but instead individual doctors talking to their patients about end-of-life decisions. Currently, these kinds of conversations are no reimbursable. Continually referring to “panels” like some star-chamber has long been a disinformation tactic that apparently continues today.

  • Martha

    This does sound disturbing. I don’t know how it would work out, and the emphasis on hospice care as an alternative or an end-of-life decision alarms me; that sounds as if they’re thinking of hospices basically as dumping grounds, which is not at all the purpose.

    Also, the idea of paying doctors to basically tell patients “Better to top yerself, missus” – yes, I can see why people would be concerned. I think doctors who go for this would be very convinced that it’s a good idea, and that in turn makes me think that they’d sell it harder than someone just ‘ticking the boxes’ which might mean pressurising (without intending it) the patient or the patient’s family into making this decision.

    In his mid-70s, my father suffered catastrophic kidney failure which ended up with him comatose on life-support in hospital here and the doctors telling my mother that the best thing would be to ‘let him slip away’ but we refused and insisted on on-going treatment (which included resusitication when his heart stopped). When they sent him home it was clear they thought he was just going home to die. Instead he recovered so well, it was much to the amazement of the doctors, and lived a good eight years longer (even though he had to be on dialysis).

    But suppose this kind of thing had been in place? Might the medical team have pushed harder to make us change our minds about the ‘right’ thing to do? Then my father would have died sooner than needs be.

  • http://www.getreligion.org Mollie

    Jeffrey,

    The panels refer to the teams of people who will come up with the guidance that the doctors will be paid to give to patients.

  • Jeffrey

    Mollie, neither article discusses these “teams of people” creating the guidance. Yet you continually refer to “panels” invoking Sarah Palin’s “death panels” myth about groups of people deciding who will get health care and who won’t.

    As I said, we are in for another bout of minsinormation and the press will need to be vigilant in order to balance out the opinion press and pundit class who will want to demagogue this issue, from either the left or the right.

  • http://www.getreligion.org Mollie

    Jeffrey,

    You’re right — the story does NOT fully discuss the teams of people who will create the guidance. That’s one of its biggest flaws, probably. We know very little about how these regulations will operate in terms of how the guidance will be drafted, who will be on the teams of people drafting the guidance, what factors they will consider as they make their guidance and what role religion will or will not play in their decisions. Huge, huge story. And while the government paying doctors to spread this guidance is the thing that makes many people concerned, and that is covered in this story — the guidance itself is probably more important. And it’s just not covered well.

  • http://www.tmatt.net tmatt

    Jeffrey:

    Strange that you are not calling for more crucial information on that point.

    Where would the end-of-life info that the doctor’s are paid to hand out come from? Crucial question. Period.

    Meanwhile, it is also interesting that religious groups are NOT at all opposed to end of life directives. The government could have a powerful ally on this point if the plan empowered people to seek advice from a wider range of experts, including clergy. To avoid church-state entanglements, this could be done by voucher or tax credit.

    Otherwise, you have a secular system on a subject that — for most Americans, but not all — involves intensely religious issues.

    And when you think about hospice pioneers, who leaps to mind? Catholics, of course. Check your local phone book in most zip codes.

    As I wrote last summer:

    http://www.tmatt.net/2010/06/28/law-faith-and-the-good-death/

    The word “euthanasia” comes from two Greek words that simply mean “good death,” noted the historian. For centuries, Catholics and others have argued that a “good death” is one that is as pain-free and dignified as possible. Thus, religious groups have been at the forefront of efforts to offer in-home hospice care.

    However, several trends have aided efforts to legalize physician-assisted suicide, especially scientific advances that have increased the “graying of America,” said Dowbiggin. Thus, people are living longer lives, which also means they are more likely to face lengthy battles with cancer and neurological conditions such as Alzheimer’s and Parkinson’s disease.

    Rising health-care costs have also affected “quality of life” debates. After all, as President Barack Obama told the New York Times, the “chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here.” The stakes are rising.

    Meanwhile, the Hemlock Society has evolved into End of Life Choices, an organization that merged with Compassion in Dying to form Compassion & Choices. Physician-assisted suicide became the “right to die” which has now evolved into calls for a legal “self deliverance” option.

    If religious leaders want to keep taking part in these policy discussions, said Dowbiggin, “they must have something positive to say. It is not enough to just keep saying ‘no.’ … They need a vision of what the ‘good death’ looks like. They need to say that this is the goal of all end-of-life care — people making informed moral decisions about hospice and other forms of care that are right for themselves and for their families.”

  • dalea

    At the end of the NYT article we finally get some information on just what the various options actually do:

    In a recent study of 3,700 people near the end of life, Dr. Maria J. Silveira of the University of Michigan found that many had “treatable, life-threatening conditions” but lacked decision-making capacity in their final days. With the new Medicare coverage, doctors can learn a patient’s wishes before a crisis occurs.

    For example, Dr. Silveira said, she might ask a person with heart disease, “If you have another heart attack and your heart stops beating, would you want us to try to restart it?” A patient dying of emphysema might be asked, “Do you want to go on a breathing machine for the rest of your life?” And, she said, a patient with incurable cancer might be asked, “When the time comes, do you want us to use technology to try and delay your death?”

    This discussion would be greatly helped by extensive coverage of exactly what living wills, advance directives and hospice are and do. Most simply allow a person who is in a good mental state to explain what they do and do not want done when he is not able to communicate. Which strikes me as sensible not sinister. There exist a large range of options and people can choose which best fit their particular physical and religious status. The article finally gives a cursorary example of what these documents do at the end, but more examples would have been helpful.

  • Jeffrey

    The government could have a powerful ally on this point if the plan empowered people to seek advice from a wider range of experts, including clergy. To avoid church-state entanglements, this could be done by voucher or tax credit.

    So you want government vouchers to pay priests to tell parishoners how to handle end-of-life care? It’s like the First Amendment is meaningless, with government paying religious leaders to counsel people.

  • dalea

    While there is some small payment for having the discussion with a patient, there is a great deal more money in trying all sorts procedures at the end. I went through this when my partner was dying. He had reached the end, further treatment was futile. But a doctor came up with a plan of action. Which involved five surgeries which left him in terrible pain and pretty much comotose. The doctor refused to honor my power of attorney, saying: sue me! The bills for this were over $350,000, paid by Medicare. There are two sides to this issue.

  • Jerry

    … Charles Lane’s piece, referenced by Terry, is a rational discussion of the issues but those who hate everything President Obama stands for eliminate the possibility of a reasonable discussion by yelling so loudly that they drown out other voices and turn the debate into a “you’re evil”, “no you are” shouting match where a substantive discussion is lost amidst the dung slinging.

  • http://www.tmatt.net tmatt

    JERRY:

    The post was written by MZ, not me.

    And please try to avoid the argument that says, “People who disagree with me should not be covered in the MSM because their viewpoints and information will only mess up civic discourse.”

    JEFFREY:

    The legal key is who makes the decision to choose the advice. That decision would be made by the citizen. Besides, lawyers and others must be involved in most states. Correct?

    The issue is this: Who does the citizen of their own free will want to have involved in this decision? The citizen and the state alone or a team that may or may not include their chosen faith leader? That voucher option should at least be tested in court. Our courts are very divided on this question of citizen choice, if it involves religion. I know that.

    As a JOURNALISM issue, editors should seek highly informed voices on both sides of the question. This NYTs piece clearly failed in that regard. Where are the national level experts for religious hospice groups, etc.?

    DALEA:

    A terrible and sad story. That’s the kind of situation that hospice professions — secular or sacred — consider the worst case situation to be avoided. Was your partner’s own end-of-life directive ignored?

  • dalea

    ELCA has teachings on this subject at:

    http://www.elca.org/What-We-Believe/Social-Issues/Messages/End-of-Life-Decisions.aspx

    This dates from 1992 and seems to speak directly to the issues above. From the teaching:

    Advance directives are welcome means to foster responsible decisions at the end of life. Yet people are often overwhelmed and frightened when thinking about medical treatment and legal possibilities, and therefore do not take steps to prepare for the end of their lives. People recognize their rights as patients but at the same time feel unprepared to take on the responsibility.

    Communities of faith should, can, and often do provide holistic ministry to prepare people for end-of-life decisions. Pastors can help people to deal with their fears and hopes. Congregations can offer opportunities for conversation and deliberation about the end of life. They can invite hospital chaplains, hospice care-givers, social workers, attorneys, or others knowledgeable about advance directives to help them consider the topic’s many dimensions.

    Church-related hospitals, nursing homes and other social ministry organizations are also encouraged to provide for continuing conversation and deliberation about their ministry at the end of life. The staff of these organizations need to understand the ethical principles that are to guide the care they provide. Ethics committees can play an important role in dealing with unresolved conflicts about treatment decisions.

    We rejoice in the faithful and compassionate congregations, pastors, health care professionals, and church institutions who minister with persons who are dying and their families and friends. We give thanks for family and friends who minister to their loved ones. In the midst of often agonizing end-of-life decisions, we are reminded of the God-given mystery of both life and death. May the Holy Spirit grant to us all loving wisdom and confident hope in the Gospel’s promise of eternal life.

  • potter

    If this was a handout counseling people to seek aide in making these decisions I would support it. When Govement gets involved it never stops where it starts. It always goes in the direction of our worst nightmare. The milatary is the only thing I see the govement handeling nearly as well as private enterprise. There are too many layers of goverment employees for anything to be done well.

  • http://www.tmatt.net tmatt

    DALEA:

    Thank you for that input. Other churches have similar materials (might others offer URLS?) on these issues.

    The Catholic Church’s teachings on the issue are voluminous and highly nuanced. Rome is both opposed to euthanasia as often defined, yet highly in favor of advanced directives to help the dying avoid pain and frantic bursts of questionable medical care.

    My Orthodox parish held an advanced-directive seminar last year, led by a lawyer in our church and our priest. It left me convinced that the White House urgently needs to seek the support and input of religious groups on this issue. It’s a great chance for a genuinely pro-life consensus.

  • http://www.getreligion.org Mollie

    TMatt,

    A link to your discussion of that seminar: http://www.getreligion.org/2009/09/a-ghost-in-the-death-panel-image/

  • Jerry

    D’oh. I won’t bore you with how I made that mistake and only bemoan that I don’t have a fact checker to keep me straight :-)

    But it appears that Mollie’s (and other’s) concerns are WAY, WAY overblown based on the following from that hotbed of far left liberalism, the WSJ, so maybe the right should take some chill pills:

    The health-care overhaul in 2010 turned the welcome visit into an annual “wellness visit,” saying seniors could get covered for a checkup every year. The new directive makes clear that the annual wellness visit can include the same end-of-life planning already permitted in the welcome visit.

    Reid Cherlin, a White House spokesman, said it was incorrect to suggest the policy of reimbursing end-of-life discussions was new.

    “The only thing new here is a regulation allowing the discussions … to happen in the context of the new annual wellness visit created by the Affordable Care Act,” said Mr. Cherlin, referring to the health overhaul passed in March.

    http://online.wsj.com/article/SB10001424052970203568004576043970989095748.html?mod=googlenews_wsj

  • dalea

    tmatt asks:

    Where would the end-of-life info that the doctor’s are paid to hand out come from? Crucial question. Period.

    Mollie asks:

    We know very little about how these regulations will operate in terms of how the guidance will be drafted, who will be on the teams of people drafting the guidance, what factors they will consider as they make their guidance and what role religion will or will not play in their decisions. Huge, huge story.

    Most likely, the people involved will come from professional associations, as is done for most health care protocals. Here is the AMA guideline on end of life treatment:

    http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/about-ethics-group/ethics-resource-center/end-of-life-care.shtml

    When a patient cannot participate in the decision-making process and there is no advance directive, disputes may arise about what the patient would have preferred. Occasionally, families and physicians cannot resolve these disputes. As a last resort, disputes should be adjudicated by the courts, guided by what the patient would have wanted as best it can be determined. The goal should always be to respect the rights and dignity of the patient. Public officials, the media, family members, and all other parties also should respect the rights and dignity of the patient, including their right to privacy and to having their wishes respected.

    Medical Criteria, which is a formalized method of recognizing stages of disease and appropriate treatments, underlies the system. This is a world wide effort that is constantly being updated.

    http://www.medicalcriteria.com/

    The composition of these teams will undoubtably follow standard medical practice as seen in hospital ethics committees. That is the way medicine works.

    tmatt, yes the doctor ignored my partner’s advance planning also.

  • http://fkclinic.blogspot.com tioedong

    when my mother added “medicaid advantage”, the insurance company pressured her to get a living will. Nothing new. And as a doc, I had many “end of life” discussions with folks or their families who were dying, but thought extraordinary treatment would let them live.

    that said, for my family, I would advise a “health care proxy”, so your family can decide.

    Without it, an unknown doctor or even the EMT who comes to your house will decide.
    This is important in these days when antibiotics or Iv fluids for an acute infection might let you live another three years, but you say “no extraordinary treatment” and the health care provider follows ethicists who say these simple treatments are “extraordinary”.

    Finally, the dirty little secret is that minorities don’t sign living wills. The “health care establishment” thinks this is a problem, but they remember the Tuskegee experiment, and don’t trust doctors.

  • http://augustiniandemocrat.blogspot.com/ Irenicum

    I’ll not try to jump into this fray. It’s already too toxic for my taste. I’ll only say that as regards any “death panels” please reference http://www.factcheck.org and read what they have to say. They’re pretty much spot on. That is all.

  • Jeffrey

    My Orthodox parish held an advanced-directive seminar last year, led by a lawyer in our church and our priest.

    What’s missing in this equation, of course, is the advice and counsel of a medial expert. And to get that advise, you have to pay for those services. And for Medicare recipients, that requires reimbursement from the Medicare system.

    But we don’t have that now and all the disengenuous talk of “death panels” only denies poor people acccsss to that assistance. So they are left talking to a lot of non-medical experts but no one who truly understand their health history.

    It’s a great chance for a genuinely pro-life consensus.

    Sadly, that seems unlikely in the current political climate no matter how sincere the White House is.

  • Dan Crawford

    Having been exposed as a patient and as a pastor to the ways in which corporate medicine lies or at best deliberately misleads people to manipulate them into tests or treatments, I think intelligent, TRUTHFUL, end of life discussion among pastors, physicians, and hospital administrators is long overdue. Practically the first thing one is asked upon a hospital admission is whether one has a “living will” – though I have seen instances in which the “living will” was paid little attention to. Doctors who do everything to convince patients to undergo treatments which may or may not prolong a person’s life need someone else to counter their arguments. If end-of-life discussions do take place, there needs to be someone present who is not a physician, hospital administrator, bureaucrat, or involved family member. Sadly, today, most hospitals have no chaplains – the few that do are trying to figure out ways of dispensing with their services.

  • Julia

    In Illinois, a durable Power of Attorney for Health is preferred to a Living Will.

    The person can chose a level of care for life and death situations and include specific things they want or don’t want done.

    Additionally, agents authorized to see charts and confer with the physician about care decisions are listed in an order similar to named executors – people are advised to list several and to also talk with them about their wishes.

    Many times the exact medical situation is not mentioned or clear in either a Living Will or a POA. So the POA agent has authority to make decisions interpreting the person’s stated wishes and fitting that with the situation that is at hand in conjunction with the medical team.

    A practical tip: if you are such an authorized person carry it around with you. I was called to my mother’s home where she had not woken from a nap and the EMTs had to uselessly pound on her all the way to the hospital b/c I didn’t have the POA to show them I could call it off.

    As a lawyer, I recognize that much of this is cover for the physicians who are always fearful of being sued for not doing enough. And it’s usually the children who don’t see the parent much who fight for the extravagant care.

  • Julia

    I think the “death panels” was also referring to the regulatory agencies/committees who will make policy decisions about what the government-controlled insurance can/will pay for at the end of life and what it won’t pay for.

    Like Speaker Pelosi said, (paraphrasing)you have to pass the bill to find out what is in it. Because it’s the unelected regulatory bureaucracy that fills in the particulars.

  • Chris

    All adult patients, particularly older adults, and those with serious illness should have end-of-life decision discussions with their physician AND their family. It is best if this is done over time–not as a one-time THE TALK. As Julia points out, a durable POA for healthcare AND a living will are optimal. As a physician, I have observed that patients are often unwilling to have such discussions–largely because discussing ones own death is an uncomfortable topic. It is difficult for doctors too–and since it is largely not reimbursable, and can take a lot of time, it often isn’t done. Maximum interventional care, even if very unlikely to be effective (doctors would define that as less than a 1% chance), IS reimbursed. Economically, it becomes the default position. And–once you’re on a ventilator, it’s hard for your family or your physician to determine what your wishes might have been. The reality of ICU care is also often a shock–I don’t believe many patients or their families can imagine how bewildering, invasive, uncomfortable, and ultimately ineffective it can be.
    There has been recent research that demonstrates that palliative care improves quality of life (with no decrease in longevity) in terminal cancer:
    http://www.nejm.org/doi/pdf/10.1056/NEJMoa1000678
    Many of these articles (including the NYT’s) fail, I think, by not interviewing and quoting physicians and researchers in the palliative care/hospice area.

  • Jackson

    I believe that stating this end-of-life counseling is what is referred to as the Death Panels is a red herring. What is the real Death Panel, for the United States of America, is the exact same Death Panel used in the United Kingdom. This is a panel that decided what treatments can be offered and also who these treatments will be available for. This Death Panel is a healthcare rationing panel that will deprive persons of life-saving, life-improving, and life-extending treatments and drugs.

    The Death Panel is the equivalent of NICE empowered in the United Kingdom to ration healthcare and deem who is worthy of receiving care and who should be left to die or suffer to contain costs. This is the culture of death as opposed to the culture of love. What is the name of this Death PAnel in the United States? It is the Obama Administration’s new Council for Comparative Effectiveness Research

    Of NICE and Men
    http://online.wsj.com/article/SB124692973435303415.html

  • Julia

    I concur with Chris.

    And would like to further add: to avoid fear of Living Wills and other advanced directives, people should check out the documents in their state to see what they are really about.

    This comment is longer than usual, but it’s important that people understand these types of documents.

    In my state of Illinois:

    1) The Living Will Declaration is only applicable when you are in an irreversible terminal situation, and death is imminent. Physicians often don’t like having to interpret them.
    http://www.idph.state.il.us/public/books/Livin.PDF

    2) The Illinois Durable Power of Attorney for Health, is honored when the patient is unable to communicate about health decisions whether due to coma, heavy sedation or other reason. It is not necessary that the patient be terminally ill or near death. The form also has places for choosing a level of care in different situations and blank space for entering wishes about specific types of treatment to be refused. An agent or successive list of agents is authorized to make those decisions with the physician guided by the patient’s stated wishes – only while the patient is unable to do so his or herself.

    http://www.idph.state.il.us/public/books/PwrOf.PDF

    3) In Illinois, a person should not have both a Living Will and a POA for Health. Because the POA has space for providing the same kind of instructions as would be in a Living Will, a physician might very well be reluctant to honor either one.

    4) Because states differ, the document should comply with the requirements of the state(s) where the person is likely to be hospitalized. In my area, people often cross the Mississippi to a med school hospital under the more stringent rules in Missouri. An Illinois POA can add provisions to make it compliant with both states.

    5)The Illinois Durable Power of Attorney for Property can kick in under the same circumstances as the POA for health, but also if the person is incommunicado or is physically unable to manage his or her affairs – whether temporarily or permanently. This document will save the expense and red tape of obtaining a guardianship. The agent loses his powers when the person has recovered sufficiently or, if competent, chooses to cancel the Powers granted.

    6) Illinois has a number of other advanced medical directives, including one for mental heath care.
    http://www.idph.state.il.us/public/books/advin.htm

    This site notes the following:

    [F]ederal legislation (Patient Self-Determination Act, 42 U.S.C.A. § 1396a[w] [West 1996]) requires certain providers participating in the Medicare and Medicaid programs to furnish patients with information on advance directives. The information is to be given to patients upon admission to a facility or when provision of care begins. Providers covered by this requirement include the following entities: hospitals, nursing facilities, providers of home health or personal care services, hospice programs and health maintenance organizations.

    So Medicare and Medicaid providers are already required by Federal law to give information about these instruments.

    Bottom line: the Power of Attorney for Health is much less scary, gives more choices, is useful in circumstances other than terminal illness, and gives the physician an actual person with whom to make decisions when the specific situation falls between the cracks of what is described in the document. Even young single people can get into work, athletic or auto accidents where they are temporarily unable to confer with the medical staff. Sometimes both spouses are in the same accident and unable to make decisions.

    Google to find the similar, but possibly very different, advanced directives in other states.

  • Julia

    Forgot to include the link to the POA for Property form in Illinois.

    http://illinois-attorney.com/poapform.htm

  • Matt

    Jackson, health care is already rationed in the United States, on the basis of economics. The only difference is that you are wealthy enough that you don’t get the short end of the stick.

  • Matt

    “end-of-life” advisory panels whose aim is to “cut costs”

    Mollie, whom are you quoting here? You relentlessly insist on using the inflammatory term “death panels” (and, unlike MSM reporters, I doubt you can avail yourself of the excuse of not writing your own headlines), and you insist that their priority will be cutting costs rather than patient welfare. What is your basis for this? Whom are you quoting?

    Seconding Irenicum #19, here is a more specific link. Note the quote at the end from that well-known flaming liberal, Sen. Isakson of Georgia.

  • http://www.getreligion.org Mollie

    Matt,

    Not even sure where the confusion lies. I do NOT relentlessly insist on using the term “death panels.” The fact is that’s simply the most efficient and effective way to let people know what we’re talking about. If you have a pithier or better phrase for the headline, let me know. You’ll note that I put “death panels” in quotes.

    Anyway, if you’re looking for a quote about whether we’re talking about end-of-life advisory panels whose aim is to cut costs, here’s President Obama in the New York Times:

    THE PRESIDENT: So that’s where I think you just get into some very difficult moral issues. But that’s also a huge driver of cost, right?

    I mean, the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here.

    LEONHARDT: So how do you — how do we deal with it?
    THE PRESIDENT: Well, I think that there is going to have to be a conversation that is guided by doctors, scientists, ethicists. And then there is going to have to be a very difficult democratic conversation that takes place. It is very difficult to imagine the country making those decisions just through the normal political channels. And that’s part of why you have to have some independent group that can give you guidance. It’s not determinative, but I think has to be able to give you some guidance. And that’s part of what I suspect you’ll see emerging out of the various health care conversations that are taking place on the Hill right now.

  • Matt

    Okay, so the President mentioned that end-of-life care is a “huge driver of cost”, and he is right. As other commenters have noted, one major contributor to this is that the medical industry has financial incentives to perform needless high-tech procedures that (maybe) prolong life but do not increase its quality, and another major contributor is that people don’t talk enough about end-of-life issues before things start happening. The President went on to say that we need to talk about these issues, and he is right. But he began that line by acknowledging “difficult moral issues”, and he had previously been saying it would be wrong to deny life-improving care (e.g., his grandmother’s hip replacement) to people near death, so he is hardly focused exclusively on the cost issue. You are the one saying that the sole or primary aim is to “cut costs”, and you put those last two words in quotes without indicating the source of the quote.

    One interesting part of the above presidential quote is that he lists “doctors, scientists, ethicists” as the people who should be involved in this “conversation”. I echo Tmatt’s point that clergy should be an indispensable part of that group, and Obama’s failure to mention them is another indicator of an enduring blind spot on his part in that regard.

    I apologize for the “relentlessly insist” line. You used the phrase only once, plus in the headline and in a quote. I should have said more generally that your political hostility to the health-care bill was palpable, and that I struggled with it.

  • Jeffrey

    The fact is that’s simply the most efficient and effective way to let people know what we’re talking about.

    The irony, of coruse, it is efficient and effective despite being built on overblown rhetoric and a coarsening of discourse.

  • Matt

    “Despite” or “because”?

  • dalea

    A group of academics and practitioners known as ‘bioethicists’ seem to be the nexus between health care and religion. These are people who study the implications of health care decisions from an ethical perspective. One institue for training is at Johns Hopkins Medical School:

    http://www.bioethicsinstitute.org/web/page/869/sectionid/387/pagelevel/2/interior.asp

    There is also one at Georgetown University:

    http://clinicalbioethics.georgetown.edu/

    They have an ‘ethics consult’ available 24/7:

    What is an ethics consult?

    Making decisions amid all the complexities of modern medicine is not easy. Ethical questions can arise when a patient has lost the capacity to make decisions, when it is not clear whether the burdens of a treatment are worth the expected benefits, or when values appear to conflict. The Ethics Consult is an advisory service that is designed to assist patients, families and all health care professionals in identifying, analyzing and resolving ethical dilemmas.

    No fees are charged for this service and all consults are kept strictly confidential.

    How does one request a consult?

    The pager number for the consultant on call is: 202/405-3959. The Ethics Consult can also be initiated by calling the Page Operator at Georgetown University at 202/687-7243. The Ethics Consult Service is on-call 24 hours daily. For further information, or if a problem is encountered during standard business hours, please call the Center for Clinical Bioethics directly at 202/687-1122.

    A clinical ethicist is on-call each week. Upon receiving a request for a consult, the ethicist will make initial inquiries and along with the clinical staff arrange for a consult meeting that is appropriate to the needs of the parties involved in the case.

    Who can request an initial consult?

    Anyone may request a consult. Patients, families, doctors, nurses, social workers, chaplains, and any member of the medical team are encouraged to call us for assistance.

    What happens in a consult?

    An ethicist reviews each request to see what type of consultation is best suited to a particular situation. Sometimes, for instance, the concern may only represent a communication problem. A full consult will generally involve a meeting of several ethicists, the health care team, the patient, and/or the patient’s family as appropriate. The consultants do not judge the quality of patient care or make decisions. They help to facilitate a discussion of the situation and clarify the issues from an ethical perspective.

    The bioethicists have a cross discipline approach using theology, medical practice and cost/benefit analysis. It seems to be a growing field. Yet I do not recall any religion reporting on the subject mentioned at GR.

  • Matt

    I would also like to say that I am disturbed by one feature of the new comment-feedback system. I like the way that widely-liked comments get a special highlight, but I dislike the way that widely-disliked comments get hidden and that I have to make an extra click to read them. The result of this is a subtle censorship of minority viewpoints, and that is no way to carry on a debate.

  • http://www.getreligion.org Mollie

    Matt,

    I agree. Sometimes I just go through and “like” the hidden comments so they can be seen. Even if I don’t like the comment.

  • Chris

    When discussing the decision of so-called “death panels” we need to be more sophisticated about what constitutes a “life extending treatment”. In the medical literature, “life extending treatments” are those that statistically significantly increase average/median overall survival in a randomized controlled trial. If a trial is large enough, very small increases in median survival can be statistically significant. Some of the new chemotherapy agents (eg: erlotinib and sunitinib, to name a few) used for metastatic cancers extend median survival by only 1-6 months, at the cost of thousands of dollars per month, and may have significant costly side-effects. They do not cure the disease. NICE (National Institute for Health and Clinical Excellence) of the British National Health Service, is trying to develop a societal cost-benefit analysis for such drugs. The cost is very high. The benefit–not so much in some situations. When society (ie, the tax payer) is being asked to fund such therapies there has to be a discussion regarding where the money is going to go. These are very expensive drugs–and although they have promise–they have a high cost to benefit ratio in some clinical situations. They are not, strictly, life-saving.
    http://www.ncbi.nlm.nih.gov/pubmed/19487381
    http://www.ncbi.nlm.nih.gov/pubmed/21148614
    We need to be careful about calling bodies such as NICE “death panels”. There is a lot of spin on both sides, and there are, in some cases, substantial profits to be made by the drug companies that develop these drugs–and substantial losses if they are not approved for coverage.

  • dalea

    Regarding the unpopularity of the health reform, CNN released a poll on the subject last Monday, Dec 27. The poll found that 54% opposse and 43% favor. However when the opponenents were surveyed on why the oppose, one fourth said it did not go far enough. They favored a single payer approach. The figures are:

    Favor 43%
    Too liberal 37%
    Not Liberal enough 13%
    No opinion 7%

    Interestingly, when asked about the plan in detail the number of undecideds rose by 4%. The population that wants government run healthcare is 56%. So much for unpopular.

    The data is here in the dread PDF format:

    http://i2.cdn.turner.com/cnn/2010/images/12/27/rel17h.pdf

  • Julia

    Eilen:

    I don’t think a hospital is legally required to go by what a person with a POA and/or by the family wishes – if the hospital thinks it makes no clinical sense.

    Your recourse would have been to try to get the court to resolve the impasse and force the hospital to do what you wanted.


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