Me, Uncharacteristically Perturbed
Now, they’ve gone and done it. I’m perturbed!
One of the provisions in the health care reform bills being worked on in both the House and the Senate is an incentive, to be paid by Medicare, for doctors and other providers to have a conversation every five years with aging patients regarding what they want for end of life care. That’s the true part. I discuss that below in detail.
UPDATE: Oregon congressman Earl Blumenauer (D-Dist 3) is the author of this section of the legislation. He states that he has been so frustrated by the Republicans’ distortions and lies of what he wrote that he has developed a Myth versus Fact Sheet that can be read by clicking here. Rep Blumenauer wrote in his blog:
Those with no solutions and no answers for how to reform our health care system are hijacking positive, bipartisan efforts that have contributed to a strong bill passed out of two House committees. Republican leadership has abandoned all efforts at passing needed health care reform — even turning their attacks to legislation that has been actively crafted and supported by both parties.
One of these outrageous examples is my Life Sustaining Treatment Preferences Act.
GOP leadership has been gravely distorting the truth and misrepresenting the facts about this bipartisan effort, and in the process throwing members of their own party under the bus — those who have reached across the aisle to do something that will help Americans across the nation.
The bill simply provides people with better care as they grapple with the hardest health care issue of all — their final chapter of life. See the Myths vs. Facts sheet on this. CNN reporter Elizabeth Landau does a great job highlighting the benefits of “doctors and family members having more conversations about end-of-life issues,” which my bill addresses.
This bill has bipartisan support (the main cosponsor is a Republican doctor) as well as support from a diverse coalition like AARP, the American College of Physicians, and Catholic health systems. It is an area where — no matter from a red or blue state — many have been able to bridge the divide.
The bottom line: this is a smart and just thing to do for families going through a tough time.
Indeed, it is a smart and just thing to do. Americans are known to be among the greatest death-deniers in the world. This is very well documented. Physicians, as a profession are generally not trained in medical school to talk about dying with their patients, and the cultural norm “I’m going to live forever!” is especially deeply held by our doctors. This, too is very well documented. (One exception I have knowledge of is at Oregon Health and Science University in Portland, where medical residents are trained how to talk to patients about end of life issues. I have seen their video and am well acquainted with the faculty of the Center for Ethics in Health Care.)
But those who are opposed to health care reform are using our fears about death and distorting them into a malicious fallacy about the legislation’s impact on our lives. One provision is for providers to have a discussion about end of life care with her or his patients. As I explain below, this conversation is taking place every day thousands of times. But for the opponents, it’s another item on their list to distort and spread fear to preserve the status quo, mainly their profit margain.
As Charles Blow, New York Times columnist, stated in his latest piece, “Health Care Hullabaloo:”
I must say that this says more about them than it does about any forthcoming legislation. Belligerence is the currency of the intellectually bankrupt [emphasis added].
Trapped in their vacuum of ideas, too many Republicans continue to display an astounding ability to believe utter nonsense, even when faced with facts that contradict it.
This scare tactic is becoming ubiquitous, as expressed by a woman at a Raleigh, NC town hall meeting with President Obama, reported by ABC News reporter, Jake Tapper:
At the AARP town hall meeting last week, a woman named Mary told the president that “I have been told there is a clause in there that everyone that’s Medicare age will be visited and told to decide how they wish to die. This bothers me greatly and I’d like for you to promise me that this is not in this bill.”
“You know, I guarantee you, first of all, we just don’t have enough government workers to send to talk to everybody, to find out how they want to die,” the president said. “I think that the only thing that may have been proposed in some of the bills — and I actually think this is a good thing — is that it makes it easier for people to fill out a living will.”
After explaining what a living will is, and that he and his wife each have one, the president said, “I think the idea there is to simply make sure that a living will process is easier for people — it doesn’t require you to hire a lawyer or to take up a lot of time. But everything is going to be up to you. And if you don’t want to fill out a living will, you don’t have to…But, Mary, I just want to be clear: Nobody is going to be knocking on your door; nobody is going to be telling you you’ve got to fill one out. And certainly nobody is going to be forcing you to make a set of decisions on end-of-life care based on some bureaucratic law in Washington.”
Check out the AARP’s Myths vs Facts site here.
Here’s the text (authored by Rep. Blumenauer) of the proposed “Americans Health Care Choices Act of 2009” (beginning on page 425), the House version, regarding advanced planning:
‘‘(hhh)(1) Subject to paragraphs (3) and (4), the
term ‘advance care planning consultation’ means a consultation
between the individual and a practitioner described
in paragraph (2) regarding advance care planning,
if, subject to paragraph (3), the individual involved has
not had such a consultation within the last 5 years. Such
consultation shall include the following:
‘‘(A) An explanation by the practitioner of advance
care planning, including key questions and
considerations, important steps, and suggested people to talk to.
‘‘(B) An explanation by the practitioner of advance
directives, including living wills and durable
powers of attorney, and their uses.
‘‘(C) An explanation by the practitioner of the
role and responsibilities of a health care proxy.
‘‘(D) The provision by the practitioner of a list
of national and State-specific resources to assist consumers
and their families with advance care planning, including the national
toll-free hotline, the advance
care planning clearinghouses, and State legal
service organizations (including those funded
through the Older Americans Act of 1965).
‘‘(E) An explanation by the practitioner of the
continuum of end-of-life services and supports available,
including palliative care and hospice, and benefits
for such services and supports that are available
under this title.
What got me thinking about this post was this comment by the New York Times columnist, economist Paul Krugman. In a posting to his blog titled “Even-handedness,” he wrote:
AP: FACT CHECK: Distortions rife in health care debate:
Opponents of proposals by President Barack Obama and congressional Democrats falsely claim that government agents will force elderly people to discuss end-of-life wishes. Obama has played down the possibility that a health care overhaul would cause large numbers of people to change doctors and insurers.
So Republicans are claiming that Obama will kill old people. . .
Having just watched Bill Moyers on his PBS program interview Wendall Potter, former CIGNA executive who just testified before congress on the unconscionable tactics being regularly and deliberately used by insurance companies to deny coverage their insureds have rightfully paid for, but will dent the companies’ profits, and how they are in an all-out campaign to destroy health care reform while duplicitously endorsing it, I wrote a comment on Krugman’s blog.
Well, this time he didn’t publish it (however he had recently published my comments on 1 August 2009: “Health Reform Made Simple.“). I, however, back up all my comments on various blogs. Here, then, is what I wrote:
The “They’re Killing Granny” Fallacy:
For over a decade, as a hospital chaplain, I have helped hundreds of Grannies complete their Advance Directives. Often the doctor requests this conversation take place, because Granny has a medical condition that is approaching end-stage, or is already there. The ideal is that Granny and her physician have already had a conversation about her declining health. The Advance Directive is one tool for her to use to determine the kind of medical care she wants OR doesn’t want IF she can no longer communicate her wishes about treatment.
The purpose of the provision in the bills is to provide an incentive to medical providers to talk with Granny regarding the choice of care she wants at the end of her life. Why? Because Americans are the worst death-deniers in the world. We’ll do just about anything to avoid talking about dying and death. And physicians are just as bad as the rest of us.
Let me repeat the purpose of the provision: The Doctor talks to Granny so she has a choice to decide what she wants. The conversation is a huge benefit not only to Granny, so she can make her wishes known, but also to remove the burden from her loved ones of having to guess about the kind of medical care she wants IF she is dying and cannot communicate by any means.
Generally, the types of extraordinary treatments being considered are:
1. Being placed on a ventilator to support breathing.
2. Being fed through a tube.
3. Being provided medications or procedures that are specifically designed to cure the disease, or to artificially prolong the person’s life.
Here are the facts (and I’m assuming most other states are very similar to mine):
1. Any person over the age of 18 can complete an Advance Directive. It does NOT require being notarized, it does NOT require your doctor’s signature, and it does NOT require going to an attorney and paying a fee to fill out the form. You can download your state’s form online, or pick up a free copy at a local doctor’s office, hospital, or public health office. Be sure to give a copy to your doctor and to take it with you to the hospital if you have a procedure (my hospital will accept a mailed Advance Directive at no charge, even if the person has never been one of our patients).
2. The purpose of the Advance Directive is to allow Granny to decide in advance if she wants to have extraordinary medical measures should she be clinically assessed as being in the process of dying AND unable to communicate her wishes by any means.
3. Granny in her Advance Directive can choose to have everything from no extraordinary measures to all extraordinary measures. If Granny chooses not to have extraordinary measures, she will still receive full palliative care measures to keep her comfortable, clean, and to die as peacefully as possible. Granny, hopefully, will have access to hospice to provide this care; it is already paid for by Medicare.
4. Granny has the choice of appointing a Health Care Representative (usually a family member or very close friend) to be her “health care power of attorney” to speak on her behalf if she is too ill to communicate (but perhaps is not in a terminal condition), or to consult with her physician if she is in the process of dying.
5. Here are some of the key rules:
a. Granny has the right to decline to talk about her end of life with her provider.
b. Granny has the right to decline to fill out an Advance Directive.
c. Granny must be mentally clear (alert and oriented to time, place, and self) to fill out the Advance Directive. If Granny is suffering from dementia, or is confused or delirious due to some medical cause, she is not considered competent (at least in my state) to fill out the Advance Directive at that time. If she clears mentally later, she may can complete the document. If Granny’s condition is diagnosed as permanent (such as advanced Alzheimer’s), then the family may need to consider a guardianship, but that is another topic.
d. Granny’s doctor, or if she is in a facility, a facility employee, CANNOT be her Health Care Representative, to prevent any conflict of interest in determining her treatment.
Being at the bedside of a critically ill patient, likely to die, and supporting the family through the decision-making process of what to do, when Granny never talked about it is agonizing for everyone. One conversation would have spared all concerned the pain of indecision and second-guessing.
The AARP states,
Bottom Line: Health care reform isn’t about putting the government in charge of difficult end of life decisions. It’s about giving individuals and families the option to talk with their doctors in advance about difficult choices every family faces when loved ones near the end of their lives.
That is compassionate health care. It is no slippery slope toward euthanasia, and it is not killing Granny. It is, however, a provision (already in place in many places around the country), to ensure that the majority of America’s Grannies, truly die in peace and dignity.
A Caveat: Yes, I live in Oregon, which has the ignominious distinction of being the first state in the country to permit suicide with the assistance of a physician. I personally oppose the legalization of suicide by this means (or any other, for that matter). My hospital, being a Catholic institution, does not encourage or participate in assisting terminal patients to commit suicide. But that is a topic, perhaps, for another blog in the future.
The moment Sen. McConnell and Rep. Boehner realize the "They're killing Granny" distortion has seriously backfired. Photo: Life Magazine Archives
They Judge Themselves
This level of greed and deceit is by no means new. The actions of insurance company executives, strategists, and lobbyists, as well as the politicians who parrot their lies are condemned in this passage from the Book of Proverbs in the Bible:
A scoundrel and a villain, who goes about with a corrupt mouth, who winks with his eye, and signals with his feet and motions with his fingers, who plots evil with deceit in his heart–he always stirs up dissension.
Therefore disaster will overtake him in an instant: he will suddenly be destroyed–without remedy.
There are six things that the LORD hates, seven that are detestable to him:
- haughty eyes
- a lying tongue
- hands that shed innocent blood
- a heart that devises wicked schemes
- feet that are quick to to rush into evil
- a false witness who pours out lies
- and a man who stirs up dissension among [others].
Proverbs 6:12-19, NIV
In the article about the Seven Deadly Sins, regarding greed/avarice, Wikipedia writes:
In Dante’s Purgatory, the penitents were bound and laid face down on the ground for having concentrated too much on earthly thoughts.
“Avarice” is more of a blanket term that can describe many other examples of greedy behavior. These include disloyalty, deliberate betrayal, or treason, especially for personal gain, for example through bribery .
Take a look again at the section of the bill I quoted. Read it over several times if you like. Do you honestly see anything that even hints that the purpose or outcome of that provision will endanger Granny?
Granny is going to be so much better cared for under the new legislation. Those who oppose health care reform and are lying to get it defeated are the ones who need to be worried. Very worried.
Greed & Avarice. The sixth of the Seven Deadly Sins. In this depiction, the damned are being boiled in oil. This image appeared in 1496 in Le grant kalendrier des Bergiers, published by Nicolas le Rouge in Troyes, France
I should say in conclusion that both my wife and I have advance directives. So does my mom, the best grandma in our arm of the galaxy.