It's Not Just Conservatives With A Problem With End of Life Provision

[Annie]

If your first instinct is to think, this reporter must be from the 'right', check out his other columns:

washingtonpost.com

Undue Influence
The House Bill Skews End-of-Life Counsel
By Charles Lane
Saturday, August 8, 2009

About a third of Americans have living wills or advance-care directives expressing their wishes for end-of-life treatment. When seniors who don't have them arrive in a hospital terminally ill and incapacitated, families and medical workers wrestle with uncertainty -- while life-prolonging machinery runs, often at Medicare's expense. This has consequences for families and for the federal budget.

Enter Section 1233 of the health-care bill drafted in the Democratic-led House, which would pay doctors to give Medicare patients end-of-life counseling every five years -- or sooner if the patient gets a terminal diagnosis.

On the far right, this is being portrayed as a plan to force everyone over 65 to sign his or her own death warrant. That's rubbish. Federal law already bars Medicare from paying for services "the purpose of which is to cause, or assist in causing," suicide, euthanasia or mercy killing. Nothing in Section 1233 would change that.

Still, I was not reassured to read in an Aug. 1 Post article that "Democratic strategists" are "hesitant to give extra attention to the issue by refuting the inaccuracies, but they worry that it will further agitate already-skeptical seniors."

If Section 1233 is innocuous, why would "strategists" want to tip-toe around the subject?

Perhaps because, at least as I read it, Section 1233 is not totally innocuous.

Until now, federal law has encouraged end-of-life planning -- gently. In 1990, Congress required health-care institutions (not individual doctors) to give new patients written notice of their rights to make living wills, advance directives and the like -- but also required them to treat patients regardless of whether they have such documents.

The 1997 ban on assisted-suicide support specifically allowed doctors to honor advance directives. And last year, Congress told doctors to offer a brief chat on end-of-life documents to consenting patients during their initial "Welcome to Medicare" physical exam. That mandate took effect this year.

Section 1233, however, addresses compassionate goals in disconcerting proximity to fiscal ones. Supporters protest that they're just trying to facilitate choice -- even if patients opt for expensive life-prolonging care. I think they protest too much: If it's all about obviating suffering, emotional or physical, what's it doing in a measure to "bend the curve" on health-care costs?

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.

As it happens, I have a living will and a durable power of attorney for health care. I'm glad I do. I drew them up based on publicly available medical information, in consultation with my family and a lawyer. No authority figure got paid by federal bean-counters to influence me. I have a hunch I'm not the only one who would rather do it that way.

 

[Emma]

Health care providers establish a plan of care for every patient they encounter, regardless of age or condition or health status. These care plans must include informed decisions from the patient (or their representative) as to what the goals of treatment are to be. It's kinda hard to obtain informed input from people who are not, well, informed.

Some people fail to understand that advance care planning doesn't necessarily equate to making a person a DNR. An advance directive can also instruct providers to perform life-sustaining measures, or specific treatments and procedures (such as tube feedings, for example). It doesn't even have to include a 'living will' portion at all. That's why it's called a directive.

Many also fail to understand that advance directives are NOT written in stone. They can be revised or even reversed at any time (as can DNR orders resulting from these directives).

An advance directive that does include a 'living will' is not a DNR order. That is a specific order from a physician that must be written, regardless of the presence of a living will. Again, that is why it is called a directive. Without such a directive, the default is that we do everything. This simply guides your physicians as to what your wishes are for end-of-life care.

I see absolutely nothing wrong with compensating a physician for providing the counseling regarding advance care planning. Advance care planning is FAR more than just executing an advance directive, and can be an involved process.

My question to you (and the author) is why do you feel a physician shouldn't be paid for the time they spend on this aspect of patient care?

 

[Annie]

...
My question to you (and the author) is why do you feel a physician shouldn't be paid for the time they spend on this aspect of patient care?

Neither said, nor implied. The idea of built in incentives is the problem. Think about false medicaid reports, read about those all the time. Now imagine a computer program that can 'reeducate' everyone over 60 every 5 years. That's just one aspect.

More to the point of your post, the issues of medical power of attorney, living wills, etc., belong with the patient, family, state of health, etc. Not just because they hit a certain age and visit the doc. The state is not your daddy and you are not a child, neither is your grandmother, etc.

 

[xsited1]

See this?

FOXNews.com - Oregon Offers Terminal Patients Doctor-Assisted Suicide Instead of Medical Care - America's Future

 

[WillowTree]

Health care providers establish a plan of care for every patient they encounter, regardless of age or condition or health status. These care plans must include informed decisions from the patient (or their representative) as to what the goals of treatment are to be. It's kinda hard to obtain informed input from people who are not, well, informed.

Some people fail to understand that advance care planning doesn't necessarily equate to making a person a DNR. An advance directive can also instruct providers to perform life-sustaining measures, or specific treatments and procedures (such as tube feedings, for example). It doesn't even have to include a 'living will' portion at all. That's why it's called a directive.

Many also fail to understand that advance directives are NOT written in stone. They can be revised or even reversed at any time (as can DNR orders resulting from these directives).

An advance directive that does include a 'living will' is not a DNR order. That is a specific order from a physician that must be written, regardless of the presence of a living will. Again, that is why it is called a directive. Without such a directive, the default is that we do everything. This simply guides your physicians as to what your wishes are for end-of-life care.

I see absolutely nothing wrong with compensating a physician for providing the counseling regarding advance care planning. Advance care planning is FAR more than just executing an advance directive, and can be an involved process.

My question to you (and the author) is why do you feel a physician shouldn't be paid for the time they spend on this aspect of patient care?

have you, as yet explained the 500 billion dollars in cuts to medicare! who will suffer? who will be denied? have you explained that.

 

[geauxtohell]

See this?

FOXNews.com - Oregon Offers Terminal Patients Doctor-Assisted Suicide Instead of Medical Care - America's Future

Good for fox news for breaking this. I mean, Oregon has only been doing this for over a decade. Of course, anything to pimp the issue, right?

At any rate, 400 patients have utilized this option.

This is completely different than end of life planning. PAS is for patients who meet a distinct set of criteria, are terminal (not merely depressed), and have themselves chosen the option.

The facts:
FAQs about Death with Dignity

 

[rdean]

Not sure what "End of Life" is.

But "Living Will" was authored by Republican Senator Susan Collins. More than a third of "Obama's" bill was written by Republicans.

 

[Annie]

Not sure what "End of Life" is.

But "Living Will" was authored by Republican Senator Susan Collins. More than a third of "Obama's" bill was written by Republicans.

Anything the government defines it as, if we go along.

 

[Zoom-boing]

In an April 28 New York Times interview, the president spoke of having government guide a "very difficult democratic conversation" about "those toward the end of their lives [who] are accounting for potentially 80 percent of the total health care bill out here." Those statements sounded a little creepy to us. Deciding who gets denied care at the end of life should not be dependent on government cost controls.

Presidential health care adviser Ezekiel Emanuel, brother of White House Chief of Staff Rahm Emanuel and chairman of the Department of Bioethics at the Clinical Center at the National Institutes of Health, has argued that independent government boards should decide policy on end-of-life care. He also has defended rationing care more strictly for older people because "allocation [of medical care] by age is not invidious discrimination."

It is in that light that House Republicans warn against draft Section 1233 of the House Democratic health care bill as an area of deep concern. It provides for seniors, every five years, to be provided "advance care planning consultation" for "end-of-life services." House Minority Leader John A. Boehner of Ohio and Republican Rep. Thaddeus McCotter of Michigan warn that the provision "may start us down a treacherous path toward government-encouraged euthanasia."

If that fear sounds far-fetched, consider that similar things already are happening in several states. As Jeff Emanuel (no relation to the Obama officials) explains on the facing page, a panel of the U.S. 11th Circuit Court of Appeals this spring ruled that Georgia can override a doctor's decision about how much care is warranted for a handicapped child because the state is "the final arbiter" of medical decisions.

The situation is even worse in Oregon, which has legalized "assisted suicide." As radio host and author Mark Levin has publicized in his best-seller "Liberty and Tyranny," the Oregon health plan last year refused to pay for a recognized drug to prolong the life of lung cancer patient Barbara Wagner even after her oncologist prescribed it. Yet the same bureaucrats told Ms. Wagner that the plan would indeed cover doctor-assisted suicide if she chose that option.

Saving her life was deemed too expensive, but paying her to die was just fine.

EDITORIAL: A euthanasia mandate - Washington Times

 

[WillowTree]

In an April 28 New York Times interview, the president spoke of having government guide a "very difficult democratic conversation" about "those toward the end of their lives [who] are accounting for potentially 80 percent of the total health care bill out here." Those statements sounded a little creepy to us. Deciding who gets denied care at the end of life should not be dependent on government cost controls.

Presidential health care adviser Ezekiel Emanuel, brother of White House Chief of Staff Rahm Emanuel and chairman of the Department of Bioethics at the Clinical Center at the National Institutes of Health, has argued that independent government boards should decide policy on end-of-life care. He also has defended rationing care more strictly for older people because "allocation [of medical care] by age is not invidious discrimination."

It is in that light that House Republicans warn against draft Section 1233 of the House Democratic health care bill as an area of deep concern. It provides for seniors, every five years, to be provided "advance care planning consultation" for "end-of-life services." House Minority Leader John A. Boehner of Ohio and Republican Rep. Thaddeus McCotter of Michigan warn that the provision "may start us down a treacherous path toward government-encouraged euthanasia."

If that fear sounds far-fetched, consider that similar things already are happening in several states. As Jeff Emanuel (no relation to the Obama officials) explains on the facing page, a panel of the U.S. 11th Circuit Court of Appeals this spring ruled that Georgia can override a doctor's decision about how much care is warranted for a handicapped child because the state is "the final arbiter" of medical decisions.

The situation is even worse in Oregon, which has legalized "assisted suicide." As radio host and author Mark Levin has publicized in his best-seller "Liberty and Tyranny," the Oregon health plan last year refused to pay for a recognized drug to prolong the life of lung cancer patient Barbara Wagner even after her oncologist prescribed it. Yet the same bureaucrats told Ms. Wagner that the plan would indeed cover doctor-assisted suicide if she chose that option.

Saving her life was deemed too expensive, but paying her to die was just fine.

EDITORIAL: A euthanasia mandate - Washington Times

 

[Emma]

Health care providers establish a plan of care for every patient they encounter, regardless of age or condition or health status. These care plans must include informed decisions from the patient (or their representative) as to what the goals of treatment are to be. It's kinda hard to obtain informed input from people who are not, well, informed.

Some people fail to understand that advance care planning doesn't necessarily equate to making a person a DNR. An advance directive can also instruct providers to perform life-sustaining measures, or specific treatments and procedures (such as tube feedings, for example). It doesn't even have to include a 'living will' portion at all. That's why it's called a directive.

Many also fail to understand that advance directives are NOT written in stone. They can be revised or even reversed at any time (as can DNR orders resulting from these directives).

An advance directive that does include a 'living will' is not a DNR order. That is a specific order from a physician that must be written, regardless of the presence of a living will. Again, that is why it is called a directive. Without such a directive, the default is that we do everything. This simply guides your physicians as to what your wishes are for end-of-life care.

I see absolutely nothing wrong with compensating a physician for providing the counseling regarding advance care planning. Advance care planning is FAR more than just executing an advance directive, and can be an involved process.

My question to you (and the author) is why do you feel a physician shouldn't be paid for the time they spend on this aspect of patient care?

have you, as yet explained the 500 billion dollars in cuts to medicare! who will suffer? who will be denied? have you explained that.

You keep asking about that (even though it's not the topic here). Do you have a link to the section of the bill where $500 billion in Medicare is going to be cut?