I’ve been following the political dust-up regarding Section 1233 of the proposed health care reform bill (HR 3200, the current version in the House of Representatives). This is the famous (some say infamous) “Kill Granny” provision. It would allow doctors to charge Medicare for their time if once every five years they take a half an hour or so to inform Medicare patients about advance care planning, i.e. about setting written limits on the amount of life-sustaining care that is to be provided in situations where the patient’s quality of life and life expectancy are diminished.
The prime example of how a care-limitation order can help involves brain-dead patients who could be kept alive for many months or years on life support, but have no chance of ever regaining conscious awareness. Most people would agree that they don’t want to be kept alive in such circumstances; that situation, pardon the pun, is a “no-brainer”. So why not let the government pay doctors to help people who might face a similar situation to put their intent into writing, so that our base-line social ethic of preserving life at all cost can be short-circuited? Again, most of us would agree that there are situations where that base-line moral rule should be put aside so that a person can die more quickly.
The Republicans, in a battle-move typical of what we have come to expect in the never-ending political war between the GOP and the Democrats, are accusing Obama and the Democrats of promoting Section 1233 not to mitigate the relatively rare but tragic “living vegetable” situation, but to help control medical costs and thus the need for tax increases stemming from their overall health care reform proposal. In other words, the GOP sees a “slippery slope” here, whereby doctors will swindle patients into signing health care orders that go beyond the vegetable situation, allowing the health care system to pull the plug in situations where a patient could be kept alive and conscious for a while, but at great cost. According to Dartmouth University data, the average cost of care for a chronically ill Medicare patient in the final six months of life is $46,400. If we could just cut that down to three months, maybe two, based on some creative legal interpretations of the care limitation orders that these sick old folks are signing, then hey, that buys some financial breathing room for the other cost-intensive provisions of Obamacare (especially the idea of imposing universal coverage without any limits on malpractice tort claims; the Dems rightly love universal coverage, but wrongly hate malpractice limits given that tort lawyers give much money to them).
The Democrats and their truth-squads are fighting back against this Orwellian, slippery-slope interpretation of Section 1233. They point out that nothing is being forced on anyone, that the patient has the right to refuse such counseling, and even if counseled, has the right to just say no to care limitation orders. And they’re right. The Republicans are pursuing the usual “scorched earth” political tactics, trying to get revenge against the Democrats for their election successes in 2006 and 2008. GOP Senator Jim DeMint said outright that he wants health care to be “Obama’s Waterloo”. Basically he’s saying that his first priority is to restore the power and glory of the Republican party, and only after that will he think about the good of the citizens, many of whom are having a real problem with health care these days. These are the kind of politics that threaten the long-range prospects of our nation.
However . . . are the Democrats totally innocent regarding Section 1233? There was a very thoughtful article yesterday about this in the Washington Post by Charles Lane, a member of the WaPo editorial board (yes, that bastion of the liberal-distorted main-stream media). Like me, Mr. Lane immediately dismisses the Republican rhetoric about “killing granny”. But when you read Section 1233 and think about how it will work with old and sick patients, you can envision situations where the Proverbial “slope” does get a bit slippery. Let me quote Mr. Lane:
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.
Mr. Lane continues,
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, [Section 1233] is vague and possibly unenforceable. What are “key questions”? Who belongs on “a list” of helpful “resources”? The Roman Catholic Church? Jack Kevorkian?
I took a look at Section1233 myself, and I encourage you to do the same. Here’s the LINK. This will open up an index to the House bill, and you have to scroll down, find “Section 1233”, and click on it yourself. The government web site doesn’t allow a direct link.
Anyway, you will see that Section 1233 includes a list of requirements for any ‘advance care planning consultation’ that it will pay for. One of these requirements is as follows:
(I)the reasons why the development of such an order is beneficial to the individual and the individual’s family
OK, so the doctor is required to talk about the pros of a care limitation order. But what about the cons? What about the possibility that the patient will die because of limited care when they might have lived consciously with a certain amount of dignity and emotional quality for several more months? You might say, oh, what are the chances of that? Well, to that I will answer: I recently saw a situation where an elderly person’s family was encouraged to sign a care limitation order that, as it turned out, would have prevented the elderly person in question from additional months of dignified life.
The situation regarded my own mother, and I was involved in the decision not to sign an order that was proposed by my mother’s doctor along with various staff members of the hospital where she was being treated. (But I’m not the hero; it was my brother who finally told the doctor NO). She was having severe breathing problems and could only be kept alive with a ventilator in an intensive care ward. She required about 40 days of very expensive care, mostly paid by Medicare. The hospital in question is owned by an order of Catholic nuns, and has crucifixes in every room. However, after two weeks, the hospital staff started getting antsy about my mother; the social workers started telling my brother and me about “meaningful options”. Her doctor was honest with us; he told us that the hospital is going broke and wanted to get my mother out, since Medicare doesn’t adequately compensate them in such situations.
Luckily, after 5
weeks my mother started rallying and got off the ventilator. Still, in the final week of that incident, the doctor took my brother and me aside and showed us a form printed and used by the hospital, a form that would allow us to limit my mother’s care should she have future breathing incidents. Following a stand-up discussion near a nursing station, one that reached an emotional pitch, my brother finally told him that we did not want this order (even though my brother had initially signed it). The doctor later told us that he was brought before a hearing by a hospital committee about this; kind-of like, “why couldn’t you close the deal”.
About a month later, my mother had a repeat breathing seizure and was brought back to the hospital and placed on a ventilator once again. But this time she rallied back after about 3 weeks, and soon went home. For the past 6 months, she has been living a comfortable life with my brother and her home care assistants. She is aware of her surroundings and knows who is with her. She can open her eyes and say a few words; she coherently answers questions, albeit with a simple yes or no. She still smiles. This possibly would not have happened had we signed that order; given that it would have remained in her file, the hospital might not have installed the ventilator when she showed up a second time.
Interestingly, I remember one provision on that form; it listed pre-printed reasons for limiting care, in a “check box” format. My mother’s doctor had checked a box saying “not expected to live longer than six months due to health conditions”. Well, it’s now seven months since we refused to sign off on that statement.
I don’t have evidence that would hold up in court proving that the doctor and the hospital were trying to limit my mother’s health care before she was in a “no-hope” situation, inspired by their financial crisis. But there is enough evidence to make me worry, to give me a creepy feeling. I’m not saying that provisions like Section 1233 should be banned, and I certainly will admit that our nation may not be capable of promising everyone the level of care that will allow them to enjoy every last second of “positive life”, i.e. life where there is still some form of mutually loving relationship going on. But I DO believe that there is a danger here of “sleepwalking” into something Orwellian. I’m sorry that the GOP brought this up in such a stupid, venal fashion. But I am glad that they brought it up. I’ll let Mr. Lane have the last word:
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.
Jim,
I am not sure where to start in responding to the “WILL OBAMACARE KILL GRANNY?” blog. This entire topic and the very emotional and fearful response of so many people to the topic has me wondering if the response is a response to the “health care for everyone” issue OR a response to what seems to me the baby boomers response to their own growing age concerns.
First of all, the “kill Granny” approach to the topic (or Palin’s approach that goes something to the effect that Obama’s plan would kill her son who has Down syndrome) seems to me to be entirely out of line, designed to elicit an primal and fearful emotional response to even approaching the topic of the health care issue—all the while demanding that everyone in the U.S. get the same health care as the members of Congress get.
Part of the problem, as I see it, is a broader one that involves the fact that science has gotten way ahead of any careful, ethical tho’t on what it can do, not only in considering when/if/how a person will die but other broad issues such as cloning of individuals, all the surrogate mother issues, etc. Science, for years and years, has been barreling ahead with what it can do—and goes ahead and does what it can do—without allowing people in general to assimilate all that science can do or to engage first in any discussion or consideration of the concept that just because something CAN be done, it SHOULD be done.
Another point that bothers me about the discussion of this topic is that the GOP is flatly and blatantly forcing the discussion into a no-win position for anyone who wants to calmly and seriously discuss health care issues. It seems that the town hall meetings have turned into people in some kind of panic insisting on the one hand that all people should receive the very best of health care while on the other hand unhesitatingly labeling all who do not agree with their very emotional position as “killers” of some sort. One way or the other, emotions of earthquake intensity have taken over the discussion, crowding out any calm, careful, thoughtful, and seriously considered openness to anyone who does not agree with the opinion of those who have taken the “emotional road.”
Then too, I think about Hillary Clinton’s health care approach some years ago. It seems she did not have an “idea” that allowed Congress to come up with the practical aspects of the plan; her proposal (if I understand correctly) was very specific and concrete. It was shot down faster than one could say “new health care plan.” Now Obama comes along with just the IDEA of changing the health care system, and all hell breaks loose because now he will “kill” all the unwanted members of society. Please, give me a break! Once again I say, it seems to me that somehow this issue is tapping into the fear of the baby boomers that some day they will actually have to die. Further evidence of this fear is what I have watched over the last few decades as the baby boomers have grown older. First it was “don’t trust anybody over thirty.” Then it was “thirty is the new twenty”; then forty is the new thirty; then fifty is the new forty; now it seems sixty is the new fifty. And in a few years probably seventy be the new sixty. (In fact, I actually did hear something akin to exactly that last one recently in a discussion of people retiring.) Again, I say, please, give me a break!
(Continued….)
Comment by MCS — August 10, 2009 @ 3:39 am
Jim,
I am not sure where to start in responding to the “WILL OBAMACARE KILL GRANNY?” blog. This entire topic and the very emotional and fearful response of so many people to the topic has me wondering if the response is a response to the “health care for everyone” issue OR a response to what seems to me the baby boomers response to their own growing age concerns.
First of all, the “kill Granny” approach to the topic (or Palin’s approach that goes something to the effect that Obama’s plan would kill her son who has Down syndrome) seems to me to be entirely out of line, designed to elicit an primal and fearful emotional response to even approaching the topic of the health care issue—all the while demanding that everyone in the U.S. get the same health care as the members of Congress get.
Part of the problem, as I see it, is a broader one that involves the fact that science has gotten way ahead of any careful, ethical tho’t on what it can do, not only in considering when/if/how a person will die but other broad issues such as cloning of individuals, all the surrogate mother issues, etc. Science, for years and years, has been barreling ahead with what it can do—and goes ahead and does what it can do—without allowing people in general to assimilate all that science can do or to engage first in any discussion or consideration of the concept that just because something CAN be done, it SHOULD be done.
Another point that bothers me about the discussion of this topic is that the GOP is flatly and blatantly forcing the discussion into a no-win position for anyone who wants to calmly and seriously discuss health care issues. It seems that the town hall meetings have turned into people in some kind of panic insisting on the one hand that all people should receive the very best of health care while on the other hand unhesitatingly labeling all who do not agree with their very emotional position as “killers” of some sort. One way or the other, emotions of earthquake intensity have taken over the discussion, crowding out any calm, careful, thoughtful, and seriously considered openness to anyone who does not agree with the opinion of those who have taken the “emotional road.”
Then too, I think about Hillary Clinton’s health care approach some years ago. It seems she did not have an “idea” that allowed Congress to come up with the practical aspects of the plan; her proposal (if I understand correctly) was very specific and concrete. It was shot down faster than one could say “new health care plan.” Now Obama comes along with just the IDEA of changing the health care system, and all hell breaks loose because now he will “kill” all the unwanted members of society. Please, give me a break! Once again I say, it seems to me that somehow this issue is tapping into the fear of the baby boomers that some day they will actually have to die. Further evidence of this fear is what I have watched over the last few decades as the baby boomers have grown older. First it was “don’t trust anybody over thirty.” Then it was “thirty is the new twenty”; then forty is the new thirty; then fifty is the new forty; now it seems sixty is the new fifty. And in a few years probably seventy be the new sixty. (In fact, I actually did hear something akin to exactly that last one recently in a discussion of people retiring.) Again, I say, please, give me a break!
(Continued….)
Comment by MCS — August 10, 2009 @ 3:39 am
(Continued from above)
With regard to the example you give of your own mother’s health care, I say bravo to you and your brother for holding your own position against the doctors. HOWEVER, I can cite the exact opposite in my own mother’s case. She was extremely clear that when she came to her last illness, she wanted to be left to die in peace. Before she lapsed into the coma that preceded her death, she explicitly answered carefully and fully EACH AND EVERY question the doctors posed to her about sustaining her life—all in the “NO, I don’t want that” category. YET my siblings and I had a terrible “fight” with the doctors to respect her wishes. (Simply the exact opposite of what your situation with your mother currently is.) My mother was in a coma, incommunicative, yet the doctors took an attitude that we were less than remiss in care for our mother, fought us at every turn, insisting that she be put on life-sustaining machines, when she had been insistent she wanted none of that. My siblings and I were left to hold our ground against doctors, nurses, and other hospital care givers who led us to feel we were not doing the BEST we could for our mother. To say we were distressed by this attitude is to underestimate the effect the doctors’ (and other hospital personnel) unsolicited opinions about our mother’s care had on my siblings and me. Yet, as your and your brother have done/are doing, we too in our own situation had to form a bulwark and stand our ground for love of our mother.
Perhaps the real problem in the discussion of “slippery slopes” and oh-you-could-choose-hospice-in-this-case (“hint, hint” really meaning, let’s get rid of this one) is a lack of respect for those who disagree with the position we ourselves may feel guilty about, may not be too sure we want to take for ourselves, have given no careful tho’t to looking into before the time comes when such decisions are made, the ever present tendency of today’s society to refuse to take any serious responsibility for themselves and always to be looking for “who-is-to-blame-for-this-situation”, and the inability of the baby boomers to accept the fact that they too will some day reach a point where they will have to die. It seems to me that no matter what happens these days, few people are able to stand up (as you and your brother have done in your case—and as my siblings and I had to do in my mother’s case) and take the responsibility for the disparate positions chosen by the ones we lovingly care for.
Furthermore, I find the general conservative GOP position—especially the conservative GOP position represented by Rush Limbaugh, Sarah Palin, etc., to be close to treasonous. To work for FAILURE of the government in power is bordering on treason, it seems to me. Yet, it seems that so many of the GOP conservatives, just because they lost the election, have taken this “I hope you fail” position. I find myself wondering: Are they really treasonous? OR are they simply—literally—CHILDISH? As in little kids who, when they don’t get their way, say things like “I hate you” or “I hope you die” without truly understanding what they are saying. Can it be that this group of people has not advanced beyond the emotional level of five or six year olds?
I wonder why it cannot be that disparate opinions cannot be respected, why people cannot think through what it is they want for themselves and take the responsibility for that decision without a feeling of serious guilt—even in a discussion that tends to arouse deep, “earthquake” emotions. Well, perhaps one good thing has come of the Obama health care plan: Perhaps, when all the emotion has calmed down, people will be able to take responsibility for their decisions without feeling that someone else must be responsible and will assume, without guilt, their own responsible decision-making.
MCS
Comment by MCS — August 10, 2009 @ 3:52 am
(Continued from above)
With regard to the example you give of your own mother’s health care, I say bravo to you and your brother for holding your own position against the doctors. HOWEVER, I can cite the exact opposite in my own mother’s case. She was extremely clear that when she came to her last illness, she wanted to be left to die in peace. Before she lapsed into the coma that preceded her death, she explicitly answered carefully and fully EACH AND EVERY question the doctors posed to her about sustaining her life—all in the “NO, I don’t want that” category. YET my siblings and I had a terrible “fight” with the doctors to respect her wishes. (Simply the exact opposite of what your situation with your mother currently is.) My mother was in a coma, incommunicative, yet the doctors took an attitude that we were less than remiss in care for our mother, fought us at every turn, insisting that she be put on life-sustaining machines, when she had been insistent she wanted none of that. My siblings and I were left to hold our ground against doctors, nurses, and other hospital care givers who led us to feel we were not doing the BEST we could for our mother. To say we were distressed by this attitude is to underestimate the effect the doctors’ (and other hospital personnel) unsolicited opinions about our mother’s care had on my siblings and me. Yet, as your and your brother have done/are doing, we too in our own situation had to form a bulwark and stand our ground for love of our mother.
Perhaps the real problem in the discussion of “slippery slopes” and oh-you-could-choose-hospice-in-this-case (“hint, hint” really meaning, let’s get rid of this one) is a lack of respect for those who disagree with the position we ourselves may feel guilty about, may not be too sure we want to take for ourselves, have given no careful tho’t to looking into before the time comes when such decisions are made, the ever present tendency of today’s society to refuse to take any serious responsibility for themselves and always to be looking for “who-is-to-blame-for-this-situation”, and the inability of the baby boomers to accept the fact that they too will some day reach a point where they will have to die. It seems to me that no matter what happens these days, few people are able to stand up (as you and your brother have done in your case—and as my siblings and I had to do in my mother’s case) and take the responsibility for the disparate positions chosen by the ones we lovingly care for.
Furthermore, I find the general conservative GOP position—especially the conservative GOP position represented by Rush Limbaugh, Sarah Palin, etc., to be close to treasonous. To work for FAILURE of the government in power is bordering on treason, it seems to me. Yet, it seems that so many of the GOP conservatives, just because they lost the election, have taken this “I hope you fail” position. I find myself wondering: Are they really treasonous? OR are they simply—literally—CHILDISH? As in little kids who, when they don’t get their way, say things like “I hate you” or “I hope you die” without truly understanding what they are saying. Can it be that this group of people has not advanced beyond the emotional level of five or six year olds?
I wonder why it cannot be that disparate opinions cannot be respected, why people cannot think through what it is they want for themselves and take the responsibility for that decision without a feeling of serious guilt—even in a discussion that tends to arouse deep, “earthquake” emotions. Well, perhaps one good thing has come of the Obama health care plan: Perhaps, when all the emotion has calmed down, people will be able to take responsibility for their decisions without feeling that someone else must be responsible and will assume, without guilt, their own responsible decision-making.
MCS
Comment by MCS — August 10, 2009 @ 3:52 am