{"id":168,"date":"2009-08-09T11:35:00","date_gmt":"2009-08-09T11:35:00","guid":{"rendered":"http:\/\/jimgworld.com\/blog1\/2009\/08\/09\/168\/"},"modified":"2010-05-10T19:30:50","modified_gmt":"2010-05-11T00:30:50","slug":"168","status":"publish","type":"post","link":"https:\/\/jimgworld.com\/blog1\/?p=168","title":{"rendered":"WILL OBAMACARE KILL GRANNY?"},"content":{"rendered":"

I’ve been following the political dust-up<\/a> 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) \u201cKill Granny\u201d<\/span> 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. <\/p>\n

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 \u201cno-brainer\u201d. 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. <\/p>\n

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 \u201cliving vegetable\u201d 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 \u201cslippery slope\u201d 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). <\/p>\n

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 \u201cscorched earth\u201d 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 \u201cObama’s Waterloo\u201d. 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. <\/p>\n

However . . . are the Democrats totally innocent regarding Section 1233? There was a very thoughtful article<\/a> 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 \u201ckilling granny\u201d. 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 \u201cslope\u201d does get a bit slippery. Let me quote Mr. Lane:<\/p>\n

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.<\/p><\/blockquote>\n

Mr. Lane continues,<\/p>\n

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?<\/p><\/blockquote>\n

I took a look at Section1233 myself, and I encourage you to do the same. Here’s the LINK<\/a>. This will open up an index to the House bill, and you have to scroll down, find \u201cSection 1233\u201d, and click on it yourself. The government web site doesn’t allow a direct link. <\/p>\n

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:<\/p>\n

(I)the reasons why the development of such an order is beneficial to the individual and the individual’s family<\/p><\/blockquote>\n

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.<\/p>\n

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<\/span> the hero; it was my brother<\/span> who finally told the doctor NO<\/span>). 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 \u201cmeaningful options\u201d. 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. <\/p>\n

Luckily, after 5
\n 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, \u201cwhy couldn’t you close the deal\u201d. <\/p>\n

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. <\/p>\n

Interestingly, I remember one provision on that form; it listed pre-printed reasons for limiting care, in a \u201ccheck box\u201d format. My mother’s doctor had checked a box saying \u201cnot expected to live longer than six months due to health conditions\u201d. Well, it’s now seven months since we refused to sign off on that statement.<\/p>\n

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 \u201cno-hope\u201d 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 \u201cpositive life\u201d, 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 \u201csleepwalking\u201d 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:<\/p>\n

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. <\/p><\/blockquote>\n","protected":false},"excerpt":{"rendered":"

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) \u201cKill Granny\u201d provision. It would allow doctors to charge Medicare for their time if once every five years they take a half […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[7,8],"tags":[],"_links":{"self":[{"href":"https:\/\/jimgworld.com\/blog1\/index.php?rest_route=\/wp\/v2\/posts\/168"}],"collection":[{"href":"https:\/\/jimgworld.com\/blog1\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/jimgworld.com\/blog1\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/jimgworld.com\/blog1\/index.php?rest_route=\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/jimgworld.com\/blog1\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=168"}],"version-history":[{"count":3,"href":"https:\/\/jimgworld.com\/blog1\/index.php?rest_route=\/wp\/v2\/posts\/168\/revisions"}],"predecessor-version":[{"id":1513,"href":"https:\/\/jimgworld.com\/blog1\/index.php?rest_route=\/wp\/v2\/posts\/168\/revisions\/1513"}],"wp:attachment":[{"href":"https:\/\/jimgworld.com\/blog1\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=168"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/jimgworld.com\/blog1\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=168"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/jimgworld.com\/blog1\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=168"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}