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End-of-Life Counseling Back from the Dead

Tuesday, December 28, 2010

Welcome to Politics Bites, where every afternoon at It's a Free Country, we bring you the unmissable quotes from the morning's political conversations on WNYC. Today on the Brian Lehrer Show, medical ethicist Daniel Callahan and journalist Trudy Lieberman discussed a new federal policy that will allow the government to pay doctors to discuss options for end-of-life care with their patients.

Politifact.com’s “Biggest Lie of 2009” is back, in a way.

During the health care reform battle, the phrase “death panels” was used to describe a provision in the bill that would fund end-of-life counseling. That language was eventually removed from the legislation, but through some recent federal rulemaking, the government has decided that next month it will begin paying doctors to discuss end-of-life options with their patients.

Taken collectively, these options are called an “advance directive,” and include things like a living will, whether or not you have a health care proxy, and organ donations. Trudy Lieberman says that these decisions shouldn’t be made lightly.

I think it’s important to remember that it’s really important for people to have these discussions, and I think that importance got totally lost in all that “death panel” business that was going on and the political hysteria that accompanied it. We in the consumer business have always recommended that people have this discussion, and it’s an uncomfortable one. Nobody wants to think about the end of their life and nobody wants to discuss this with their families, but it’s better to think about it than to have your family worry about something at the end.

Both Lieberman and Daniel Callahan said that end-of-life counseling is a necessary good, but Callahan pointed out that the recent debate about who should be paying for it has drawn attention to a major trend in how Americans treat health care.

In our country, culturally, we have a bias toward spending as much as we can at the end of life to prolong life. This is what we, as America, sort of like. That’s been called into question certainly during the health debate and before that, about the money being spent at the end of life and is it worth it.

That concern is relatively new, according to Callahan. With ballooning costs and a struggling economy, legitimate worries about the affordability of such a service have eclipsed the need for elder care in the eyes of many politicians. For decades, Callahan said, it’s been the other way around.

To me, what’s remarkable about the recent turn of things is that for 40 years, there’s been practically no controversy whatsoever about this issue, left or right, everybody agreed patients should have more choice, doctors should be better educated…so a lot of things were started and put in place and there was very little dissent. And somehow this issue got caught up in the other health reform debates and I think a lot of the confusion was in part a confusion between issues of end-of-life care and the rationing of end-of-life care.

Regardless of whether counseling is covered by the government or not, or whether you even make use of it, Callahan insisted that you’re better off having an advance directive than going without one.

If you don’t have an advance directive you are pretty much at the mercy of the physician that takes care of you, and that may be a physician you have never met before in your life, in an emergency room or an ICU, and in that sense you are really quite vulnerable to the ethic of the hospital, to the ethic of the physician. Plus, I’d mention physicians are paid to do things to you, so you’ve got financial incentives working against the good conversation. If you’ve left no directions, you better hope you have a very good and sensitive doctor.

When asked if the federal government’s move to fund counseling is an example of backdoor democracy, since it was a policy that had been removed from accepted legislation, Lieberman said that it’s the kind of thing our government is always doing. What’s most important is that we know about it.

There’s rulemaking going on all the time in the federal government. The issue is we need to be looking at those rules and finding out what’s going to happen and reporting on them. They kind of did this on the quiet hoping they wouldn’t have the...backlash, and they did it during the holidays when people aren’t paying as much attention, but we need to be looking at those rules.

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Comments [7]

Milton from Roslyn, NY

I am posting this comment to join others that may agree. Religion aside, I believe I have the right to end my life when I choose to\.

Jan. 01 2011 09:48 AM
alicia

Thank you for this good segment.

As a trust & estate attorney, I have the unique perspective of counseling clients on this very issue. I am commenting on this topic with the intention of sharing that a living will (& health care proxy) is imperative because the document speaks for you when you can't speak for yourself (just remember the unfortunate example of Terry Schivo).

It is a simple process - a simple form that appoints a health care agent to act on your behalf and also indicates how you'd like to be treated if you can't decide for yourself.

It is an issue of empowerment, not death (and inexpensive to complete - I believe that you can even download the form from the NYC or NYS Bar Association website- however, I always recommend consulting with an attorney prior to completing any legal documents).

Dec. 28 2010 10:57 AM
EJ

Brian has twice used the phrase "accurately or not" to describe Sarah Palin's use of the term 'death panels'.

Accurate or not? Not. Very clearly not.

Hyperbolic, yes. Catchy, yes. But accurate? No.

It definitely had legs, and you can say that some people still believe it, or don't understand the reality of what's been proposed, but suggesting that 'death panels' was ever an accurate term is, well, inaccurate.

I get that you want the show to be balanced, but this kind of false equivalency drives me bananas.

Dec. 28 2010 10:55 AM
Michelle from Forest Hills, NY

My husband had a very explicit living will. He made it abundantly clear that he did not want to be incapacitated for life. After emergency surgery, we entered a slippery slope in which the ICU Director did not adhere to the living will. As a result, my husband died a torturous death after one month and millions of dollars of ill-advised treatment. I was helpless despite having all of our preparations. It really does depend on the integrity of the physician in charge and his or her willingness to refrain from imposing his will on others.

Dec. 28 2010 10:54 AM
lafou

The end of life decisions are very confusing for families. It is hard for a "lay person" to absorb all the medical information when a loved one is dying. There is also the lack of objectivity - a trained counselor could pull the information together and help families make humane and intelligent decisions.

Dec. 28 2010 10:45 AM
Mark Hannay from East Village

Please do not use the term "Obamacare" -- it is a term intentionally created by the opponents of health care reform to disparage the new health care reform law. By using this moniker, you foster a quasi-epitath about reform, which was not President Obama's sole act anyway but rather joint with Congress, and actually based on bills crafted in the Senate by Senators Dodd, Baucus, and Reid. Please use the correct term of the new law, the "Patient Protection and Affordable Care Act" (or the "Affordable Care Act" in the vernacular.) The new regualtion concerning advanced directives announced by Obama administration is not part of the ACA per se, which is already enacted law, but is a new Medicare regulation.

Dec. 28 2010 10:42 AM

The biggest case management problems for hospitals are patients who are in serious condition, but have not made advanced directive decisions. Those who have not set criteria for Do Not Intubate and/or Do Not Resuscitate orders, e.g., which may changed with updated directives while in the hospital cannot have their chart marked with those criteria. This means that frail patients may be subjected to aggressive intervention. Most relatives don't recognize that emergency resuscitation involves opening the chest & spreading the ribs for open heart massage, etc. This trauma may, by itself. speed the patient's demise. It is not the only outcome, but it is one that the patient's guardians must take into account if they are forced to make that decision because the ill relative neglected to express wishes by advanced directives.

Dec. 28 2010 10:17 AM

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