Death Panels

Newt Gingrich and Sarah Palin have something in common . . . they both have attacked the end-0f-life planning section of the House's health care reform bill. Newt was more sophisticated in his attacks, refraining from using Sarah's term, "Death Panels," but called it the same in so many words. Sarah really believes it. Newt is too smart to believe it, but too Machiavellian to pass up the opportunity to terrorize the simpler-minded in our country for his own political gain.

Have you read the "Death Panel" clause? It begins on page 424 of the House bill (the version authored by Rep. Dingell, et al.) Before you start hiding your grandparents and your children with Downs Syndrome in the cellar, just take a look at this section of the bill amending Sec. 1861 of the Social Security Act. When you actually read it you'll discover that it is, very simply, an amendment that requires Medicare to pay for "advance planning consultations" not more than every five years.

And what is an advance planning consultation? It's an opportunity for a Medicare beneficiary to sit down with his or her physician and have an honest conversation about what is often inappropriately called "end of life" issues. In fact, these are issues we all face every day, but those of us who are young enough to be in denial about our mortality successfully avoid. They are decisions that every one of us should already be thinking about, in case we get hit by a bus, or get diagnosed with leukemia, or suffer some other trauma or life-threatening disease.

There are several elements to an advance planning consultation. The practitioner educates the patient about these issues, and then the patient asks questions and thinks out loud. The practitioner provides resources to the patient. The patient might make some decisions during the consultation, or he might go home and think about all these issues. The patient is not required to make any decisions regarding end of life care. Here are the things you talk about:

• Advance directives (living wills, durable powers of attorney for health care, etc.)
• What kind of life sustaining treatments you want - or don't want - in the event that you get really sick and you are not able to speak for yourself (you're unconscious or on a ventilator, etc.).
• Health care proxies: the person who will speak on your behalf in the event you can't speak for yourself, to make sure your wishes are carried out.
• Palliative care and hospice. These are not the same thing, by the way. Palliation is treatment that eases your symptoms, like pain management. You can receive palliative care while being aggressively treated, as well as when receiving only supportive care. Hospice is "end of life" care for the terminally ill. It is not euthanasia. It's symptom management when cure is no longer possible, allowing nature to take her course, and death to come naturally.

Is advance planning morbid? In the mind of most people, yes. That's because most people are afraid of death and don't want to think about it. Ever.

I don't have the luxury of living in this denial. In my work, I have seen many people die. I have been in the patient's room a hundred times - in the ICU, in the oncology unit, in the Emergency room. I have seen people die good deaths. They were prepared. They knew they were dying, and so did their families and loved ones. These patients are usually the patients who made these difficult decisions about the end of life. And because they faced the difficult decisions, they were able to die peacefully, surrounded by family, often in prayer, sometimes even singing hymns.

I have also seen patients die horrible deaths. I have seen patients coded over and over again, shocked with defibrillators, their ribs cracked from chest compressions. I have seen patients kept in the dark space between life and death, tethered to ventilators and dialysis machines, with no hope for survival, but trapped by loved ones who can't let go or won't let go. Sometimes they're trapped by the guilt of a survivor who didn't make amends for hurts inflicted long ago. Other times patients are kept in literal purgatory because a husband or wife or adult child has been asked to make a decision - a decision they never before considered - to "withdraw care"; that is, to stop treatment. And he can't. Because it feels like he is actively taking the patient's life.

The common denominator in these terrible deaths is that these patients, and often their physicians, avoided those difficult end-of-life discussions, hoping to escape the necessity. And then the crisis arrives like a thief in the night, leaving them no time to make those decisions.

In the House bill, advance planning consultations are purely voluntary. The patient must request it from the practitioner. All the bill attempted to do was to provide payment to the doctor for taking the time to have these conversations. Because right now, your doctor does not get paid to sit with you for an hour and talk you through these difficult but necessary decisions. And with what Medicare pays your doctor, he or she can't afford to give up six paying patients to spend an hour with you for free. This bill was going to enable your doctor to make time for you.

Alas! Because of intellectually challenged people like Sarah Palin, and morally challenged people like Newt Gingrich, the odds are now that the advance planning consultation clause will be struck from the bill.

Now let me say one more thing about "Death Panels." The purveryors of scare tactics want you to believe that a government-run health care system will ration care, focusing on the brightest and best of society and putting the weak and old to death. Don't you know that this is already happening? And not at the hands of the federal government, but under private health insurance and market driven health care.

When I was a case manager for oncology patients in the hospital, I could not count the number of times I was pressured by an insurance case manager to talk to their beneficiaries about hospice. I would call the insurance company to give them an update on the patient's condition. The nurse on the other end of the line would often say something like this: "Well this patient has cancer. She probably doesn't have long. Why is she getting treatment? Don't you think she should go on hospice? You need to bring up hospice with the patient." Sometimes the patient really was near the end of life. Sometimes the patient had just gotten diagnosed. If the patient's cancer had just recurred, or if it had spread, I was sure to get the hospice "option" pushed onto me.

Let me say this about hospice: it is a wonderful service for somebody who needs it and wants it. But the decision to choose hospice care is a philosophical decision, not an economic one. And it's the patient's decision, not the payer's.

Advance planning consultations - are they Death Panels? Not at all! They are actually Life-giving conversations. Because, in the words of a great prayer, until we are prepared to die, we never really are prepared to live. The issue, friends, is not whether the big bad government is going to take the decision of life an death away from us. The issue is whether we choose to exert control over that decision ourselves. The enemy is not the government, and it isn't even the insurance company. The enemy, in the words of Pogo, is us.