Come, eavesdrop on a Death Panel discussion . . .

Today's Wall Street Journal lead editorial confirmed what I wrote in my last column: that the new provision in CMS regulations paying for end-of-life discussions between Medicare beneficiaries and their physicians is actually a good thing. You might have a hard time coming to that conclusion, because the WSJ's approval was buried in a series of tirades against the President and the CMS bureaucracy, as well as a glowing endorsement of Sarah Palin's prescient understanding of the dangers of socialized medicine.
Sidebar: it's becoming increasingly clear that NewsCorp owns the WSJ, as the editorials get snarkier. At least Mr. Murdoch hasn't ruined the reporting. Yet.
I can't vouch for what President Obama would say to a senior, nor what a Council of Liberal Democratic Senators might impose upon that poor Medicare beneficiary, but I can tell you what I talk about when I have these end-of-life discussions with patients.
Here's the first thing you should know: in my experience, physicians only mention "hospice" and "palliative care" in passing, and then someone else - someone who's paid a lesser salary - actually shares the details with the patient. That someone might be a social worker, or a nurse, or somebody like me.
Maybe because I'm not on the government payroll, I don't know any better, but rather than imposing a guilt trip on Granddad ("don't you know that by clinging to life, you're depriving your grandchildren of a decent standard of living??"), I start by listening. I ask a series of questions, to find out what this person believes about life, about quality of life, about family and relationships, about what's most important. And then I listen.
We talk about mortality. The WSJ said it today: no matter how much we improve medical care, we still haven't found a cure for death. Mortality is still 100%. So what we really think about is life-sustaining or death-delaying, and, to put it simply, at what point is death a better option than life.
The reason that so many political pundits on both sides of the aisle are having trouble with the whole "death panel" issue is not their political persuasion. It's something much, much deeper. It's because they haven't dealt with their own mortality. They're scared to death of dying. When I speak with elderly patients about life and death, they are usually at peace with the idea. It's their grown kids (usually the same age as Sarah Palin, or thereabouts) who can't deal with it. This same latent fear is what causes people to say irrational things and make irrational decisions in the political sphere.
We talk about prognosis. That's a fancy word for what we expect the outcome to be. Specifically, what will the outcome be if we do everything, and if we do nothing (or something in-between). On my ball field (oncology), physicians and patients often have conversations about what treatments are available, but sometimes - maybe often - they don't really talk seriously about whether any of those interventions will make a real difference in survival or quality of life. Thus I have seen patients die in the ICU after spending two months on a ventilator, and I wonder, would they have chosen this death?
We talk about how long is long enough. An 89 year old with metastatic lung cancer may decide she's lived a good life and doesn't want to go through the treatment gauntlet for another four months. A 38 year old mother of three with advanced breast cancer, on the other hand, may value as precious beyond price the opportunity to spend the extra two months with her kids (the median improvement in progression free survival from Avastin) that treatment might buy her.
We talk about Quality of Life . . . the elusive, enigmatic quality of life. The problem with quality of life is how to define it. Unfortunately, medical professionals often, arrogantly, assume to define quality of life for their patients. We even try to calculate treatment effectiveness in terms of "quality-adjusted life years." The problem is that nobody can define quality of life for a patient except the patient himself. So what I have to do is ask the patient, "what does 'quality of life' mean for you?" For some it's freedom from pain, or anxiety. For others, it's preservation of autonomy. For some people, quality of life means being allowed to fight for survival to the last breath. For others it means spending their life savings on a trip to Italy, rather than three weeks in the ICU.
After I've listened to the patient talk about what's important to him, we can move to the part of the interview where I talk and the patient listens. I'll tell you about that in the next installment of "Miranda Writes."