Patterico's Pontifications

12/27/2010

Return of the mythical death panels? (Bumped and Updated)

Filed under: General — Karl @ 7:43 am

Update: Bumped by Aaron Worthing, because I think this does not deserve to be lost over the Christmas weekend.

[Posted by Karl]

All the news that is fit to bury on the Christmas weekend:

When a proposal to encourage end-of-life planning touched off a political storm over “death panels,” Democrats dropped it from legislation to overhaul the health care system. But the Obama administration will achieve the same goal by regulation, starting Jan. 1.

***

Congressional supporters of the new policy, though pleased, have kept quiet. They fear provoking another furor like the one in 2009 when Republicans seized on the idea of end-of-life counseling to argue that the Democrats’ bill would allow the government to cut off care for the critically ill.

The terms of controversial section 1233 of the House version of ObamaCare are to return by regulatory fiat? And its supporters want to keep it a secret? Yeah, it is tough to see how that plays well.

Of course, Sarah Palin was not the only person who had the heebie-jeebies over this proposal. Liberals like Charles Lane and Eugene Robinson, and civil libertarians like Nat Hentoff ranged from uneasy to scared after considering the issue. As Lane wrote at the time:

Section 1233 *** addresses compassionate goals in disconcerting proximity to fiscal ones. Supporters protest that they’re just trying to facilitate choice — even if patients opt for expensive life-prolonging care. I think they protest too much: If it’s all about obviating suffering, emotional or physical, what’s it doing in a measure to “bend the curve” on health-care costs?

Though not mandatory, as some on the right have claimed, the consultations envisioned in Section 1233 aren’t quite “purely voluntary,” as Rep. Sander M. Levin (D-Mich.) asserts. 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. So when Rep. Earl Blumenauer (D-Ore.) denies that Section 1233 would “place senior citizens in situations where they feel pressured to sign end-of-life directives that they would not otherwise sign,” I don’t think he’s being realistic.

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)…

Incidentally, as I did not write much about the “death panels” kerfuffle, I should state for the record that I always thought it a term that would have been better applied to proposals like those for the Independent Payment Advisory Board, which would become a key part of “bending the cost curve down,” just as is happening with global budgeting in Massachusetts. Obama and his minions always said those recommendations for rationing would be non-binding, but as we see today, the statists will always come back for more, even if they have to do it undemocratically and as secretly as they can.

Update: You will be shocked to learn that the unconfirmable Donald Berwick was behind this.

–Karl

182 Responses to “Return of the mythical death panels? (Bumped and Updated)”

  1. It’s all of a part, Karl, with Obama priding himself in deliberating about whether his grandmother should get the hip replacement, Berwick’s comments about NICE, Emmanuel’s qualms about the hippocratic oath, it is their mindset, it’s not one single thing, Holdren’s crazy mad scientist vision,

    narciso (6075d0)

  2. It’s beautiful that the weaselly Rep. Blumenauer gets nailed by the NYT telling people to keep quiet about this because the fewer people notice it’s getting passed, the better, not that it’s controversial or anything. Hey, he just knows what’s best for everyone!

    daleyrocks (bfdac7)

  3. TRANSPARENCY!!!!!

    It’s what’s for dinner.

    daleyrocks (bfdac7)

  4. Shhhhhhhhhh. You are not supposed to tell anyone.

    JD (85b089)

  5. “The first rule of fight club, (er death panels) is you’re not supposed to talk about. . .”

    narciso (6075d0)

  6. That link from “greg” is one that the cowardly dishonest lying plagiarizing racisr midget hilljack that is scared of brown people that can spell has used, repeatedly. It is one of his feedback loops memes.

    JD (b98cae)

  7. JD – Badge licking authoritarians like greg believe the government has unlimited funds to solve any and all problems. He kills kittens in his spare time.

    daleyrocks (bfdac7)

  8. What link from “Greg”?

    In an unrelated observation, Michael Hiltzik’s employer found his sock puppetry and dishonesty enough to take action against him.

    Patterico (4ef72a)

  9. Two can play the veiled threats game.

    And if it ever comes to anything — and I mean anything — more than that, two can play that game as well.

    Although on our side, there are certainly more than one who would sign up to play.

    Patterico (4ef72a)

  10. It is interesting that so much time has been spent claiming that something does not exist, when it not only appeared in the legislation but is now speedily being inserted back in after deletion via regulation.

    A large part of the loss of public support for Obamacare came from the dishonest treatment of issues like these. The brazen lying about the content of the legislation, and the repeated hiding of key details, legislative language etc. just kept demonstrating that Pelosi/Reid/Obama had no credibility. Couple that with the equally brazen dishonesty of the CBO scoring.

    The trolls only reinforce the dishonest nature of the arguments in favor of the legislation.

    SPQR (26be8b)

  11. I’m with Karl. I always thought the “death panel” concern had more to do with the potential denial of certain drugs and treatments (through regulation) for “certain” people than the end of life counseling itself. But since it’s all so hush hush apparently it’s both. A two-fer for our progressive friends!

    I am stunned this appeared in the NYT.

    elissa (a014d4)

  12. So much of the bill, is a shell, like a nasty taco,
    designed by George Tiller’s primary beneficiary of
    campaign funds, doesn’t that give you a warm feeling

    narciso (6075d0)

  13. I think it’s naive to believe Obama and his Administration won’t oversee a significant curtailment of health care to all but a privileged group of Americans, especially when it comes to end-of-life treatments and expensive drugs for the chronically ill. Unless Americans agree to exorbitant, never-ending tax increases, how else can they fund ObamaCare?

    DRJ (d43dcd)

  14. Patterico – it would be interesting if the MTSU Prof of Plagiarism would be honest for one day, maybe list every name it has sock puppeted under, including all of the female names. It is a disturbed demonic cowardly midget.

    JD (d48c3b)

  15. “Fess up, Krugman, you owe Sarah Palin an apology for so often scandal-mongering her … When you said “death panels” on that Sunday morning, you knew and meant what you were saying. As an economist dedicated to deficit-reduction you were not lamenting the coming of death panels. Clearly, you were affirming their inevitability under President Obama’s determination to prevent government subsidization of ‘extreme care.’ “
    – Nat Hentoff

    Brother Bradley J. Fikes, C.O.R. (fb9e90)

  16. I have two problems with this from the get go: A giant red flag is that the most transparent Congress ever wants to keep this a secret from the American public.

    I am reminded of Nancy Pelosi curtly informing CSPAN last year when pressed for access to negotiations reconciling the House and Senate bill, “There has never been a more open process for any legislation.”

    Also, when money is involved in the counseling, and with an administrative swinging toward death more than life, how is this not a serious conflict of interest? Also, one must take into consideration that our elderly population (like my own parents) grew up revering medical professionals as almost godlike and their decisions were not to be quibbled with because they knew better. Medical professionals who are paid to advise patients and whose own views line up with the Administration may exert pressure over the vulnerable to acquiesce to their *encouragement* and/or suggestions.

    Under the new policy, outlined in a Medicare regulation, the government will pay doctors who advise patients on options for end-of-life care, which may include advance directives to forgo aggressive life-sustaining treatment.

    Dana (8ba2fb)

  17. Exactly, Nat Hentoff and Brother Bradley.

    It amazes me that anyone can claim Obama and ObamaCare won’t restrict access to expensive end-of-life/chronic disease health care. Only a fool would believe we can pay for everything without significantly and endlessly raising taxes, and Obama is no fool. He must think we are, though.

    DRJ (d43dcd)

  18. “Only a fool would believe we can pay for everything without significantly and endlessly raising taxes”

    DRJ – I’m still waiting for Obama to pay my mortgage. Sucker hasn’t come through yet!

    daleyrocks (bfdac7)

  19. Killing the old and useless is wrong?

    When my turn comes I will have a different positon than the one expressed above.

    highpckets (d42ce5)

  20. daley- Only with Michelle do you get the mortgage payment.

    Only real men can be hen pecked TOTUS’s.

    highpckets (d42ce5)

  21. highpckets – I do not want Michelle or her stupid rules about food. Real men eat what they want and engage selective hearing to hen pecking.

    daleyrocks (bfdac7)

  22. They also have sex very infrequently.

    daleyrocks (bfdac7)

  23. For those who actually read Palin’s posts on “death panels”, it was apparent that end-of-life counseling was not the center of her concern. Her metaphor was used to describe the bureaucracy that would determine how resources would be used for the purpose of treatment and the rationing of health care.

    Palin’s first post, her second post, her third post, her fourth post.

    Palin outlined it very well. The media, the Dems, and some Republicans, chose to mis-characterize what she wrote. A careful read of her writings will show that she was the only one that grasped the full impact of ObamaCare’s treatment of the elderly and disabled.

    RefudiateObama2012 (f82fbb)

  24. “Early advance care planning is important because a person’s ability to make decisions may diminish over time, and he or she may suddenly lose the capability to participate in health care decisions,” the lawmakers said in a letter to Dr. Berwick in August.

    Or a person’s ability to make decisions may not diminish because their specific illness does not impact their cognitive decision making skills. According to the study cited by the NYT, of 3746 decedents, 42.5% (95% CI, 39.9 to 44.5) required decision making about treatment in the final days of life. – that is less than half of the case studies.

    Dana (8ba2fb)

  25. it is shameful the way this administration will do this kind of news release, all the time, when no one is paying attention.

    Aaron Worthing (a767d3)

  26. Granted, this President is adept at releasing information on dead news days but don’t most politicians do that? What’s shameful is media complicity in helping Obama bury news.

    DRJ (d43dcd)

  27. Here’s where I offend our host (again); but,
    perhaps we need to consider the establishment of “death panels” “career counseling” for those who have been feeding at the public trough for extended periods of time?

    AD-RtR/OS! (fbd2a3)

  28. Aaron, credit to the NYT for even publishing this and letting the cat out of the bag – no matter which day of the week it occurs.

    (One has to wonder if the affair between the entities is wavering…)

    Dana (8ba2fb)

  29. Dana, on every instance where the NYT seems to operate against type, I wonder just what influence Carlos Slim is exerting in the upper-circles of the paper?

    AD-RtR/OS! (fbd2a3)

  30. DRJ

    i have never seen a president more prone to this.

    Aaron Worthing (a767d3)

  31. Then you’ve forgotten the Clinton and Bush years, I see.

    DRJ (d43dcd)

  32. RefudiateObama2012,

    I did link to Palin specifically on this subject, and she did use the term “Death Panels” in the title of her note on section 1233. And she elaborated on section 1233 in the second note you linked. I agree she had broader concerns, but she got around to the IMAC proposal in September, as your links show.

    Karl (928df3)

  33. And, if it’s really bad news, it gets released after 7pm (ET) on a Friday
    (unless it’s really-really bad news: that’s released late Saturday -
    and then anyone who could be invited to a Sunday-Talker to discuss it is out-of-town).

    AD-RtR/OS! (fbd2a3)

  34. “Then you’ve forgotten the Clinton and Bush years, I see.”

    DRJ – Perhaps it’s my incipient Old Timer’s disease, but I’m having trouble remembering comparable end runs by regulatory agencies and Cabinet Departments in previous administrations to those employed by Obama to avoid Congressional authority. So far we’ve had aggressive moves by HHS, the Department of the Interior, the EPA, the FCC, and I’m sure I’m leaving some out.

    daleyrocks (bfdac7)

  35. daleyrocks,

    I think it’s true Obama wants to enhance his executive powers but some argue he isn’t the first to do so. But I thought we were talking about the timing of releasing news.

    DRJ (d43dcd)

  36. However, I share your concerns regarding Obama’s enhanced regulatory moves, not mention his propensity for doing things Michael Barone and PowerLine refer to as gangster government.

    DRJ (d43dcd)

  37. “But I thought we were talking about the timing of releasing news.”

    DRJ – I thought the topic of the post was the reemergence of the Death Panels through silent regulatory fiat. The timing of the release of bad news emerged as a subtopic, but I could be wrong.

    daleyrocks (bfdac7)

  38. Anyway, Jets and Bears in a shootout at Soldier Field. Bears lead 38-31 after 3, outscoring Jets 21-7 in 3rd quarter.

    daleyrocks (bfdac7)

  39. Charles Lane summed (and sums) it up nicely.

    If Section 1233 is innocuous, why would “strategists” want to tip-toe around the subject?

    Perhaps because…Section 1233 is not totally innocuous.

    Dana (8ba2fb)

  40. “But I thought we were talking about the timing of releasing news.”

    Sorry about that, daleyrocks. This was my discussion with Aaron. You’re right that wasn’t the original topic.

    DRJ (d43dcd)

  41. Mr Lane wrote:

    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.

    Consider the setting: how many of those meetings will occur with a concerned physician talking to a disheveled patient, laying in a hospital bed with tubes in his arm and a nasal canula putting more oxygen to his nose?

    Yeah, now that’s an equal power relationship setting!

    The Dana married to a nurse (bd7e62)

  42. DRJ – There’s no problem. Apart from weekend news releases like the Van Jones firing, another tool used by the Obama Administration is the deliberate delay of finished reports by various departments which don’t wholeheartedly support policy goals.

    daleyrocks (bfdac7)

  43. Bears win!

    daleyrocks (bfdac7)

  44. I don’t like Obamacare, but this is kind of absurd. This happens every day anyway…right now. We have advanced directives, living wills and believe it or not doctors do not recommend expensive treatment for elderly people who have little hope of living long enough to benefit from it.

    I think the thing that amazes me the most is that so many conservatives complain about Medicare Part D so bitterly and then they get all hyperbolic about this. The truth is there are old people out there who would die without their meds and they can not just drive off to Canada to buy them for less either.

    I think Obamacare is a terrible idea and I think there will have to be reform of the medicare system, but some of this just seems like demagoguery to me.

    Terrye (7c855d)

  45. Incidentally, as I did not write much about the “death panels” kerfuffle, I should state for the record that I always thought it a term that would have been better applied to proposals like those for the Independent Payment Advisory Board,

    That is precisely what Sarah Palin did apply the term to in the first place. The idea that she meant this end-of-life consulting came out of nowhere. And in fact she was on record as supporting a publicity campaign aimed at encouraging patients to talk to their doctors about end-of-life issues. The crucial difference, of course, is precisely in who initiates the conversation.

    Milhouse (ea66e3)

  46. “I don’t like Obamacare, but this is kind of absurd.”

    Terrye – The part about the doctors being compensated by the government for providing “voluntary” end of life counseling is “absurd” or “demagoguery”?

    daleyrocks (bfdac7)

  47. What the amoral lying leftist are doing is taking an option for living and turning it into a responsibility to die on a purely cost basis…nothing less.

    MJN1957 (6e1275)

  48. “I don’t like Obamacare, but this is kind of absurd. This happens every day anyway…right now. We have advanced directives, living wills and believe it or not doctors do not recommend expensive treatment for elderly people who have little hope of living long enough to benefit from it.

    I think the thing that amazes me the most is that so many conservatives complain about Medicare Part D so bitterly and then they get all hyperbolic about this. The truth is there are old people out there who would die without their meds and they can not just drive off to Canada to buy them for less either.

    I think Obamacare is a terrible idea and I think there will have to be reform of the medicare system, but some of this just seems like demagoguery to me.

    Comment by Terrye — 12/26/2010 @ 1:12 pm”

    We would not be having this problem if we were not financing the rest of the worlds pharmaceutical R & D. We ought force the drug companies to charge the same prices in the US as they charge in the EU and Canada. Either the drug companies will pull out of those countries or raise their prices worldwide to average out the R&D costs and thus lower ours.

    cubanbob (409ac2)

  49. “Either the drug companies will pull out of those countries or raise their prices worldwide to average out the R&D costs and thus lower ours.”

    cubanbob – Or tort reform here might lead to lower prices, but that will never happen as long as Democrats can fog a mirror.

    daleyrocks (bfdac7)

  50. Terrye:

    “I don’t like Obamacare, but this is kind of absurd. This happens every day anyway…right now. We have advanced directives, living wills and believe it or not doctors do not recommend expensive treatment for elderly people who have little hope of living long enough to benefit from it.

    What’s different is that the government will make the rules and have oversight over these end-of-life discussions between patients and their caregivers. Is it really so absurd to be concerned about that?

    As for patients who “have little hope of living long enough to benefit” from treatment, I have a family member who was given a 95% chance of dying … and who is alive today. Good thing we didn’t have one of those doctors or ObamaCare.

    DRJ (d43dcd)

  51. Terrye, you seem to be missing the entire point. The point is not that doctors engage in discussions with patients and families about these issues. The point is that the government is incentivizing the discussion and potentially the answers.

    We’ve seen real issues pop up about the state intervening in such decisions in state-run medical systems.

    SPQR (26be8b)

  52. 46.“I don’t like Obamacare, but this is kind of absurd.”

    Terrye – The part about the doctors being compensated by the government for providing “voluntary” end of life counseling is “absurd” or “demagoguery”?

    Comment by daleyrocks — 12/26/2010 @ 1:49 pm

    They are compensated right now. When a doctor counsels a patient on what their prognosis is and what their alternatives are, they will be compensated…they are right now. Back in the 90s my 93 year old Grandmother was dying. She was tired, she was in pain and she wanted to move onto what she truly believed was a better place. She kept pulling out her feeding tubes. The doctor and the nurses who were caring for her recommended that we not keep putting them back in..even though it meant she would die…but then she was already dying.

    The point is that people do receive this counseling, especially when it is obvious they are dying and doctors get paid for giving them that medical. Should they do it for no pay, or not do it all?

    My point is that because people don’t like Obama and they don’t like Obamacare, they are assuming that there is something under handed about this…and the truth is this sort of thing happens all the time in medicine..so yeah, it seems over raught to me. And no I don’t like Obamacare. I just think that after years of hearing about how Part D is socialism when it helps older people buy medicine they could die without it is kind of absurd to hear people label this sort of thing as a death panel.

    Terrye (9d8507)

  53. 50.Terrye:

    “I don’t like Obamacare, but this is kind of absurd. This happens every day anyway…right now. We have advanced directives, living wills and believe it or not doctors do not recommend expensive treatment for elderly people who have little hope of living long enough to benefit from it.

    What’s different is that the government will make the rules and have oversight over these end-of-life discussions between patients and their caregivers. Is it really so absurd to be concerned about that?

    As for patients who “have little hope of living long enough to benefit” from treatment, I have a family member who was given a 95% chance of dying … and who is alive today. Good thing we didn’t have one of those doctors or ObamaCare

    There will always be miracles, my father survived an accident that was supposed to kill him, but there was no medicare to pay for it in any event. He was on his own.

    And who do you think makes the decisions for the doctors who take care of all those old veterans out there? And who makes the decision with older people on medicare and medicaid right now? The nursing homes are full of them. And what about insurance companies and trial lawyers? They make decisions every day about the health care of individuals.

    My point is that this is already happening and it is not just between you and your doctor when medicare is paying for it..it has not been for years…if you have the money to pay for your own care you can probably get whatever you want, but if you have a third payer source then professionals are already doing this sort of counseling and as the population ages they will go on doing the counseling in one way or another.

    Like I said, I have been listening to so many people on the right complain about medicare for years and years that now it seems to strange to me that they assume the government is a bottomless pit and that there will be and can be no attempt made to do any kind of rationing.

    Terrye (9d8507)

  54. 51.Terrye, you seem to be missing the entire point. The point is not that doctors engage in discussions with patients and families about these issues. The point is that the government is incentivizing the discussion and potentially the answers.

    We’ve seen real issues pop up about the state intervening in such decisions in state-run medical systems.

    Comment by SPQR — 12/26/2010 @ 2:27 pm

    I don’t want a state run health care system myself..and I am not missing the point. I work for a health care agency. I deal with sick and dying people every day. I used to deal with more, but back in the late 90s a lot of the medicare people were turned over to hospice to help people die. Remember when they balanced the budget back then? Well, cuts in medicare were part of that and this was one place those cuts were made, home health care for people in end stages of life.

    The point is that the doctors do a lot of this counseling now and people seem to think that as long as they don’t get paid for it, then it is okay fine. Guess what? If they don’t pay them for doing the counseling, then it follows that if the only thing the doctors care about is making money that they will go right on treating people whether it is doing them any good or not…and just bill the government.

    Terrye (9d8507)

  55. Terrye, you claim to have been listening, but you don’t seem to be paying any attention to what people are saying.

    SPQR (26be8b)

  56. “Should they do it for no pay, or not do it all?”

    Terrye – My point is not that it is not occurring now, but that because doctors will be compensated for “voluntary” end of life counseling sessions, whether patients want them or not, how “voluntary” are such sessions when conducted under the guise of medical authority prompted by kick in the azz from the government. It is neither absurd nor demagoguery to complain about it.

    daleyrocks (bfdac7)

  57. “it seems to strange to me that they assume the government is a bottomless pit and that there will be and can be no attempt made to do any kind of rationing.”

    Terrye – Which side of the debate have you been listening to?

    daleyrocks (bfdac7)

  58. Why is it every time someone comes on here to argue the opposite of the death panels issue they always, always, always feel the need to include how they’re knee – deep into the healthcare system, and of course they’re also face – to – face with those most affected by it?

    Get over yourself, please.

    Dmac (498ece)

  59. but you don’t seem to be paying any attention to what people are saying.

    Yeah, that as well.

    Dmac (498ece)

  60. I understand what you are saying…you are saying that since there is compensation then doctors are being paid to let people die..I get that.

    Terrye – My point is not that it is not occurring now, but that because doctors will be compensated for “voluntary” end of life counseling sessions, whether patients want them or not, how “voluntary” are such sessions when conducted under the guise of medical authority prompted by kick in the azz from the government. It is neither absurd nor demagoguery to complain about it.

    Comment by daleyrocks — 12/26/2010 @ 3:00 pm

    This is the thing, you say they are not voluntary even if they say they are voluntary because doctors are telling people about their alternatives while they are in the process of treating them..as if this information was a bad thing, a thing designed to kill people in and of itself.

    I am saying that when a person is really ill or infirm doctors already tell them what their alternatives are, right now. They may not bill for it, they may not get paid for it, but it happens.

    Terrye (9d8507)

  61. 58.Why is it every time someone comes on here to argue the opposite of the death panels issue they always, always, always feel the need to include how they’re knee – deep into the healthcare system, and of course they’re also face – to – face with those most affected by it?

    Get over yourself, please.

    Comment by Dmac — 12/26/2010 @ 3:04 pm

    I am over myself, and I am not a supporter of Obamacare.

    But fine, you are right…the government is going to pay doctors to kill people and they are going to do by coming up with the panels that will make the decisions as to what is and is not viable life, so the government decides who lives and dies not the doctors or the patients…got it…

    But then again, allowing free market principles to govern the pharmaceutical industry so that the cost of medicine is not so high is a bad thing because then they can’t do research and development…but then again Medicare Part D is socialism even though we don’t have a free market system for meds anyway…

    That is the point, there is already so much control from government and insurance companies that all sorts of outside forces help make these decisions every day anyway.

    Terrye (9d8507)

  62. Terrye,

    You are intentionally missing the point, aren’t you? I don’t think you want to acknowledge it because home health care, especially, is susceptible to pressure from regulators.

    DRJ (d43dcd)

  63. I am saying that when a person is really ill or infirm doctors already tell them what their alternatives are, right now. They may not bill for it, they may not get paid for it, but it happens.

    Everyone knows this. And you know that everyone knows this. So why are you using this strawman to avoid the real issue?

    SPQR (26be8b)

  64. Terrye – are you in favor of government rationing care, determing who gets treatment, or the extent of the treatment to be rendered?

    Oh, just in case, Yelverton buggers underage non-consensual lambs.

    JD (0d2ffc)

  65. I have a really good relationship with my PC, and I just can’t envision him doing this for a wellness visit for which Medicare pays an average of $35. I’ve got really mixed feelings on this. If under the guise of this regulation they are really implementing any portion of Zeke Emanuel’s “Complete Lives” philosophy, I’d be on the short list due to my MS. On the other hand, I was a Risk Manager by trade, and I can’t imagine any sensible adult not having end of life directives in order.
    Sadly, I will lean towards not trusting the rats in the current administration. And plenty of Democrats like Zeke embrace eugenics, they just don’t call it that.

    sybilll (463495)

  66. “Either the drug companies will pull out of those countries or raise their prices worldwide to average out the R&D costs and thus lower ours.”

    cubanbob – Or tort reform here might lead to lower prices, but that will never happen as long as Democrats can fog a mirror.

    Comment by daleyrocks — 12/26/2010 @ 2:04 pm

    Good point and indeed that is part of the overhead but foreign price controls are main reason the US market covers the R & D costs. The Canadian government in the past has threaten to invalidate drug patents if the drug companies were to raise prices or quit doing business in Canada. Mind you most US pharma company drugs sold in Canada are made in the US yet while in the US the companies allocate R&D to the markup to cover costs in other countries the allowed the allowed markup is actual mfg. costs plus a normal G&A. Considering all the oil and hydropower we get from Canada it isn’t worth picking a fight with them over this.

    cubanbob (409ac2)

  67. “Oh, just in case, Yelverton buggers underage non-consensual lambs.”

    This does not seem like the usual intelligent Terrye. She is intentionally missing the point.

    My father passed away last weekend, in his mid-80s, ZOMG, he had no such end of life counseling. Oh Noes!!!!!

    daleyrocks (bfdac7)

  68. Republicans love to talk about death panels until someone points out that the Republican states kill people all the time if they’re poor.

    Comment by Not Fan — 12/26/2010 @ 4:06 pm

    Really? Who knew? Tell me which Republican States engage in killing poor people on a routine basis? Please enlighten us.

    cubanbob (409ac2)

  69. Not Fan – Bill, how many goats have you fellated today?

    daleyrocks (bfdac7)

  70. There will always be death panels. It cannot be avoided. However one can sue an insurer but the government is sovereign. Insurance can refuse to pay for treatment but only the government can require you be not treated.

    cubanbob (409ac2)

  71. Not Fan’s Arizona example illustrates what will happen under ObamaCare:

    Cash-strapped Arizona has drawn national scrutiny for its decision to drop Medicaid coverage for some organ transplants as the state tries to plug a $1 billion gap in its health-care budget for next year.

    The state agency that recommended that Arizona stop paying for transplants of lungs and, for certain patients, hearts and livers, has defended the move by citing studies and figures that it says demonstrate the ineffectiveness of the procedures. Several transplant experts, however, point to flaws in the data and the way the state’s Medicaid agency, called the Health Care Cost Containment System, has used the figures.

    The coverage cuts directly affect just a few dozen Arizonans each year and are projected to save the state about $4 million annually, but the situation may provide a preview of controversies to come if other states with a Medicaid deficit trim such coverage.

    We have money problems in America and Medicaid patients are facing these hard choices now. We all will if ObamaCare takes effect but do we really want state and federal government agencies making these decisions?

    DRJ (d43dcd)

  72. And of course, neither of Not Fan’s examples are equivalent to the issue at all. Neither of Not Fan’s examples are Republicans “killing” people. Just more of the troll style misrepresentation.

    SPQR (26be8b)

  73. “None at all. You see, the Bible says that, in the event that an animal is sodomized by a human being, it is to be put to death.”

    Not Fan – Bill, I was not aware you followed the Bible or that this country used it to enforce our laws. Try again. Please tell us about your incestuous relationships with your relatives.

    daleyrocks (bfdac7)

  74. As SPQR notes, the Texas legislation is a different issue. Its purpose is to address where a hospital and patient/family disagree on the value of continued care and no other hospital is willing to provide care.

    DRJ (d43dcd)

  75. Do you want state and federal governments making these decisions or not?

    DRJ (d43dcd)

  76. By the way, who’s going to pay for your health care if not someone with a wallet?

    DRJ (d43dcd)

  77. Not Fan, as usual you call people liars when in fact it is you who are misrepresenting the law.

    The Texas law does nothing other than establish a procedure by which a hospital can choose to move forward with withdrawing care – it does not compel it and it does not encourage it.

    Why is it that you feel the need to misrepresent a simple statute to feed your irrational hatred of people who disagree with you?

    SPQR (26be8b)

  78. Not Fan, you continue to make misrepresentations. Anyone who bothers to read of the statute knows that you claim is false.

    Why is it that supporters of Obamacare work so hard to make such brazen misrepresentations? Why is it that the Obamacare legislation itself cannot be defended factually?

    The obvious implication is that the Obamacare supporters know that they can’t win an objective and honest discussion and have to play these games and shout “squirrel!”

    SPQR (26be8b)

  79. The Arizona decision with respect to some transplants is a different issue. One can argue about the reasonableness of deciding that certain classes of transplants are not effective enough compared to their costs. And obviously that is the kind of decision that public assistance funds must go through.

    That’s the reason however that we don’t want to convert our entire health care system into government-run health care. Because then there is no escape from these decisions.

    SPQR (26be8b)

  80. Not Fan, you call people liars while the evidence that it is you who are dishonest is evident. Anyone who bothers to read the statute knows that it is not I who is dishonest.

    SPQR (26be8b)

  81. The bottom line for me is that once the Feds assume a strangle-hold on the Health-Care process, every decision will have to be bucked up the chain-of-command for a Yeah/Nay on spending the bucks; and there is no way to make the Feds accountable for their decision, or as most likely, their lack of a decision.
    The easiest thing for any bureaucrat to do is to cubby-hole something, and just wait for the situation to solve itself;
    except in the case of Health-Care, the solution to a spending decision is to let the patient die, and the point becomes moot.
    At least Insurance Co’s have a bottom-line to protect one way or the other, but the Feds have Sovereign Immunity, so there is no one to answer for a lack of feasance.

    AD-RtR/OS! (f9a039)

  82. That’s true, AD. But we also have the problem that is posed by the attitude of the Netherlands, wherein even people with no particular terminal illness are encouraged to accept euthanasia … and in some cases, have been subjected to it without any input from family or other review.

    SPQR (26be8b)

  83. Not Fan, why is it that you think it is acceptable to lie about other people’s positions? If this is how you feel superior to others, it would appear that you have a rather disturbing sense of inferiority that is affecting your basic ability to relate constructively with others.

    SPQR (26be8b)

  84. Not Fan…
    just another in a long line of dissembling obfuscators who think that they have something important to add to the discussion, when all they’ve got is Bupkis!

    AD-RtR/OS! (f9a039)

  85. and now, if you’ll excuse me, I have hockey game to watch.

    AD-RtR/OS! (f9a039)

  86. Not Fan, your diatribe is bordering the ridiculous. I live in a very, very blue city, and just as recently as June, an old high school friend needed a liver and kidney transplant. She was denied because she has been a drug addict and alcoholic for the better part of a decade. The hospital made her comfortable, but, they told her family 2 days after her admission that she would die. And she did, 9 days later. It was based on the rules of, at the time, a state controlled by a Democratic Governor, and a Democratic State Assembly, and a Democratic House. So, get over this tripe that Republican states kill for the almighty dollar. What Zeke, an Obama advisor, advocates is eugenics, plain and simple.
    I am surprised people have engaged you for this long.
    P.S. My state wised up, and all 3 branches are now controlled by Republicans.

    sybilll (463495)

  87. William Yelverton is a snivelling whiny little beeyotch that buggers goats. This is about his 50th different name. At least he is not cross dressing and posing as a “woman” again. Get help, midget racist hilljack. Step away from the bong and the acid. It is not serving you well.

    JD (822109)

  88. SPQR:

    That’s the reason however that we don’t want to convert our entire health care system into government-run health care. Because then there is no escape from these decisions.

    Exactly.

    DRJ (d43dcd)

  89. the government is going to pay doctors to kill people and they are going to do by coming up with the panels that will make the decisions as to what is and is not viable life, so the government decides who lives and dies not the doctors or the patients…got it…

    Yeah, that’s exactly what I mean – except I never said anything remotely related to your rant. Try again.

    Dmac (498ece)

  90. Not Fan, I can tell you that many of us conservatives have been fighting that law here in Texas. I will however note that prior to the law’s passage, the hospital did not have to give the patient or the family any notice at all, so at least now they have ten days to find an alternative health care facility. Not that doing so is terribly easy. Also, this law was a reaction to a unilateral move by the AMA as an attempt to give the patient and the family an alternative to what is effectively euthanasia. And the law was crafted by a majority democrat legislature and was signed by GWB only after the right to life lobby agreed to the compromise.

    From the National Review article on the law
    :

    “How did Texas, of all places, become ground zero for futile-care impositions? Back in 1996, a group of Houston hospitals adopted internal administrative protocols, called the Collaborative Policy, in which they granted themselves the right to refuse life-sustaining treatment even to a patient who still wants it. As described in the August 21, 1996, Journal of the American Medical Association (“A Multi-institutional Collaborative Policy on Medical Futility”), if a doctor wished to refuse treatment, but a patient or family wanted it, the dispute was to be adjudicated behind closed doors by an institutional ethics committee; the patient/family would be given three days’ notice of the meeting. If the committee members decided that the patient should not continue to receive life-sustaining treatment, such treatment could then be cut off immediately, with only comfort care rendered thereafter.

    “Needless to say, the Collaborative Policy was controversial, and legislation was soon introduced in the Texas legislature to thwart the Houston hospitals’ futile-care scheme. Unfortunately, lawmakers were divided on the issue. Eventually a compromise was worked out, giving families ten days to find an alternative institution to provide care once a hospital ethics committee ruled that treatment for a patient should be terminated. Governor George W. Bush eventually signed the bill into law in 1999 after right to life groups agreed to the compromise, never dreaming that patient transfers would become almost impossible to secure.”

    Rorschach (7a2fd6)

  91. BTW, I worked in a nursing home that was run by Mother Teresa, and I saw many people die right in front of my eyes, so I have more moral authority than you do on this issue.

    See how that works?

    Dmac (498ece)

  92. Utterly off topic, I’ve been reconsidering just how much value there is in college education. This fall, teaching at the local community college, I started wondering how much responsibility I had for the college talking students into signing up for increasing amounts of debt for degrees of dubious worth.

    SPQR (26be8b)

  93. I like the Almighty Dollar a lot, and I’m conservative.

    What is No Fan going on about?

    ag80 (e03e7a)

  94. William Yelverton is slightly less smart,and way less honest, than an oozing hairy rectal fistula.

    JD (395555)

  95. ag80, no one really knows. It is a set of behavior of no interest to anyone but a neurologist.

    SPQR (26be8b)

  96. Teaching ukulele at a 4th rate directional college gives William Yelverton the academic credentials that prove anything he thinks is a fact you racist anti-science new earth denialists.

    JD (395555)

  97. And just so we are clear, “no fan” is the infamous fatuous mendoucheous William Yelverton.

    JD (395555)

  98. And yet, over the course of Xmas, Instapundit did the public the favour of linking several videos of the delightful ukelele player Wade Johnston. Thus proving that the instrument doesn’t turn its players into cretins. In Yelverton’s case it must be the person behind the instrument.

    Milhouse (ea66e3)

  99. JD,

    No who?

    Patterico (e60827)

  100. Patterico – That little height and hair challenged hilljack adult track sprinter wannabe just cannot quit you.

    JD (395555)

  101. JD – He probably just took a break to run out and buy another bottle of Jergens.

    Fap…Fap…Fap…Fap…Fap…Fap

    daleyrocks (bfdac7)

  102. Patterico – For one reason or another, I’m pretty sure Yelverton is very familiar with the favorite Christmas carol of schizophrenics – Do You Hear What I Hear.

    daleyrocks (bfdac7)

  103. I am saying that when a person is really ill or infirm doctors already tell them what their alternatives are, right now. They may not bill for it, they may not get paid for it, but it happens.
    Comment by Terrye

    I think this is in part one of those problems that would never exist if people “did the right thing” to begin with. I believe over the last 25 years doctors have spent less and less time adequately discussing issues with patients and their families, including doctors who would like nothing better than to spend 30 minutes reminiscing about the years spent caring for someone, and trying to make difficult decisions that everyone can accept. A doctor should be able to have that conversation and bill for it at a reasonable rate. That a doctor can’t, so a special law needs to be put in place, or that Obama thinks doctors don’t/won’t (because they are too busy taking out tonsils and cutting off limbs), reveals the upside down nature of overdependence on government regulation and the condescension of this President.

    his propensity for doing things Michael Barone and PowerLine refer to as gangster government.
    Comment by DRJ

    Some months ago I heard an interview of a fellow who had been neck-deep in the mob and went informant. He said what Obama was doing in coming to the aid of the GM and Chrysler, for example, was exactly how the mob would infiltrate legitimate businesses. The mob would “help out” a little, and then the company would be beholden to the “helpers”, enough at least to give good return to the mob for their “investment”.

    MD in Philly (3d3f72)

  104. The biggest obstacle to sensible end of life decisions is the government and lawyers (I consider them pretty much the same thing). The reason why there were no “shovel ready” projects is the same reason why end of life planning is so screwed up. Imagine, if you can, a baseball game equipped with lawyers to decide balls and strikes and safe or out, instead of umpires.

    One interesting thing is that Berwick, who has never practiced outside of an academic institution, is pushing the death panels. The only place I have ever seen abusive practices toward terminal patients is in academic institutions where some twerp with a grant will keep a dying patient in the hospital to study their end of life experience or to use a hopeless therapy, probably painful, to get more cases for a paper.

    Many new doctors have trouble talking to people about death. We now teach a course on how to handle the dying patient with all the scenarios, including the left wing daughter who hasn’t seen her father in years but who flies in from New York and wants everything done. I don’t think these people like Berwick know anything about common medical practices.

    Mike K (568408)

  105. No fan or not fan, we’re all not fans of no fan or not fan but I’m a fan of the stuff that makes the world go ’round.

    Because of that feeding the poor and progress and keeping the house warm.

    It does so many good things, I can’t imagine why someone wouldn’t like it. Especially someone who’s toil consists of pushing a pencil in an air-conditioned office or boring young people in a comfortable lecture hall.

    It seems some don’t like the almighty dollar, not because it’s bad, they just want to tell you how to spend it. Of course, they are exempt.

    ag80 (e03e7a)

  106. Whose

    ag80 (e03e7a)

  107. “Her metaphor was used to describe the bureaucracy that would determine how resources would be used for the purpose of treatment and the rationing of health care.”

    You don’t need a metaphor. You just need to read about the Tuskegee syphilis experiment. If liberals get power to control people’s healthcare, they’re going to use that power to murder people in cold blood (just like they did in the Tuskegee syphilis experiment) the minute they think it’s expedient to do so.

    NOTHING has changed between then and now. Liberals haven’t changed, and governments haven’t changed. Governments can’t be trusted with that kind of power, least of all governments run by totalitarian liberals. It always has been that way, it’s that way now, and it’s going to always be that way.

    Only a complete fool would rely on government provided healthcare…unless you have no choice.

    Dave Surls (7f3cc4)

  108. I can think of about a million reasons not to like Obamacare, but this particular issue is not one of them. In fact the truth is doctors talk to patients about end of life issues every day, without reimbursements..they do it so that if and when the moment comes there will be no question as to what the patient wants. It is voluntary in that patients do not have to listen…to say that it only appears voluntary is to say that patients can not get up and walk out of the room. Of course they can.

    Medicare is the government, that is what it is. There are all sorts of things it does not cover, that is what supplemental insurance is for..as far as that is concerned, medicaid has also been known to refuse to pay for certain treatments.

    The idea that the government is trying to kill old people off and ignoring the will of the Congress by reimbursing doctors for discussing end of life issues with their medicare patients seems over the top to me.

    Terrye (3d4bc9)

  109. #

    “Her metaphor was used to describe the bureaucracy that would determine how resources would be used for the purpose of treatment and the rationing of health care.”

    You don’t need a metaphor. You just need to read about the Tuskegee syphilis experiment. If liberals get power to control people’s healthcare, they’re going to use that power to murder people in cold blood (just like they did in the Tuskegee syphilis experiment) the minute they think it’s expedient to do so.

    NOTHING has changed between then and now. Liberals haven’t changed, and governments haven’t changed. Governments can’t be trusted with that kind of power, least of all governments run by totalitarian liberals. It always has been that way, it’s that way now, and it’s going to always be that way.

    Only a complete fool would rely on government provided healthcare…unless you have no choice.

    Comment by Dave Surls — 12/27/2010 @ 3:17 am

    Murder? Please. This is just what I am talking about.

    And this does not ration care. Advanced directives and living wills are not new. It is not as if the regulation states that people with downs syndrome will get this lecture, but others will not.

    The truth is people need to think about what they want to do about their own care. If they have an advanced directive, or a living will, or they have assigned someone who will make these decisions for them…then they don’t need and won’t get this talk.

    There are plenty of things to complain about with government run health care, but going off the deep end does not help the case, it only makes it easier for liberals to claim that conservatives are being dishonest about the issue and trying to scare people into not supporting it.

    Terrye (3d4bc9)

  110. “Murder?”

    Yes, murder.

    Dave Surls (7f3cc4)

  111. Was the Complete lives system, a figment, or NICE, out of the UK, or the reports out of Holland. From
    a President who has clearly expressed the view that
    people are too stupid to make their own choices.

    narciso (6075d0)

  112. Turns out some new information (long suppressed by the libby-wibby government that just wants to help poor folk) just came out a couple of months ago about our fabulous system of government provided healthcare, liberal Dem style…

    “In October 2010 it was revealed that in Guatemala, the project went even further. It was reported that from 1946 to 1948, American doctors deliberately infected prisoners, soldiers, and patients in a mental hospital with syphilis and, in some cases, gonorrhea, with the cooperation of some Guatemalan health ministries and officials. A total of 696 men and women were exposed to syphilis without the informed consent of the subjects. When the subjects contracted the disease they were given antibiotics though it is unclear if all infected parties were cured.[14] Wellesley College’s historian Susan Reverby made the discovery while examining archived records of John Charles Cutler, a government researcher involved in the now infamous Tuskegee study.[15]”

    “In October 2010, the U.S. formally apologized to Guatemala for conducting these experiments.”

    http://en.wikipedia.org/wiki/Tuskegee_syphilis_experiment

    Nice of the feds to apologize for deliberately infecting people with various venereal diseases 65 years or so after the fact. I know I’m touched. Also nice of them to share the “benefits” of their Nazi-like medical experiments (aka government controlled “healthcare”) with foreigners like those in Guatemala as opposed to selfishly limiting those “benefits” to American citizens.

    This ought to do wonders for our image in Latin America.

    And…take your government controlled healthcare plans and stick ‘em where the sun don’t shine.

    Dave Surls (7f3cc4)

  113. Well elements of the Public health service, did seem to have a ‘mad scientist complex’, but that wasn’t government policy from on high. The problem is this provision was negotiated with Blumenauer, of the ‘right to die’ state, I’m a little surprisedthat this leaked out. But it’s better to ‘nuke it from it, just to make sure’

    narciso (6075d0)

  114. Terrye – opposition is not only based on the end of life planning. Why is it that you continue to insist that it is?

    JD (395555)

  115. Terrye,

    I guess you either did not read my comment at #108 or we just disagree. (Fine to disagree, but you didn’t respond to my point- not that you had to, but if you have a good response I should see I’m happy to.)

    There are a lot of “forrests” and “trees” to look at with this, I started with the “forrest”:

    1. No way coverage of more people can be done for less cost (with increased bureacracy) unless care is articially limited. To propose so is like saying 2+2=3.
    -One could begin to make this claim I suppose if you really think doctors are amputating limbs and taking out tonsils unnecessarily “just for the money” and need to be stopped on a massive scale
    -or if one thinks there is that much waste that can be cut- but if that is the idea, you shouldn’t need major reform imposing all kinds of new things.

    2. Look at:
    - the long-held views of those Obama has put in places of responsibility
    - Obama’s views related to medical care, such as justifying the “putting to death” infants live-born from attempted abortions
    I don’t care so much what someone says when they know people are watching, I care about what people say or do when out of the spotlight and among those who are like-minded.

    As I’ve tried to say before, reimbursing doctors for discussing end-of-life care should ba a no-brainer, like reimbursing doctors for taking time discussing any important topic with their patients. The idea that it needs to be explicitly legislated is primae facia (I believe that’s the term) evidence of how bad the government has already mismanaged things, or evidence there is an agenda present, because, as you say, doctors do try to do these things because it is what doctors are “supposed to do”. It is a prime example of the governmant trying to micro-manage doctor behavior via a nebulous and huge cloud of smoke from Washington that will be quietely implimented by layers of bureacrats.

    My only disagreement with Mike K. is that at academic medical centers there are also docs who like to push the idea of being “socially responsible” by helping people die sooner than necessary. Either his experience or mine, they are both examples of doctors with agendas other than taking care of the patient in front of them. And that is what is wrong with a governmental system (or a private corporate system not led by good doctors), when the focus is not giving good care to individual patients, too many individual patients will not get good care.

    There may be very smart and wise doctors out there, but in my experience trying to give good care to the one patient in front of you at any given time is enough of a task. When my child, wife, or mother get cared for, I want the doctor to be focused on them.

    I understand the idea of trying to “look at the big picture” and have tried it myself in the past, but when you see that one’s idea of taking care of the “big picture” doesn’t make sense with the responsibilities in front of you, you have to do something to reconcile the dilemma.

    In a few moments I am going to help my daughter get breakfast. Even though we don’t have a lot in the frig this moment by American standards, we have more choice than the majority of the world’s children. Am I supposed to feel guilty about that and give her a handful of rice instead? And even if I made Eggs Benedict with hot chocolate made with the most expensive chocolate on the market, what have I done? I’ve contributed to the livelihoods of egg farmers, pork producers, dairy farmers, china manufacturers, truckers, sailors, import/export companies, cocoa farmers, employees at the supermarket, etc. The only “wasted” money is that sitting in a bank not going into someone else’s pockets, and even that, for most of us, is going to get spent too, eventually.

    MD in Philly (3d3f72)

  116. “Researchers in the United States have performed thousands of human radiation experiments to determine the effects of atomic radiation and radioactive contamination on the human body, generally on people who were poor, sick, or powerless.[50] Most of these tests were performed, funded, or supervised by the United States military, Atomic Energy Commission, or various other US federal government agencies.”

    “The experiments included a wide array of studies, involving things like feeding radioactive food to mentally disabled children or conscientious objectors, inserting radium rods into the noses of school children, deliberately releasing radioactive chemicals over U.S. and Canadian cities, measuring the health effects of radioactive fallout from nuclear bomb tests, injecting pregnant women and babies with radioactive chemicals, and irradiating the testicles of prison inmates, amongst other things.”

    Don’t worry about it. Just a few mad scientists in the PHS…and the Army…and the AEC…and “various other US federal government agencies.”

    http://en.wikipedia.org/wiki/Human_radiation_experiments_in_the_United_States#Psychological_and_torture_experiments

    Anyone who puts blind faith in doctors is asking for it, anyone who puts ANY faith in doctors working for or with the United States government (especially when it’s run by liberals) is a certified loon.

    There are ALWAYS going to be death panels. The only question is who is going to be on them. Is it going to be you who decides whether or not to pull the plug on your loved ones when that day comes, or is it going to be the sort of folks who inject pregnant women with plutonium just to see what happens who decide?

    Let the government continue to take over control of government healthcare, and you are simply begging for more of the stuff that the above linked article talks about.

    Dave Surls (7f3cc4)

  117. “Let the government continue to take over control of government healthcare…”

    Whoops. Strike that second “government”

    Dave Surls (7f3cc4)

  118. Dave Surls – Didn’t Democrats also invent AIDS to kill black people and gays? Obama’s spiritual adviser and moral compass, Reverend Jeremiah Wright made this point in public and was ridiculed, but it seems like the logical continuation of the eugenicist Planned Parenthood movement. I acknowledge the facts are murky, probably due to a cover up. Yelverton knows the truth, but will deny it.

    daleyrocks (bfdac7)

  119. Thanks for reminding me, daley, that was like Jim Jones, as your local pastor for 20 years, but that
    didn’t matter to Brokaw and company

    narciso (6075d0)

  120. “Dave Surls – Didn’t Democrats also invent AIDS to kill black people and gays?”

    Considering the stuff the government really has done, it’s not too surprising that a lot of black people think that the government invented AIDS. Doubt if too many of them would lay it at the feet of the Democrats though.

    Dave Surls (7f3cc4)

  121. “Doubt if too many of them would lay it at the feet of the Democrats though.”

    Dave Surls – Prolly because they don’t understand the real history of Planned Parenthood and the eugenics movement. Like I said, just another cover up. Heh!

    daleyrocks (bfdac7)

  122. Now lets not confuse things, Tuskegee was a failure to treat, the Guatemala experiment seems at least one order worse, the AEC is roughly in the latter
    category, now San Francisco’s city council, not closing the bath houses, in the early 80s, seems in the former category, doubly ironic considering the
    health commissioner there, went on to be the founder
    of AMFAR

    narciso (6075d0)

  123. As I’ve tried to say before, reimbursing doctors for discussing end-of-life care should be a no-brainer, like reimbursing doctors for taking time discussing any important topic with their patients. The idea that it needs to be explicitly legislated is primae facia (I believe that’s the term) evidence of how bad the government has already mismanaged things, or evidence there is an agenda present, because, as you say, doctors do try to do these things because it is what doctors are “supposed to do”. It is a prime example of the governmant trying to micro-manage doctor behavior via a nebulous and huge cloud of smoke from Washington that will be quietely implimented by layers of bureacrats.

    I mentioned this upthread but would like to know from either Mike K or MD in Philly: given this administration’s (& president himself) swing more toward death than life (for lack of a better expression) – pro-abortion, late term stance, etc. – do you believe this will influence medical professionals during their interaction with patients in that it gives them a tacit approval for switching priorities to first, watching the bottom line, and *then* the patient’s wishes?

    Or perhaps even taking it further, now that reimbursement is specifically spelled out, does it come with an unspoken expectation that doctors will shift their focus of influence toward the greatest monetary savings rather than the wishes of their patients? And if their ethos are such that this isn’t a problem (with unspoken approval of the administration), how much of a danger is there in this cost-savings first becoming normalized? Perhaps this is the eventual goal.

    Dana (8ba2fb)

  124. “Thanks for reminding me, daley”

    narciso – No problem, the truth is what’s important.

    daleyrocks (bfdac7)

  125. sorry for the post briefly disappearing. i was trying to bump it and accidentally had it scheduled in the future (i keep forgetting that this blog is on pacific time)

    Aaron Worthing (e7d72e)

  126. “does it come with an unspoken expectation that doctors will shift their focus of influence toward the greatest monetary savings rather than the wishes of their patients?”

    Dana – Not who you wanted a reply from, but do you recall a feature of ObamaCare that would force rank doctors by their utilization of various treatment methodologies? The clear implication being that doctors with the top utilization rates of expensive treatments or treatments to be discouraged, independent of the composition of the doctor’s patient practice, would be discouraged from high utilization in the future through reduced reimbursement rates or other penalties. I found such a rule facially offensive and objectionable.

    daleyrocks (bfdac7)

  127. Thanks, daley. Interesting to see the correlation between the current administration’s value (or devaluation) of human life and this section. This transformation would not occur under a more pro-life administration. I guess the pro-life (or lack thereof) stand of a candidate is far more reaching than just the individual abortion issue…

    With financial incentives given to withhold care and penalization if given too much care coupled with doctors evaluated in part by how much money is being spent, one wonders how life even stands a chance?

    Dana (8ba2fb)

  128. Updated.

    Karl (928df3)

  129. Karl – Didn’t Berwick give some Congressional testimony earlier this month? I looked for a transcript of his testimony at the time, but found nothing. Have you seen anything yet?

    daleyrocks (bfdac7)

  130. Donald Berwick who adores Britain’s NHS? Time to be reminded that not even Britain’s healthcare professionals are comfortable with their end of life care:

    In a letter to The Daily Telegraph, a group of experts who care for the terminally ill claim that some patients are being wrongly judged as close to death.

    Under NHS guidance introduced across England to help doctors and medical staff deal with dying patients, they can then have fluid and drugs withdrawn and many are put on continuous sedation until they pass away.

    But this approach can also mask the signs that their condition is improving, the experts warn.

    As a result the scheme is causing a “national crisis” in patient care, the letter states. It has been signed palliative care experts including Professor Peter Millard, Emeritus Professor of Geriatrics, University of London, Dr Peter Hargreaves, a consultant in Palliative Medicine at St Luke’s cancer centre in Guildford, and four others.

    “Forecasting death is an inexact science,”they say. Patients are being diagnosed as being close to death “without regard to the fact that the diagnosis could be wrong.

    “As a result a national wave of discontent is building up, as family and friends witness the denial of fluids and food to patients.”

    The warning comes just a week after a report by the Patients Association estimated that up to one million patients had received poor or cruel care on the NHS.

    Dana (8ba2fb)

  131. Karl

    > Update: You will be shocked to learn that the unconfirmable Donald Berwick was behind this.

    i am surprised paul krugman wasn’t.

    Aaron Worthing (e7d72e)

  132. “Under NHS guidance introduced across England to help doctors and medical staff deal with dying patients”

    Dana – The most important question is do those patients get counseling before the doctors turn them into drooling vegetables.

    daleyrocks (bfdac7)

  133. Some ukelele strummers are drooling vegetables without ObamaCare’s help.

    JD (6e25b4)

  134. Comment by Dana

    Perhaps if we got everyone to sing along with this: All we are saying,…is give life a chance…, the left would be persuaded.

    As far as the legal/business issues, yes, a major thing that all (that I know of) HMO’s do is carefully watch all kinds of statistics, how many tests a doctor orders, how frequently you see a given patient, hospitalization rates, etc. etc., and they break these down according to group practice, individual doctor, individual diagnosis or groups of diagnoses, etc., etc.. In fact, one reason to make this discussion a “procedure” with its own diagnostic code would be to keep track of which doctors are doing it, how often, with which patients, and is there any difference in end of life care/ i.e. billing between those counseled and those not, whether for all docs or selected.
    Such stats are not only used as incentives, but get used in making standards of practice that all doctors are then asked to comply with. (“Drs. Smith, Jones, Doe, Williams group does this 45% of the time with a 20% decrease in what we consider “futile” care, we’re asking all practices to at least hit 40% and 10%, respectively.”- Making up these kinds of policies uses up money that should be going to taking care of people).

    I doubt there would be many doctors who changed their practice directly because of this, except perhaps a doc who already does it but doesn’t get reimbursed for it then starts billing. More likely, those docs already doing this would be encouraged, and then on the basis of their stats the “powers that be” would push to conform others to the same performance. In all I would say it is a growing ball of snow, or a building tidal wave, it’s slowly increasing momentum that will be hard for individual docs or practices to resist.

    That’s my Gestalt, anyway. We’ll see what Mike K. and others say.

    MD in Philly (3d3f72)

  135. they can then have fluid and drugs withdrawn and many are put on continuous sedation until they pass away

    The hospice movement (at least to some degree) was started by docs who didn’t like when patients were told, “There’s nothing more we can do for you” because there were no additional treatments left to attempt a cure of a cancer or whatever. The idea was a lot could be done for symptom management, etc., to help a person “live as well as possible” until they died. This subtly morphed into “death with dignity” which leads to the idea of helping people die which leads to the idea of terminal sedation where people become unconscious, no longer eat or drink, and die of something, be it cancer, heart failure, dehydration, or narcotic overdose.

    Which is very different from giving someone enough morphine to control their pain, something else to control nausea, a little Ritalin to help them stay alert, so they can have some more “quality” time with family members and friends.

    I have been on the brink (pushing over it at least once) of arguing with other docs about such matters loudly and publicly in the hallways, etc.

    Sometime circa 2000 I encountered the first student who said, “I really don’t understand why people make such a big deal about Dr. Kavorkian”. Prior to that, at least even those who were in favor of assisted suicide knew they were pushing the envelope and that Kavorkian had in some instances clearly pushed it too far. Encountering someone who thought there was no need for debate, that Kavorkian’s “work” was self-evidently correct, was a new and frightening experience.

    MD in Philly (3d3f72)

  136. But some ukelele strummers are quite impressive:

    http://www.youtube.com/watch?v=J5qakFIecBU

    (“While my Ukelele Gently Weeps”)

    MD in Philly (3d3f72)

  137. In bringing up the Tuskeegee and related episodes of “medical research”, I am prompted to ask:
    Just how much, in the Medical Community of the time (particularly in the Progressive Medical Community), was Mengele an outlier?

    AD-RtR/OS! (4fe32b)

  138. “Just how much, in the Medical Community of the time (particularly in the Progressive Medical Community), was Mengele an outlier?”

    AD – I don’t think it is by any means a stretch to point out that Democrats are kindred spirits with Nazis and other totalitarians. Just look at how many members of Congress are members of the Democrat Socialists and how overall the party sees the government as the solution for every problem and the ultimate authority. I think the framers of our Constitution had quite another view and were actually trying to prevent the tyranny of government which today’s Democrats seem bound and determined to implement.

    daleyrocks (bfdac7)

  139. MD, what part of the hippocratic oath, did he miss?

    narciso (6075d0)

  140. narciso, no one swears the original Hippocratic oath any longer.

    SPQR (26be8b)

  141. Senatus Populusque Romanus wrote:

    narciso, no one swears the original Hippocratic oath any longer.

    No, we’ve replaced it with the hypocritic oath these days.

    The saddened Dana (bd7e62)

  142. e e cummings Mr Worthing wrote:

    Update: You will be shocked to learn that the unconfirmable Donald Berwick was behind this. (Karl)

    i am surprised paul krugman wasn’t.

    Dr Berwick simply beat him to it. Or maybe even Mr Krugman was embarrassed to actually put it down on paper . . . and that would be a high threshold to meet.

    The unsurprised Dana (bd7e62)

  143. Terrye wrote:

    The truth is people need to think about what they want to do about their own care. If they have an advanced directive, or a living will, or they have assigned someone who will make these decisions for them…then they don’t need and won’t get this talk.

    Even with that statement, you have just said that if you haven’t taken care of this on your own, you do need this talk, and will get it!

    Of course, “this talk” all sounds so innocuous . . . now. It was meant to sound that way, but as the government takes more and more responsibility for this — and given that most of the people who “need” this talk are on Medicare, a government program — we’ll see in the not-too-distant future that this talk becomes mandatory, not “voluntary,” and that a refusal to sign the forms presented to you will result, at first, of the government refusing to pay for the procedures, and, eventually, the government specifying that sorry, you just can’t have them, even if you pay for them yourself.

    It’s referred to as “futile care,” which is defined as a medical situation in which a treatment would not cure the patient but, at best, provide only a short additional time of life. When you read the articles on futile care, you’ll see that they are primarily about the effects of providing futile care on others: prolonging the mourning process for the family and consuming limited resources which could be used to treat non-futile cases.

    From Wiki:

    Arguments against futile care generally center on two issues. First, futile care has no possibility of achieving a good outcome and serves only to prolong death. No physical or spiritual benefit comes from such care. Futile care also prolongs the grieving process and frequently raises false hope. Also, futile care can be very difficult on caregivers, who may see themselves as forced to act against the best interests of their patient.

    Note that the entirety of the argument is based upon the perceptions of other people, not the patient. How can a third person decide whether a particular patient receives no “spiritual benefit” from however much additional time he has?

    The entire concept is designed to make the cost, not the patient, the primary consideration. If we haven’t reached real death panels, and if Logan’s Run isn’t really on the horizon, it’s only because the word “yet” hasn’t been appended.

    The very serious Dana (bd7e62)

  144. The only link in that section, is to the Huff n Po,
    and carousel everyone

    narciso (6075d0)

  145. It’s all the liberals’ faults. The whole world is cock-eyed because of the liberals. They ruined everything. Damn liberals and Obama. Everything was going so smoothly before they came along. Healthcare wasn’t a problem until they made it one. The economy wasn’t a problem until they made it one. The deficit wasn’t a problem until they made it one. Hell, Iraq and Afghanistan weren’t a problem until they made it one. The Financial industry going out of control due to poor regulation was their fault, too. If global climate change was real, that would be the liberals’ faults also. It is so fun living in a Republican/Conservative fantasy world.

    Chris Hooten (1254ac)

  146. Chris Hooten – Damn straight, except for the fantasy world bit at the end!

    daleyrocks (bfdac7)

  147. Crissyhooten eats boogers, but managed to kil an army of strawpeople in one comment.

    JD (0d2ffc)

  148. Are the trolls managing the previously thought impossible task of becoming stupider?

    JD (0d2ffc)

  149. I’m curious when the regulations call for the doctor-patient discussion to occur. Since now doctors will be paid and since they never know when their patients will get sick/hurt, isn’t there an incentive for doctors to initiate this discussion earlier in the doctor-patient relationship?

    The reason I ask is that my impression is the younger we are, the more likely we are to decline end-of-life interventions. Young people, especially, seem to feel they are immune to bad things happening and are more reluctant to agree to feeding tubes, catheters, IVs and ventilators. But as we get older, we often look at these choices in a more discriminating way. I wonder if the health care regulations will take this into account.

    DRJ (d43dcd)

  150. Chrissy, you left out the Howard Dean Yeeeaaaaarrggh! at the very end. Otherwise, it was a near perfect liberal rant. Well played, very well played.

    vote for pedro (e7577d)

  151. “But as we get older, we often look at these choices in a more discriminating way.”

    Depends

    daleyrocks (bfdac7)

  152. The original Hippocratic Oath included prohibition against doing abortions, so any version of it than has been used in the last 30+ years was already diluted.
    Originally it described the values of the Greek physician Hippocrates and those who learned under him, and not something that was accepted as normative for medicine at the time. There have been some physicians and organizations that have worked on returning it to its place of prominence to describe the commitment of physicians who agree to it, including the original prohibition on abortion; so once again people would have a choice of going to a Hippocratic physician or not.

    I wonder if the health care regulations will take this into account.
    Comment by DRJ

    Whatever the regs take into account, it will not be nearly enough, unless the regs are wide open. People can change their mind, and do. They may think they want to forgo some level of treatment in theory, but when the time comes near it’s another story, or the opposite. People may want to stay alive because of the next generation, or they want to die to “not be a burden”. Whatever the decision and at what point in time, it can’t be done purely by explicitly rational criteria and it can’t foresee every potential circumstance that may be involved in the specific situation when it does come.

    MD in Philly (3d3f72)

  153. Somewhere along the line did anyone notice this isn’t a death panel?

    imdw (8bb588)

  154. WH response via WSJ editors today.

    The White House on Sunday said the new Medicare directive, reported Sunday by the New York Times, doesn’t constitute a resurrection of the original health-care-bill language. It said the George W. Bush administration had already put in place guidelines allowing for Medicare to pay for end-of-life consultations.

    A Medicare revamp in 2003 created a “welcome to Medicare” visit for seniors newly entering the program to get a checkup. Another law passed in 2008 specifies that the welcome visit can include a discussion of “end-of-life planning.”

    Reid Cherlin, a White House spokesman, said it was incorrect to suggest the policy of reimbursing end-of-life discussions was new.

    “The only thing new here is a regulation allowing the discussions … to happen in the context of the new annual wellness visit created by the Affordable Care Act,” said Mr. Cherlin, referring to the health overhaul passed in March.

    “Medicare should reimburse physicians for counseling patients on the medical decisions they may face,” said Betsy McCaughey, a former New York lieutenant governor, in an interview. “But government should never prescribe what is discussed between doctor and patient, or pressure doctors financially to push their patients into living wills and advanced directives.”

    Dana (8ba2fb)

  155. ______________________________________

    Of course, Sarah Palin was not the only person who had the heebie-jeebies over this proposal.

    Stripping away the politics, there does need some tough reality applied to situations involving elderly people and ultimately fatal conditions. So prolonging life mindlessly and painfully, in which the quality of that life is no where to be seen, does nothing more than eat up finite resources. But that’s all the more reason why IRS-type or DMV-type bureaucracies should keep their noses out of such complicated aspects of society.

    I hear certain people — almost all of the left — wail about “greedy big business” or “powerful corporatists.” But the private sector is nothing compared with the maze-like fiefdom of the public sector. Government offices full of people who know that the power of the legislature (state and federal) and judiciary (state and federal), in tandem with government-employee unions, gives them immunity from the pesky civilian. Sort of like the hubris or mindset of a cop handing out speeding or jaywalking tickets. Or instead of a cop, a bureaucrat handing out “end of life” coupons.

    Mark (411533)

  156. Thanks for the information, Dana. So presumably these directives could be discussed annually in connection with a patient’s annual wellness visit.

    MD in Philly: Would this be something a doctor is likely to discuss with all his/her patients, perhaps as an item on a checklist, or would a doctor be more likely to raise it with patients of a certain age or who face serious health issues? My guess is different doctors would handle it different ways, depending on how important the issue is to them.

    DRJ (d43dcd)

  157. “perhaps as an item on a checklist”

    DRJ – Color me cynical, but if people get paid for it, it will become an item on a check list.

    daleyrocks (bfdac7)

  158. I also wonder if women experiencing at-risk pregnancies would be subject to these consultations as they close in on their due dates?

    Dana (8ba2fb)

  159. Dana – A little more on your WSJ link:

    “Corrections & Amplifications
    Congress passed a law making changes to Medicare in 2008 by overriding President George W. Bush’s veto. A previous version of this article incorrectly said Mr. Bush signed the legislation.”

    daleyrocks (bfdac7)

  160. Oh thanks, daley, I didn’t catch that.

    Dana (8ba2fb)

  161. Dana – That makes trying to pin it on Bush sort of a BS explanation.

    Another difference, the 2008 Medicare changes went through Congress. Sebelius is implementing this reg. without going through Congress, so the comparison falls apart there as well.

    daleyrocks (bfdac7)

  162. Blumenauer’s rapid response team fell on its face with this one.

    daleyrocks (bfdac7)

  163. I blame Texas and Arizona, who kill people en masse.

    JD (07faa1)

  164. If a youngish person is in good health, an urgent life-threatening situation is likely to be trauma or overwhelming infection, like meningitis. In either case, virtually everybody would do whatever they could. Otherwise healthy people can recover from devastating trauma, etc., and you will not know how it turns out until it does.

    If a 20 year old gets leukemia they will be treated to the max initially because many leukemias have impressive cure rates. Now, if that person is now 23 and has relapsed multiple times and has failed 2 bone marrow transplants, the desire/will/ability to keep going will be an issue to discuss.

    The problem with checklists is that they are…checklists, a list of things to go through by rote, not because you expect anything of usefulness. Now, I know fighter pilots have their checklists, and I imagine the consequences of missing something are great motivations to stay alert, but often a checklist means you can do it with your mind not really paying attention (mine anyway).

    I’m not sure how many docs would take the time to discuss this with a healthy 30 year old, or what use it would be, an abstract discussion with a healthy 30 year old and the real thing in your face are two different things. In an “old-fashioned general/family practice” a doc might be taking care of several generations of a family and these discussions have happened multiple times over the years in the contexts of different family members in different situations. That information really means something, and an ER or hospital physician would do well to have 5-10 minutes of discussion with the primary MD.

    I think one underlying assumption is that you can treat people and their health the way you take care of a car with a warranty, it is assumed you treat people as case numbers passing through the steps outlined on a flow chart.

    The reality is, IMO, that asking a doc to sometime have a discussion so that it can be marked in a record somewhere to guide the decision-making when a person comes into the ER with no prior relationship between the pt and doc is not caring about the treatment of sick people- they’re trying to make a health system work. Auto assembly lines work well, human ones, not so good.

    I’ve often had patients who had their forms filled out a certain way but when you discuss it in the context of a real illness, what they want is different than what was written down. And we all know how pressure can be applied, “If your heart stops beating, you don’t want us to go through all of those heroics to try to bring you back, right?”

    The more we discuss it, the more it seems that Big Brother wants to make sure limbs aren’t being amputated to make money- which is offensive to physicians and patients.

    Other docs, join in to agree or disagree.

    MD in Philly (3d3f72)

  165. “I’m not sure how many docs would take the time to discuss this with a healthy 30 year old”

    MD in Philly – Not sure they would have to, remember it’s a Medicare rule.

    daleyrocks (bfdac7)

  166. Death panels are a lying lie. A political website from St Petersburg told timmah so. Lie. Liar liar pants on fire.

    JD (07faa1)

  167. MD in Philly,

    I understand doctors most likely would not take time to discuss this with healthy young people but I wondered about at-risk pregnant women (any age) as they close in on their due dates? Will it strictly be determined by age and/or risk levels in spite of age?

    Dana (8ba2fb)

  168. Thanks for the reminder, daley. I guess I fell into thinking once the government wanted to regulate, why stop, especially when ObamaCare takes over. Also, having the “discussion” yearly from 30 on would give opportunity to get the person thinking in the “proper” direction.

    When I said “youngish and healthy” that goes for at least 60-65, even 70 or more. If you look ar the life expectancy of healthy 70 year olds it will not be just another 5 years or so.

    MD in Philly (3d3f72)

  169. Doctors would tend to give the information most appropriate, so you will not go through all of the details of preeclampsia with a normal pregnancy, just a few warning signs. That said I knew of a nurse who was having a normal pregnancy and at term elevated her blood pressure and ruptured a brain aneurysm, kept on life support until the baby could be delivered by C-Section, then allowed to die. No one would have expected a need for such a conversation, even if one had happened it would have done little to guide/prepare the family or medical staff.

    A woman who was in our wedding “dropped dead” during a volleyball game years ago. She was maybe 30, 3 kids and a husband, and playing with friends from work-which thankfully was a hospital, so when she collapsed there were people around who knew CPR. She was unresponsive a long time in the ICU. Eventually they came to the decision to take her off the respirator and see if she could make it on her own- at least that was how the family saw it while the medical staff was seeing it as time to “give up”. Well, she kept breathing on her own. She continued to hit new milestones as the professionals doubted until she walked out of the hospital. Had the doctors been of a different mindset, and/or the family not medically sophisticated, it would have been easy to see them give morphine to “ease the discomfort” of fighting to breathe, which might have been enough to do the job. Big difference between watching nature take its course and assisting it.

    MD in Philly (3d3f72)

  170. Great comment, MD.

    Also, I agree with daleyrocks that if the regulations say doctors will get paid for discussing directives with their patients at an annual well-check, it’s common sense for doctors to do that. And like Terrye, I don’t have a problem with doctors discussing directives with patients.

    The issue to me is whether the government will try to influence or even mandate how doctors present the information patients use to make their decisions. Frankly, I can’t imagine the government will continue to pay doctors year-after-year for consultations without having guidelines or mechanisms to evaluate whether the discussions are worth paying for.

    DRJ (d43dcd)

  171. I would imagine that there will be “bullet points” that are variable due to the individual circumstances of each patient,
    and that doctors will be “encouraged” to emphasize a certain course of action accordingly.

    Or, as we used to say in the military:
    I need three volunteers. You, you, and you!

    AD-RtR/OS! (4fe32b)

  172. The issue to me is whether the government will try to influence or even mandate how doctors present the information patients use to make their decisions. Frankly, I can’t imagine the government will continue to pay doctors year-after-year for consultations without having guidelines or mechanisms to evaluate whether the discussions are worth paying for.

    I think this will depend largely on whether a doctor is an employee of an HMO or in private practice. With exorbitant malpractice insurance costs and a change in mindset by younger medical pros about quality of life (in terms of hours worked each week) the trend seems to be more opting for being an employee.
    In Japan the doctors share patient info with immediate family. Not a bad approach imo but that is more culturally amenable to their society.

    vor2 (c9795e)

  173. Ah, the HMO bill, who forgot that last effort of cost containment brought to you, by Ted Kennedy.

    narciso (6075d0)

  174. “It’s all the liberals’ faults”–Rootin Tootin Hooten

    Always nice when a lefty shows signs of growing a brain.

    Dave Surls (8bd411)

  175. AD-RtR/OS! wrote:

    Or, as we used to say in the military:
    I need three volunteers. You, you, and you!

    The term is voluntold.

    The Army daddy Dana (3e4784)

  176. FYI–The Medicare Prescription Improvements Act passed by a GOP majority and signed by Bush already provides for Medicare to pay for end-of-life counseling sessions for people in hospices:

    `(5) for individuals who are terminally ill, have not made an election under subsection (d)(1), and have not previously received services under this paragraph, services that are furnished by a physician (as defined in section 1861(r)(1)) who is either the medical director or an employee of a hospice program and that–

    `(A) consist of–

    `(i) an evaluation of the individual’s need for pain and symptom management, including the individual’s need for hospice care; and

    `(ii) counseling the individual with respect to hospice care and other care options; and

    `(B) may include advising the individual regarding advanced care planning.’.

    Jim (8de501)

  177. Jim,

    You do see the difference between individuals who are terminally ill and those who aren’t, don’t you?

    Ellers (f07e38)

  178. I do, Ellers. But wouldn’t the terminally ill people feel more coersed into giving up treatment and less likely to be of sound mind than people who discuss these things in connection with an annual checkup?

    Jim (8de501)

  179. Jim,

    First, my apologies for leaving my sock-puppet on this PC.

    Second, terminally ill people in hospice care are typically there precisely because they have already given up on treatment options other than pain management.

    Karl (75b130)

  180. A few comments:
    1. This is a good example of the problem, IMO, be it passed by Repubs or Dems. The law as stated applies explicitly to the medical director or an employeee of a hospice program. Why is it limited in that way? Are there other laws that provide for the patient’s primary care doctor to do this same service? Why do we need different laws describing the same thing dependent on different doctor’s specialties?
    2. What decision is there to make if a person is already enrolled/admitted to hospice?

    Maybe there are good answers to those concerns that someone more knowledgible than I can explain.

    Karl, depending on the philosophy of the individuals involved, hospice care may be significantly broader than pain management (alone), and include symptom relief and maximize function in the setting of no definitive curative treatment being available. As I mentioned previously, a strong emphasis of (at least some) physicians involved in hospice care had as their prime goal to not effectively “abandon” the patient; to avoid saying, “There’s nothing more I can do (go home and don’t bother me again…)”. In that spirit, the idea was to help a person be as comfortable and functional as possible in spite of no curative treatment being available, NOT simply to help the person die “pain-free”.

    In the 90′s this was a focal point of discussion concerning what was appropriate for hospice care. Before the Highly Effective Anti-Retroviral Therapy (“HEART”) combinations became available for people with AIDS, some patients were literally forced into the choice of:
    1. Would you like the benefits of hospice care (but you will need to stop your treatment for CMV retinitis, so you might go blind before you die)?
    OR
    2. Do you want to stay on the treatment for the eye condition, and lie alone in your bed at home with no one coming in to help you, but at least you probably will not go blind before you die?

    In that context more sane and humane ideas held the day and multiple treatments in addition to control of physical pain with analgesics/ narcotics became widely accepted.

    To qualify for hospice a physician needs to certify that a patient’s life expectancy is no more than 6 months. Well, we all know life is unpredictable, and there are occasions where patients actually stabilize and improive and go off hospice. Sometimes it is in the midst of inadequately treated pain, fear, a recent miserable time in the hospital, etc., that a person will decide for hospice, and with a little attention and “TLC” the person decides to jump back into treatment if there is something possible that they passed on previously.

    I would personally try to stay away from any hospice where the director doesn’t acknowledge this phenomenon, because there are places, or at least individuals within institutions, that pretty much see their job as “help the person to die painlessly”- so the more one can facilitate that process the less opportunity for “things to come up” and cause more discomfort.

    MD in Philly (3d3f72)


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