Profiles in Cowardice

December 26, 2010

The Obama administration may come to regret its decision to sneak a rule into a Medicare’s annual update for reimbursement rates that would reimburse physicians for helping the elderly write end-of-life directives. As today’s New York Times revealed, the rule was published in “early November,” yet was deliberately kept quiet by supporters to avoid invoking the wrath of the “death panels” crowd. By violating their own promise to run an open government, they’ve needlessly endangered a much-needed policy.

First, let’s be plain about the importance of this measure. As I and millions of other Americans know from first hand experience (in my case, from my mother, who passed away two years ago at age 86 after a long, debilitating physical decline that involved crippling arthritis, diabetes and heart disease), it is crucial to begin these discussions before an elderly person loses the capacity to make decisions on his or her own. Doctors need to be encouraged, i.e., reimbursed, to engage individuals and their families in these discussions. As I sat with mom in her final days, which were spent more or less in a coma, I was glad I could spend those final hours holding the hand of a person who did not have a single tube attached to her body, and who had made that decision to die that way on her own when she had the capacity to do so.

Similar scenes take place every day and in every state and community in the nation. If people like Elizabeth D. Wickham, executive director of LifeTree, which is described in the Times story as a pro-life Christian educational ministry, wants to die with tubes sticking out every orifice, unconscious for days or weeks, and cut off from family and friends while surrounded by machines that go “ping,” that’s their business. But they should not be allowed to impose their religious values on anyone else.

If certain politicians want to win votes by stoking ignorance about the realities of end-of-life decision-making, such as happened earlier this year during the debate over health care reform and was preceded by the Terry Schiavo circus, they need to be confronted. Their political opportunism is not only cruel, it is fiscally irresponsible, since creating an environment where individuals can make voluntary decisions to reduce or eliminate useless interventions near the end of life can save Medicare billions of dollars annually.

It would have been better if the new leadership at the Centers for Medicare and Medicaid Services used adoption of this new rule to educate the public about the importance of developing end-of-life directives, while simultaneously stressing that such actions are totally voluntary. Instead, CMS chief Donald Berwick snuck it into a rule that no one reads. If this winds up becoming the next political football for opponents of health care reform, reformers like Berwick will have no one but themselves to blame.

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11 Responses to Profiles in Cowardice

  1. jim jaffe on December 27, 2010 at 7:58 am

    I’m a little confused about the role of the press here. On the one hand, we’re told the proposed rule was published in early November. Publishing stuff is pretty tranparent. Now we’re told that the NYTimes has “revealed” this. Sounds to me like this is a media failure. While all the thumb-sucking was going on about whether the President was relevant or not, appears some people — a lotta people, the entire health media community — was asleep at the switch and not bothering to even cruise the Federal Record. Guess we can blame the administration if we choose to, but it seems to me another institution has dropped a stitch.

  2. stats on December 27, 2010 at 8:10 am

    Appending significant policies is standard operating procedure when cms wants to bury what they are doing. For example when they undertook the massive expansion of cancer drug coverage they put it in the payment reg also. Cowards and opportunists run cms – so much for the transparency admin.

    • John Abramson MD on December 28, 2010 at 10:11 am

      Important comment, do have a reference for the expansion of cancer drug coverage? Thanks

  3. Kate Murphy on December 27, 2010 at 8:21 am

    If there is more than one child in the family, there are always worries about “what Mom wanted” and probably one who would opt for hanging on with aggressive measures or calling the ambulance for a trip to the ICU.

    These are crucial discussions. And if “What Mom Wanted” was to end her life in the ICU, we will know it.

    The death panel red flags were despictable. Home with the support for family and hospice is a kind and generous choice.

  4. John James on December 27, 2010 at 9:03 am

    @Jaffe: There isn’t much real reporting any more. And what used to exist is overrated. Mainstream media does entertainment, as prompted by powerful interests. So we have war after war.

  5. Bill Baar on December 27, 2010 at 10:23 am

    Your Primary Care Doc who hopefully devoted his/her’s years of service towards keeping you health seems the least likely person to help a patient write one’s EOL wishes. It’s too much of a mission change for them, they’re not trained for it, and have no business collecting reimbursement for it.

    “Useless interventions” should never happen regardless of the stage of life as every intervention carries a risk. If the intervention useless, it’s poor practice to take the risk. In fact expecially poor practice if at an early stage of life when the consequences could be far more damaging.

    So please get that medical concept straight.

  6. Bill Peckham on December 27, 2010 at 11:52 am

    I don’t know, the important thing is that there will now be “encouragement” for doctors to talk about the critical choices that often have to be made as people die. I’m sympathetic if the administration saw having a public discussion as being hopeless.

    A discussion requires two parties that are willing to listen as well as talk. I think it would be wonderful, hugely helpful, if we could have a discussion about end of life care but I see no evidence that a discussion could take place in these overwrought times. It seems to me that the administration did the right thing.

  7. Maggie Mahar on December 28, 2010 at 8:00 pm

    I agree with Bill Peckham.

    Merrill, you write: “It would have been better if the new leadership at the Centers for Medicare and Medicaid Services used adoption of this new rule to educate the public about the importance of developing end-of-life directives.”

    I couldn’t agree more.

    But Merrill, can you give me one example of a case where health care professionals have been able to educate the public about anything that runs contrary to the current conservative convemtional wisdom? (the dangers of overtreatment? PSA tests? mammograms for women under a certain age and over a certain age? back surgery? the importance of providing healthcare for immigrants? how much we could improve the healthcare of the nation by providing free tobacco cessation clinics? the fact that obesity is a disease and that 98% of obese patients will only put back on the weight that they lose when exericising and dieting under a doctor’s supervision? the fact that if we want to combat obesity among chilren we need to pay the taxes need to provide them with safe places to exercise in their neighborhoods, gyms and gym teachers in public schools, and affordable nutritous foods in their neighborhoods?)

    I completely agree that education is needed. But this will be a long, long process. It is very difficult to change the convetional wisdom about health care, especially when many (mainly older) doctors tend to support the CW. .

    In this case, oncologists and others object to talking to patients about end-of-life issues, offering palliative care, etc. because you’ll “take away their hope” etc.

    Meanwhile, conservative think tanks pour billions into spreading misinformation. This is why CMS was wise to make this part of a regulation.

    Congress, in particular is loathe to go against he convetional wisdom, because the CW tends to support big profits for those who can afford to hire powerful lobbyists. (Companies that produce cancer drugs that keep patients alive for a few futile months;companies that produce the equipment involved in futile end-of-life-treatment; hospitals that depend on ICU revenues while ICUs keep hopeless patients alive; physicians who make profits on those end-of-life treatments . . .

    It is truly unfortunate that, at this point in time, we have a Congress that is controlled, to such a large degree, by lobbyists, and a government that dominated, to a large degree, by ideologues who,as Peckham points out, are not willing to listen.

    I’m hopeful that, if health care reform survives, over a period of 10 years or so, much of this country (the public as well as politiicans) can be involved in meangingful, educational discussions about heatlhcare.

    But in the meantime, we cannot afford to continue to prolong the process of dying by torturing people–we cannot afford to continue doing this morally or financially.

    Merill, as you know Don Berwick is a person of great courage and integrity.

    If there were another way to to do this, he would.

  8. GoozNews on December 29, 2010 at 8:56 am

    Who is responsible for overtreatment, overuse of PSA tests and mammography, and too much back surgery? The same health care professionals whom you say have not been able “to educate the public about anything that runs contrary to the conventional wisdom.” With all due to respect to Dr. Berwick and others with the bully pulpit at their command, it seems to me that the re-education of the broad population of health care professionals and their patients when it comes to difficult end-of-life decisions or any other issue must begin now and it begins with public declarations of changes in policy with an opportunity for an open discussion by those affected.

    Even if Medicare succeeds in “sneaking one by them,” how many additional physicians and patients will take advantage of this new ICD-9 code, beyond those who would have already engaged in advanced planning anyway? At some point, you have to begin educating people. Until that happens, all this new (secret) policy will do is add another layer of reimbursement for those already engaged in advanced planning (without reimbursement) without changing the underlying high-cost behavior of the broader population and their physicians.

    • Doc Frankie on December 30, 2010 at 9:04 pm

      With all due to respect to Dr. Berwick and others with the bully pulpit at their command, it seems to me that the re-education of the broad population of health care professionals and their patients when it comes to difficult end-of-life decisions or any other issue must begin now.

      Sure! It is also well known that in time of elections, universal peace is within grasp and the foxes suddenly develop a keen interest in the survival of the poultry.

      Please, let’s not kid ourselves here, shall we? Like Maggie said, there is a confluence of negative forces and interested factions consciously and purposely conspiring against ANY change in thinking or beliefs when it comes to health care. There are way too much profits to be made with the current status quo, the population’s set of health care beliefs is deeply entrenched and goes totally against the body of evidence-based medicine such as the works of the Dartmouth Research.

      Therefore, picking on Dr. Berwick as a “coward” is way off base IMO. There is just so much one can do against the powerful right wing propaganda machine, their allies in the GOP and medical-industrial complex.

      While we’re at it, let’s not forget the enablers of all the above, a.k.a. the morally depraved, slothful and reliably comatose mainstream media, which last exploit consisted in being put to absolute shame on the filibustering of the health care bill by none other than a comedian on the Daily Show.

      Again, it would’ve been nice for Dr. Berwick to act in a fully transparent manner. But there is a limit to the kind of abuse someone can take from the most dishonest and relentlessly craven people in the Union.

  9. Bill Peckham on December 29, 2010 at 12:48 pm

    It appears the Republicans intend to use the Congressional Review Act and work to pass Resolutions of Disapproval, about individual administrative actions. These resolutions of disapproval will then go to the President to be vetoed (or signed). Assuming this is one of the regulations that the Republicans plan to target, problem solved! Maybe end of life care will be discussed for 10 minutes on a Sunday show.

    Meanwhile great docs will be paid for the care they’ve been giving all along and hospitals will be able to institute policies and procedures based on the reimbursement … the practice will become more standardized rather than based on physician benevolence.

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