Tuesday, January 4, 2011

Doing The Right Thing

When I read this, I knew there'd be hell to pay for President Obama. It also impressed the hell out of me. It's political... courage.

WASHINGTON — 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.

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.

No question the president knew what would be coming. Shit like this. And yet, because it's the right thing, he presses on, politics be damned. That's leadership. That's guts, or some other slightly more southerly anatomical metaphor.

Even readers of The New York Times, evidently, are caught up in the fecal efflux coming from the right (as in "wrong") side of our politics. Here's a recent letter to the editor, among several:
I read your article about “end-of-life planning” and I am completely appalled. I have been a longtime supporter of President Obama, but it appears as if death panels are becoming a reality.

My mom, 93, recently received a diagnosis of colon cancer, and her doctors recommended an operation to remove the tumor. It was successful and she can now expect to live several more years.
Who are we, or any doctor, or any president to judge when the end of life is and when to deny aggressive care?
What a shame. How sad to be so misinformed.

For the length of my career as a physician, and in the recent declines and deaths of my parents, I've come to appreciate the need for health care directives, and, unlike the mouth-breathers of the right wing and the fears of the letter-writer, I came easily (for it's simple, obvious, and completely logical, absent the screamings of the screamers) to understand what they are. And, more importantly, what they are NOT. Once again, the so-called controversy begs the question: are the dissemblers really that stupid, or are they, per usual, grasping at anything they think they can sell to a gullible public in an effort to discredit our president? (My opinion: there's a lot of stupidity seeping sadly from the screamers, but they can't be so dumb as to believe their own words in this matter. It's cynical politics at its very worst.)

That the lady of the letter is so misinformed is not entirely her fault. For one thing, there's confusion -- because our fourth estate is so damned incompetent -- between end of life directives and the concept of effectiveness research. Though very different (and useful) ideas, such intellects as Sarah Palin and Glenn Beck have used the concepts interchangeably in their race to the bottom of the pickle barrel of demagogues. Because they're cynical assholes (to use diagnostic terminology), I doubt it's accidental.

Simply put, end of life directives are a way for people to ensure that their wishes are carried out. Shall I repeat? Ensure that their wishes are carried out. Carried out!!! It's the absolute opposite of a "death panel." It's a directive. By the patient. And it applies only when that patient is unable to express his/her wishes. It's not an unbreakable contract that overrides one's current wishes. Like my dad. In his directive, he'd said he didn't want to be hooked up to a ventilator. When the time came, he chose to be intubated. No one did -- or could have -- told him, sorry, we have your directive here, and it says no.

As long as you're capable of expressing your desire, the directive does not apply, no matter what it says. DOES NOT APPLY. There is no panel, nohow, nowhere, that can decide otherwise. Period.

No. Fricking. Panel.

[What panels there are, by the way, are those instituted by Republican governors, in Republican states.]

The other concept -- effectiveness research -- is more complicated and, because of the very nature of medical research, rightly a subject of controversy and disagreement. But, for one thing, that's not what the president and the NYT article were talking about. For another, who, given a moment's thought, would want to be treated using methods shown to be ineffective? If -- and it's not a tiny "if" -- research could point to the best treatment and away from those that are a waste of time and hope and effort and suffering and money, would that not be something we'd want? Demand??!! Even if the idea came from a black guy?

But the Sarah Palins and Foxobeckians of the world, the teabaggers, are neither capable of such subtle thinking nor interested in what's reasonable or factual. Not to mention what's in the best interest of our country. Never missing an opportunity to lie and to frighten, they spew their dishonesty and people like that poor letterer are deceived. Like my ninety-three year old aunt who just underwent colon resection and chemotherapy for cancer, the writer's mother got the treatment she needed. There's nothing about end-of-life directives that would have changed that -- or even addressed it! -- unless she were in a coma and had previously directed that, under those circumstances, she'd not want aggressive care.

Likewise, effectiveness research might have prevented her from having her back manipulated and taking homeopathic remedies or aromatherapy for her cancer, or, possibly, from receiving Avastin for it; but, until the day arrives that there are data showing surgery doesn't cure colon cancer, she'd receive that, too.

Unless, of course, we ever get around to looking at the books and deciding how much we want to and/or can afford to spend on medical care; and if, when we realize that there's a limit, we're willing to confront whether, given limits on resources, paying for colon surgery for a ninety-three year old carries the same weight as doing so for a forty year old.

But that's another matter entirely. Nor will it ever fit into the minds of teabaggers, who want simultaneously to reduce taxes and bitch about cuts in medical care; who call it "rationing" to refuse to pay for treatments that don't work.


Anonymous said...

Yeah, lotta courage, maybe he'll close "Gitmo" next...
and can I get this off of my massive 180lb bench pressing chest(thats alot when you way 140)??
It's "Camp X-ray" he might close, not "Gitmo" which is the whole base we stole from the Cubans over 100 years ago, and still rent for $100/year, that we still pay in Cuban Pesos just to piss Fidel off..
OK, I made up that part about the Pesos...
and must be an elipse or sumthin, cause I'm with ya on the end of life thang, don't need my parents wastin any of there $5million plus(last time I checked) linin those Critical Care Quacks pockets, good thing you can print one of those "Living Wills" yourself, copy your parents signatures(just like 4th grade:), and did I tell you my Mom's got one of those Notary Stamps???

Frank "gave my Dad a copy of "Final Exit" for Hannukah" Drackman

Anonymous said...

Dr. Sid,
It's very unfortunate how some of the population seems to be confused with the concept of Advance Directives (a good thing) vs. long waits and rationing of care in countries with socialized medicine (not good). They are 2 separate topics and should be discussed as such. Unfortunately, Palin's Death Panels comment has come to encompass both topics.


p.s. Did I ever tell you guys about how the tax paying post-gastrectomy lady in Toronto with nausea/vomiting so severe she was down to 90 pounds couldn't get Ondansetron from her government run healthcare system? Luckily someone found a way to combine ondansetron powder and pill casings and "export" it to Canada. She's up to ~120 now. :) Rumor has it that it was really cheap to make too; maybe even cheap enough for a country with government controlled medicine. :)

Anonymous said...


And speaking of "courage"....

Obama signed a bill that both STOPPED construction of 45 hospitals AND made quality healthcare harder to access.

Maybe he should ban chefs from owning restaurants too? Ban pilots from investing in airports? Ban farmers from owning their own farms? Ban dairy farmers from owning cows? Ban authors from also publishing books? Ban small manufacturers from owning their own factories/machinery? Ban couriers from owning their own vehicles? Ban construction companies from owning their own materials warehousing/wholesale divisions? Ban security companies from owning their own weapons?

Hospital/Surgery Center ownership promotes pride in ownership and increased responsiveness to patient/market needs. If they're too expensive, insurance companies will simply cancel their contract with that facility. Happens all the time.


Anonymous said...

Full link for the article in my last post. It was cut off for some reason.


Sid Schwab said...

PT, I'm re-reading my post and trying to figure where I was addressing socialized medicine. For that matter, I'm trying to see evidence of socialized medicine in the ACA, and I'm having a little trouble. But thanks for mentioning it.

We could, if it were on the subject, trade stories, I suppose, about individual cases and anecdotal stories of poor care on both sides of the border. And, I guess, we could consider the numbers of people who get care easily, in each system, and those who don't.

We could ponder whether the obstacles to proper care for the under- or uninsured in this country add up to more or less instances of people being under-treated compared to Canada. We could even, if we were on that subject, look at polls conducted in each country, revealing percentages of people satisfied with their care.

If any of that had been what I was talking about, that is.

I can't speak to the issue of POH in terms of the ACA. It's not something I've heard about before. If it's as you say (and the snarkiness of your referenced article leads me to question its veracity or thoroughness of reporting) then I'd say it's something that needs correcting. My part in the creation of my clinic's surgical center is one of my proudest achievements, and the quality of care provided therein -- to the benefit of everyone -- has been a source of even greater satisfaction. You only need to re-read my posts on the ACA to find that it fell far short of my expectations.

I don't, however, see the relation to Obama's "courage" in regard to POH, sarcastic or not.

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