Wednesday, December 17, 2008
(wave your hands in front of face to time travel)
Palliative Care Nurse: Hey Dr. Palliativist, we got a new consult, Mr. John Q. Moneybags, the famous billionaire in our fair city. Our CEO knows how much palliative care consults can really make the patient feel valued so he wants us to go see him.
Dr. Palliativist: Hmmm...not good...he's in the ICU, and it looks like he has been diagnosed with the fatal Moon Virus, discovered just this week in late December 2009.
Palliative Care Social Worker: Hey I heard about that fatal moon virus. I think they are going to have a cure....but not until January 1, 2011.
I wonder how Mr. Moneybags might feel about his health care advanced directives?
a)"An endotracheal tube doesn't scare me. Bring it on!"
b)"I fear being kept alive on machines and the horrible effects of that nasty Moon Virus of 2009. Please let me go gently into the good night."
c)"Please keep me alive until we get into 2010 so I can give more money to my children!"
d)"Please keep me alive until we get into 2010 so I can give more money to your wonderful hospital!"
(wave your hands again to get back to the present)Well, thanks to a concise article by Dr. Mendenhall in the December Annals of Internal Medicine, we all have a good primer on the chances you may get this consult. The year 2010 will see the extinguishing of the Estate tax, pejoratively known as the 'death' tax.
So in 2009, a dying millionaire would pay nearly $3mil in taxes on $10mil of assets.
In 2010, that millionaire would pay ZERO.
And in 2011 that same millionaire would pay nearly $5mil in taxes.
I hope you did not get whiplash.
Now technically the Estate tax only affects those with over $1mil in net assets in 2011 and over $3.5mil in 2009 so it is not your everyday patient in the hospital for sure. But if the news over reports this and it gets featured on the front page of the WSJ, then you might get more people thinking it affects them.
So the $3.5mil dollar question is: Does it matter if a patient includes the distribution of one's finances into health care decision making, particularly when it comes to choosing OR refusing potentially life-sustaining treatments?
Dr. Mendenhall writes that awareness of this information can "...affect the ability of all involved parties to make unbiased decisions." Besides making the case for the non-existence of unbiased decisions, I think the inclusion of financial matters is a valid fulcrum for health care decision making. In a whole-person approach, the financial stability and security of one's assets may be a demonstration of love, good parenting, thrift, rebellion against taxes, or many other things representing high personal value to a patient and therefore part of the patient's image to one's family and peers.
Would it 'feel yucky' to be part of a medical team advocating for health care decisions based on a patient's thoughts about their finances. Yes. Is there room for abuse of power in this situation? Absolutely. Does that invalidate the reasoning of the patient? No. And by extension is does not necessarily invalidate the reasoning of the surrogate, but I think investigating surrogate reasoning would be appropriate if sufficient cause exists.
It is part of the medical communities role to help avoid abuse in this type of decision making when finances may be an influence and this article is a good quick step to understanding the potential impact.
Oh by the way the end of the fictional story is:
e) Dr. Sinclair saves the billionaire from the fatal Moon Virus of 2009 with a single dose of morphine! Mr. Moneybags is so grateful he open up the Mr. Moneybags Institute for Palliative Studies That Sometimes Cure with Dr. Sinclair as the CEO!
Bonus: Great interactive page on where your taxes go. Did you know the National Cancer Institute ($4.8B) gets more Federal funds then the FDA ($1.7B)?
G. Stuart Mendenhall (2008). Death and Taxes Annals of Internal Medicine (149), 822-824