Wednesday, July 29, 2009

Policy: ACP as Euthanasia

The last couple weeks' 'national discussion' about health care reform has reminded me of Winston Churchill's famous quote:

Democracy is the worst form of government except for all those others that have been tried.
While this could be a reasonable reflection to make about much of the ill-informed & ideological debate that is going on (see for instance this Paul Krugman column), in the last couple of weeks the wingnutosphere has also attacked a small provision in HR 3200 which essentially says Medicare should (occasionally) reimburse advance care/end-of-life care planning conversations.

In the hysterics of our 24h news cycle some pundits/wingnuts/et al have taken this and made wild, shocking, and inaccurate remarks about it - state sponsored euthanasia, rationing care at the end of life, etc. Joanne Kenen at the New Health Dialogue Blog probably has the most complete discussion of this and I'm not going to duplicate her work in this post - read her post. I will quote from the beginning of hers, though, for a flavor of what has been said:
You may have seen the latest message tirade from the right -- health reform equals rationing equals hospice equals euthanasia.
Give us a break.
The House bill would encourage advanced planning. It would not mean that "old people could be visited in their homes and essentially be told, 'all right, sweetie, you have had a good life.'" It would not send government bureaucrats into homes to counsel seniors about how to cut their life short. It would not "start us down a treacherous path toward government-encouraged euthanasia."

Further reading can also be found at:
Rep. Earl Blumenauer (a co-sponsor of the provision) takes this on in a blog post here.
Daily Kos.
Some thoughts about this:

We try to keep the blog apolitical, and yes all the posts I'm linking to are from liberal blogs, but such is the nature of the political blogging world.
You can think HR 3200 is a load of crap - fair enough - but these attacks on this provision are wrong, and corrosive to our democracy. Rep. Blumenauer's post notes that his provision is co-sponsored by a Republican, and I think this is as much to do with the nature of contemporary political discourse and the reality that, for political ends (ie to undermine HR 3200 as a whole) people will attack small provisions in it with any outlandish thing they can think of. We live in a world in which this provision (which creates a voluntary mechanism to reimburse advance care planning conversations) is represented as: "Congress would make it mandatory — absolutely require — that every five years people in Medicare have a required counseling session that will tell them how to end their life sooner." And this lie, instead of being ignored, gains major traction as it serves some political end.

As such, I'd like to dismiss this as another pathetic example of debased political rhetoric in the US. I find it hard to believe that the individuals making these claims are ignorant fools; more likely craven, pandering, political opportunists (which is no better). However these people make these claims in part because they believe they will have traction with some of the public and should give us pause as a community to acknowledge that this speaks to some portion of the public, and thus our patients. And as better end-of-life care and palliative care are being put out there as potential solutions (in part) to the US health care crisis, this is likely to escalate. Anytime it's pointed out that 'palliative care' (or discussing end of life options) saves money; that is going to be sufficient for some to conclude that this is a government conspiracy to euthanize people with disabilities and deny Grandma dialysis because she's 80. Bleh.

I say Be Out, Be Proud, Superb End-of-Life-Care for All - No Apologies! We are aided by the fact that close to no one wants burdensome treatments/hospital stays/etc. that don't improve quality of life, or frequently even quantity of life, as a terminal illness advances. Close to no one wants to spend 3 out of their last 4 months of life going in and out of the hospital, getting tests that don't help them, and getting treatments and support that will at least make them feel better sporadically, if at all**. What we do helps people, tremendously, and it's what most want (when it's time), and the fact that it probably saves Medicare a few bucks should be seen as good news by everyone.

If you'd like to weigh in on this formally, AAHPM has released an advocacy alert about it as well today, with some suggestions for action.

Thanks to Christian & Joanne Kenen for sharing much of this with me.

**I concede that this is a little idealistic, but I'll say that if you ask people how they'd want to be cared for when they were dying and there was little/nothing to be done to stop that, the vast vast majority of people would agree with this. In real life, the issue is often one of first 1) clinicians actually identifying a patient is dying and these treatments aren't going to help and then 2) communicating that to patients in a way that is understandable, and acceptable, to them.

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