Wednesday, September 2, 2009
Huckabee, Kennedy, and the Politics of Distortion
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"[I]t was President Obama himself who suggested that seniors who don't have as long to live might want to consider just taking a pain pill instead of getting an expensive operation to cure them," said Huckabee. "Yet when Sen. Kennedy was diagnosed with terminal brain cancer at 77, did he give up on life and go home to take pain pills and die? Of course not. He freely did what most of us would do. He choose an expensive operation and painful follow up treatments. He saw his work as vitally important and so he fought for every minute he could stay on this earth doing it. He would be a very fortunate man if his heroic last few months were what future generations remember him most for."Senator Kennedy's death has been politicized by many on all sides of the healthcare debate. Politics aside, though, anyone in the field of hospice and palliative medicine (and many others) can see the obvious errors in Huckabee's thinking. I hope to add to the internet "chatter" that refutes his claims because I don't think there can be enough chatter on this side of the issue.
Let's assume that Sen. Kennedy's diagnosis was glioblastoma multiforme. While we know that he had a "successful" surgery (unclear how success was defined), I don't know what other therapies he received. But here are some studies related to gliomas:
- In a small randomized trial, patients older than 65 were randomized to receive resection of tumor vs. a biopsy. All subjects received radiation therapy. Median survival in the surgery group was 5.7 months vs. 2.8 months for the biopsy group.
- In one randomized trial that looked at the role of adjuvant radiation therapy for older patients (>70 years old) with glioblastoma multiforme, the median survival for patients who received radiotherapy plus supportive care was 29.1 weeks, as compared with 16.9 weeks for patients who received only supportive care. The regimen studied was 50 Gy in 1.8 Gy fractions, in other words, about 28 treatments.
- Non-clinical trial data suggests that temozolomide may confer a survival advantage to older patients of a few months on average. It's an oral agent that is taken for five consecutive days every 28 days.
Huckabee may accurately state that most of us would elect to proceed with at least some of these therapies. The operative word is most, and given the statistics above, a significant proportion might be inclined NOT to proceed with the therapies (as Huckabee quotes Obama as saying although Huckabee's inference is that the "government" would make the choice for the patient). Furthermore, some may not be candidates for the therapies because of comorbdities or advanced stage at diagnosis. The common denominator amongst all patients diagnosed with this is that they will be burdened with symptoms and eventually die from their disease: A population that would be well supported by palliative care. Palliative care should not only be the alternative to disease modifying therapy when the physician obtains informed consent, it should be the standard of care regardless of other therapies offered. Any legislation that bolsters palliative care efforts will be good for every patient with this diagnosis.
It's plausible that Kennedy received disease-modifying therapy up until the very end, but there's little doubt that he and his physicians put limitations on the intensity of attempts at life-prolongation towards the end. He died at his home and one can reasonably assume that he therefore did not undergo resuscitative measures, likely after an "advance care planning" discussion with his physicians (or maybe his lawyers) perhaps even before he was diagnosed. In other words, he probably stayed at home, took pain pills, and died. Who would argue with this approach (since most Americans would prefer to die at home and all want to be comfortable) and who would accuse him of "giving up on life" in the process of doing so? Which patient wouldn't benefit from an early discussion to clearly delineate what preferences they have for such therapies near the end of life, regardless of what those preferences might be? This is the intention of HR 3200 Section 1233.
As with Christian's recent post, pain medications and death are once again juxtaposed inappropriately. I've not known a patient with this diagnosis that didn't benefit from pain medications long before they died, and the cause of death in the end has always been the brain tumor or some other complication.
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9 Responses to “Huckabee, Kennedy, and the Politics of Distortion”
September 03, 2009
The combination of arrogance and ignorance demontrated by the likes of Mr Huckabee is overwhelming to me. I'm unclear how to respond. I've found that using facts (such as those that you've so well summarized) are innefective. Logic is also of little value. (Demonstrated by the "I don't want socialized medicine and don't touch my Medicare" comments I frequently hear from my patients). I would appreciate any suggestions as to how best counter these positions in a way that would penetrate the apparently locked minds of these individuals.
September 03, 2009
While Drew, Ron, and most of us, in the field are preaching to the choir, the PR train has left the station. The bigger problem, however, is that the train does not have an engineer on board - since G Beck's GOP is (wisely) cheering from a safe distance. We and only we are to blame for the public lack of understating what Palliative Medicine is: we were suppoosed to be the engineer. Having marketed the specialty with avoidant strategies (we are not, aah so not about dying) the mis-marketing has caught up with us.
September 03, 2009
What gets me is how these politicians like Huckabee are not being held accountable for the misinformation and, basically, lies they are spewing publicly for personal political gain.
Thank you, Drew & Christian, for making us aware of the nonsense that goes on in the public forum. I agree that we, the palliative care community, need to do a better job about defining who we are; but it's hard to get a pedestal as tall as those used by our elected officials.
September 03, 2009
The whole death panel thing seemed to have quieted down for a bit, but I have a feeling it is not over, and as I have said before I am very concerned that the words 'palliative care' or 'hospice' may be swept up and demonized in this debate. It is already starting to happen in the UK with NICE and the Liverpool Care Pathway, which I will post on soon. We try not to be too political here, but this is one of the only places to discuss some of these issues so relevant to our field.
Thanks for your comments all. And Anon #2, this post was written by Lyle Fettig, MD our newest contributor so just wanted to give him a little credit.
September 03, 2009
Thanks for the comments. I wonder if the only way to penetrate locked minds is to continue to expand services so that more people (including those with locked minds) have personal experiences with quality palliative care.
The recent "debates" have been disheartening because of a double-whammy: 1) PC related concepts have been distorted in an effort to 2) defeat much needed attempts at overall healthcare reform. The arguments of reform opponents are so twisted with opponents espousing two opposing philosophies at once... "we don't want government providing healthcare for all, but for those for whom healthcare is already provided, any measure that could lead to fewer interventions (even if this may represent higher quality/patient centered care)is taboo."
Lyle
September 04, 2009
Lyle, I came across this story in the Washington Post: http://www.washingtonpost.com/wp-dyn/content/article/2009/09/03/AR2009090303833.html?hpid=topnews
which details the origin of the controversy surrounding "death panels". It's amazing that 90% of the town's residents have completed advance directives. I don't know anything about Wisconsin, I thought Drew might like to read this story.
September 04, 2009
Thanks JP.
I saw that article this AM as well. The project took place in LaCrosse across state buy my mentor David Weissman was around for it in the 1990s. It was a really audacious, forward thinking project - one that was successful in getting ADs completed - but didn't show (from what I was told - someone correct me if I'm spreading rumors) other measurable improvements in outcomes (improvements in EOL care, increased hospice utilization, etc.). I assume their lower Medicare costs are largely from the fact that Gunderson is so dominant and has an integrated, planned, salaried model (like Mayo, etc. which delivers excellent, integrated care at lower costs compared to communities which don't have that a la the Atul Gawande New Yorker article recently).
AD outcomes aside, the article is a great reflection of why I think and have said before on the blog we have 'history' on our side: patients, including good old salt of the earth small town Wisconsonites, don't want to be flogged to death - they want control, want 'dignity,' and don't want invasive treatments which add nothing but burden.
Re: other comments:
I'm not sure Huckabee is ignorant and personally think he, Grassley, et al are more cynical and libelous: they know the legislation wouldn't set up death panels but want to defeat it for other reasons and are cynically using this as a distraction from actually engaging the merit or lack of merit of the proposed reforms.
It's easier to shout 'Get government out of my medical care' without actually engaging in any reality-based discussion about what that means.
Disband Medicare and the VA system?
Or just stop 'government interference' in Medicare (I guess stopping any public control over costs or quality measures? Sound fine to me if that means I can bill $2k for a palliative consultation - government has no right to tell me how to practice medicine after all. Of course we should all prepare then to pay 70% of our income in taxes to cover such an a system).
September 04, 2009
I an a non-clinician and a hospice care consultant. As I market our services to the rural communities the confrontation comes not only from local citizens but the family practice and internal med doctors. I chose to address the issue in an article in our local paper and received positive feedback. Perhaps the medical journals can begin a campaign of education regarding the misperceptions. If our own medical community is confused - how will the lay-person in the community learn the truth?
A family practice physician raised his voice in defense when I presented an explanation of the HC Bill with "Turn 65 and you will no longer receive medications or surgeries or any other care!" I explained he would now be paid for what he does anyway - consulting with patients regarding their end of life choices and options. He said, "Well, that I will go along with - but not the rest of it". I hope he has researched it further since then. Are there more physicians out there who actually think this way?
September 04, 2009
Article; Here is the article that I submitted if anyone cares to use it, you are welcome to it.
Americans over 65 – Prepare for Euthanasia?
By Robin M. Watts
http://hospice.yolasite.com/archives.php
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