Wednesday, November 7, 2012
Aren’t we all glad that is over! With all the attention on the Presidential race, it was easy to lose sight of some key issues which could have a large impact for palliative care providers. It was surprising how little national attention was given to Massachusetts Prop 2 on legalizing physician-assisted suicide (PAS) in the run up to the election. I was expecting this to even become part of the debates since the connection between health care and Massachusetts was obviously in play. Part of my reluctance to blog on the topic in the past month may have been related to an irrational fear of ‘death panel’ language creeping up again on the national scene.
I expect Death With Dignity (DWD) ballot initiatives will continue in the future, building off the model established by medical marijuana initiatives in the past two decades. Both PAS/DWD and medical marijuana legalization will impact how we as hospice and palliative care clinicians operate in states with a broad range of laws. For instance, with increasing access to medical marijuana and medically hastened death, should we re-examine how we address these complex issues in fellowship training? What about educating the new hospice medical director who does not have a depth of hospice experience yet? How do we deal with conscience clause laws in various states? Is there an incentive for HPM advocates to rail against PAS/DWD and choose the potentially self-serving argument of increasing funding for comprehensive hospice and palliative care services?
Frankly I feel we as a field have not addressed these issues very well. We have fought well to become established in modern medicine, and these topics are fraught with danger when discussed in the public arena. Sure we may feel very confident when in a family meeting addressing a request for hastened death, but those intimate conversations do not lend themselves well to media sound bites and internet commentary.
This week I’ll explore some of these questions about hastened death and other current election results and how it affects our work. Right now it looks as though Prop 2 will pass 51-49% with 93% precincts reporting. The raw numbers show how close this is (as of 02:30am ET):
Proposition 2 - Massachusetts
A Yes Vote would enact the proposed law allowing a physician licensed in Massachusetts to prescribe medication, at the request of a terminally-ill patient meeting certain conditions, to end that person’s life.
Official Ballot Language
Pro - YesonDignity.com
Con - Committee Against Physician Assisted Suicide
Physician-Assisted Suicide is Not Progressive - Ira Byock - (The Atlantic - 2012)
Suicide by Choice? Not So Fast. - Ben Mattlin - (NY Times 2012)
Letters to the Editor to Suicide by Choice? Not so Fast. (NY Times 2012)
Four Myths About Doctor-Assisted Suicide - Ezekiel Emanuel (NY Times 2012)
Whose Right to Die? - Ezekiel Emanuel (The Atlantic -1997)
Wednesday, November 7, 2012 by Christian Sinclair ·
Sunday, October 30, 2011
The illness and death of the iconic Steve Jobs have stimulated much conversation both online and off. I won't rehash that now.
In case you missed it, NYT published the eulogy delivered by Steve's sister, Mona Simpson, who is a novelist and English professor.
"One time when Steve had contracted a tenacious pneumonia his doctor forbid everything — even ice. We were in a standard I.C.U. unit. Steve, who generally disliked cutting in line or dropping his own name, confessed that this once, he’d like to be treated a little specially.
I told him: Steve, this is special treatment.
He leaned over to me, and said: “I want it to be a little more special.”
Intubated, when he couldn’t talk, he asked for a notepad. He sketched devices to hold an iPad in a hospital bed. He designed new fluid monitors and x-ray equipment. He redrew that not-quite-special-enough hospital unit. And every time his wife walked into the room, I watched his smile remake itself on his face.
For the really big, big things, you have to trust me, he wrote on his sketchpad. He looked up. You have to.
By that, he meant that we should disobey the doctors and give him a piece of ice."A remarkable blending of the mundane with the extraordinary. He put his two pant legs on and wanted his ice chips just like everyone else.
Oh, how I'd love to see those drawings.
The eulogy hints at how Jobs' illness and treatments interacted with his goals of care (which I'm guessing he was able to clearly define) and quality of life. Given the amount of discussion in our society which surrounded his illness and death, how special might it be to know how he went about making various decisions related to his health care? That could be a beautiful contribution to our society. There is no doubt that limitless financial resources played a role in the care which he received, but he wasn't in the ICU or even the hospital when he died.
"We all — in the end — die in medias res. In the middle of a story. Of many stories."
Sunday, October 30, 2011 by Lyle Fettig, MD ·
Wednesday, June 29, 2011
Not a good start from a newspaper that has actually been quite kind to hospice in the past. The rest of the article goes on to discuss the various fixes including every hospice medical director's new task: the face to face certification visit. (We have not yet dedicated a blog post to face-to-face home visits for certification, but one is in the works so we can has that out at a later date.)
But the article leaves out a lot and I feel it is pretty one-sided. Apparently Don Schumacher, head of the NHPCO, has found some flaws in the article too as he is communicating with the NYT editorial board. There is relatively little about potential changes to the payment structure to focus greater reimbursement during the first 7 and last 7 days of service when need is thought to be the greatest. The article does not talk about or reference the article by another NYT reporter from 2007 with the title "In Hospice Care, Longer Lives Mean Money Lost" about the aggregate cap. Nor did it quote the Duke Study that found hospice care saved Medicare an average of $2,300 per beneficiary (OPEN ACCESS PDF), calling hospice “a rare situation whereby something that improves quality of life also appears to reduce costs.” Yeah, they missed some stuff.
Which is not to say we need to look closely at fraud issues. Good oversight is important for a multi-billion part of the health care system, but we have to realize that every problem started out as the solution to another problem. The system is perfectly designed for the outcomes it gets. So let your legislators know about what hospice means to you. Talk to your organizations and actually answer the advocacy emails that moment instead of promising to get back to them later.
As the NYT usually does there is no ability to comment on the article but there is a linked blog post at "The New Old Age" which allows for comments. As of this writing there are 64 comments. Here are a few I thought stood out:
It is amusing and annoying to be complaining about the costs of hospice care, when in fact hospice patients are forgoing the ER visits, hospitalizations, specialists' visits, procedures, and many medications that Medicare would instead be covering if not for the patient making a decision to pursue comfort care only. So, what was the cost SAVINGS to Medicare by having these people on hospice, even though they stayed on longer than usual? Alot.- ras
I don't even believe desperate old people are gaming the system via hospice. But if they are, it's because this country has utterly failed them, taken payroll deductions for a lifetime in exchange for medical care in old age, and then only given the kind of medical care 70-year-olds need, not 90-year-olds. Shame on us. - jane gross
Hospice is a critical service that is offered to all. It is necessary, compassionate, and well run. So, if we discontinue it or cut services, we are a nation without merit and compassion. We will not only be third world, we should not be in this world. - Julie
The article disingenuously ignores this broader care issue while it exploits an example of an Alzheimer's patient. Please, NY Times, get perspective on the bigger picture. Help the US face its fear of dementia that keeps us in denial and prevents us from preparing to fight a huge healthcare tidal wave. Take more leadership and make a difference. - Suzanne
So it's too expensive to have an MD check on hospice patients once every six months? The health care industry has become even more shamelessly and barbaricly greedy than I thought. - Cowboy Marine
TAYLOR JR, D., OSTERMANN, J., VANHOUTVEN, C., TULSKY, J., & STEINHAUSER, K. (2007). What length of hospice use maximizes reduction in medical expenditures near death in the US Medicare program? Social Science and Medicine, 65 (7), 1466-1478 DOI: 10.1016/j.socscimed.2007.05.028
Photo credit: Flickr user: castle79
Wednesday, June 29, 2011 by Christian Sinclair ·
Tuesday, March 29, 2011
- Hospitals increasingly offer palliative care - Washington Post
- Critical (Re)thinking: How ICU's are getting a much-needed makeover - Wall Street Journal
- Special needs, Special care (Pediatric Palliative Care) - Boston Globe
- Many doctors still focus more on cure than managing pain - NPR
- Hit by the reality of cancer treatment - NYT Well Blog
All of these were making the rounds on Twitter today with lots of clicks and shares from people not in our field which is always nice to see. I am not going to go into detail on any of these articles tonight, but please share them with your team. I particularly liked the WSJ and Boston Globe one. The NYT blog deserves its own blog post to discuss the importance of language.
If any Pallimed Reader wants to write up a guest post on the WSJ, Boston Globe or NYT articles, email me your 250-500 word write up email@example.com. (Yes we are open to guest posts, more details to come! See your name in lights, or at least the faint glow of some strangers laptop.)
The NPR and WaPo articles were covering the basics. Obviously important but not sure you will gain a lot from reading those. And interestingly those were both written by the same person Michelle Andrews from the Kaiser Health Network. Not sure why they are covering palliative care issues so much, but keep it up if it gets published.
This convergence doesn't quite rival the 2010 St. Patrick's Day journal smorgasbord of palliative care but is still a pretty impressive grouping of media outlets in just a span of a few days.
Tuesday, March 29, 2011 by Christian Sinclair ·
Tuesday, March 22, 2011
Tuesday, March 22, 2011 by Christian Sinclair ·
Sunday, February 27, 2011
- Joan Didion’s “Year of Magical Thinking” (2005), (Pallimed: Arts review here)
- David Rieff’s “Swimming in a Sea of Death” (2008),
- Anne Roiphe’s “Epilogue” (2008)
- Roland Barthes’s “Mourning Diary”(2010).
Two new contributors to this growing genre are Joyce Carol Oates’s “A Widow’s Story,” (2011) and Meghan O’Rourke’s “The Long Goodbye,” (2011), and the New York Times did us the favor of letting us in on what drove these authors to write about their grief.
Sunday, February 27, 2011 by Christian Sinclair ·
Wednesday, July 28, 2010
A couple of recent NY Times articles.
The most salient one is a discussion of the movement in Washington State to officially DO SOMETHING about prescription opioid abuse, coming on the heels of course of the FDA rejecting the current REMS plan as, essentially, not going far enough. The article basically discusses the discussion in Washington about what to do; no formal new plans have been offically proposed as far as I can tell from the article. This is what they mention that is being discussed:
The regulations would not affect how narcotics are used to treat patients with cancer or those at the end of life because experts agree that such patients should receive as much pain medication as necessary.This is an exemplary quote from the article:
The panel is expected to require that, among other things, doctors refer patients to a pain specialist for review when their daily medication increases to a specified dosage level and they do not show improvement. The specialist can then determine whether to continue the drug, reduce it or use other treatments like physical therapy.
“This is not just about addicts but little old ladies with arthritis starting to die because of this kind of medical practice,” said Dr. Alex Cahana, a pain specialist involved in devising the regulations in Washington State.
Wednesday, July 28, 2010 by Drew Rosielle MD ·
Sunday, March 14, 2010
If you want a better story about the potential for social media to be another tool for connecting people to each other, you won't have to look much further than Daniela Lamas' essay in the New York Times this past week.
The essay is short, but packs several difficult questions that Daniela elucidates very well in the essay. Read it and bring it to your team to see if they have had a similar experience. You may be surprised.
(Photo by Flickr user: brykmantra)
(By the way, I have started a new NYT label. If anyone wants to help find all the NYT posts and help us label them, that would be great!)
Sunday, March 14, 2010 by Christian Sinclair ·