Undernews is the online report of the Progressive Review, edited by Sam Smith, who covered Washington during all or part of one quarter of America's presidencies and edited alternative journals since 1964. The Review has been on the web since 1995. See main page for full contents

August 29, 2009


Sam Smith, Progressive Review - Sure, the Republicans are exaggerating about death panels, but why are they getting away with it? In part because the Democrats are using denial as a rebuttal rather than dealing honestly with end of life issues in the health care debate.

Whatever health system one has makes choices about end of life, whether by law, by budget, by religion and other values, or by habit. Consider, for example, doctors who know that their hospitals are trying to cut down on costs. It doesn't matter where the insurance money is coming from; those doctors know their status will depend in part on how they handle this issue and as a result there will be less pressure to prolong life. You don't need a death panel to tell you which way the wind is blowing; all you have to know that those on top - whether public or private - are more than a little, and in some cases primarily, interested in saving money.

The whole end of life debate is an example of the bipartisan disingenuousness of the health care controversy. Here you've got a serious issue that concerns millions of people and neither side wants to use it other than to score points.

Led by Obama, the Democratic approach to healthcare has carelessly blended budget and health issues in a way that has justifiably raised concerns about the party's end of life policies. Rather than treating skeptics and critics as fools, it would be wiser - both politically and morally - to deal with the matter in an open and honest way.

Wikpedia - Futile medical care refers to the belief that in cases where there is no hope for improvement of an incapacitating condition, that no course of treatment is called for. It is dissimilar to the idea of euthanasia because euthanasia involves active intervention to end life, while withholding futile medical care does not encourage, nor speed the natural onset of death. The difference is of utmost importance to physicians who have taken and who adhere to the traditional Hippocratic oath - and have thus taken a professional vow that under no circumstances will they "prescribe a deadly drug nor give advice which may cause [a patient's] death."

One could say that it is impossible to reach a firm definition of futile medical care, because this would depend upon universal agreement about the point at which there is no further benefit to intervention, and different involved parties may always disagree about the amount and type of benefit under discussion. For instance, a cancer patient may be willing to undergo yet more chemotherapy with a very expensive medication for the benefit of a few weeks of life, while medical staff, the insurance company, and close relatives may all feel otherwise, for different reasons.

Arguments against futile care generally center on two issues. First, futile care has no possibility of achieving a good outcome and serves only to prolong death. No physical or spiritual benefit comes from such care. Futile care also prolongs the grieving process and frequently raises false hope. Also, futile care can be very difficult on caregivers, who may see themselves as forced to act against the best interests of their patient.

Secondly, in a setting of limited resources, futile care involves the expenditure of resources that could be used by other patients with a good likelihood of achieving a positive outcome. . . .

The last four decades has seen the clinical community make impressive efforts at improving the quality of their prognostic efforts. As a result, simple but imprecise rules of thumb like “percent mortality = age + percent burn” have now given way to very sophisticated algorithms based on multiple linear regression and other advanced statistical techniques. These are complex clinical algorithms that have been scientifically validated and have considerable clinical predictive value, particularly in the case of patients suffering severe burns.

While one intent of such algorithms is to provide high-quality prognostic information to aid patients and families in making difficult decisions, it takes little imagination to see how they could be used to guide resource allocation in a setting of limited resources.

While clinicians faced with difficult clinical scenarios where the probability of survival is, say, 30% might be expected to mount a valiant effort, when the chance of survival falls well below 1%, most clinicians would be expected to focus on palliative and comfort measures rather than attempting aggressive clinical measures. In a study of patients so severely burned that survival was clinically unprecedented, during the initial lucid period (before sepsis and other complications set in) patients were told that survival was extremely unlikely (i.e., that death was essentially inevitable) and were asked to choose between palliative care and aggressive clinical measures. Most chose aggressive clinical measures. This suggests that the will to live in patients can be very strong even in hopeless situations.

LA Times, 2005 - A Texas law signed by then-Gov. George W. Bush in 1999 allowing an end to life-sustaining treatment for certain patients became a point of contention Monday in the Terri Schiavo case, sharpening the focus on the president's eleventh-hour intervention in the question of the woman's fate.

The law that Bush signed as governor sets conditions for how a patient's relatives or other surrogates may make end-of-life decisions, and it spells out procedures for cases where the surrogates and medical providers disagree on whether to continue or to suspend life-sustaining care. . .

Speaking on the House floor Sunday, Rep. Debbie Wasserman Schultz (D-Fla.) said the Texas law "liberalized the situations under which a person in Texas can avoid artificial life support."

"It appears that President Bush felt, as governor, that there was a point at which, when doctors felt there was no further hope for the patient, that it is appropriate for an end-of-life decision to be made, even over the objections of family members. . . There is an obvious conflict here between the president's feelings on this matter now as compared to when he was governor of Texas," Wasserman Schultz said during a late-night House debate Sunday on the Schiavo legislation.

That measure, which Bush signed about 1 a.m. Monday outside his White House bedroom, was intended to aid family members fighting to reinstate Schiavo's feeding tube.

"If the president of the United States really cared about the issue of the removal of feeding tubes, then why did he sign a bill as governor in Texas that allows hospitals to save money by removing feeding tubes over a family's objection?" asked Rep. John Conyers Jr. (D-Mich.) during the House debate. . .

As Wasserman Schultz said on the House floor, the Texas law lays out procedures for physicians to follow when they think a patient's condition is hopeless, even if family members disagree. Doctors can make a case to their hospital's ethics committee. If the ethics committee agrees, life support can be removed.

But first, dissenting families are given 10 days to find another facility willing to care for the patient.

"That was a law that President Bush did not just allow to become law without his signature. He came back from a campaign trip to sign it," Wasserman Schultz said. . .


Anonymous Bart Windrum said...

The problem with end-of-life coverage as instigated by "death panelism" is that it focuses on external factors. This focus keeps alive the idea that "they" get to choose what kind of death we want to experience.

Each of us is responsible for how we orient to dying. Although the specifics of death cannot be predicted nor controlled, we can orient ourselves toward the type of death we want to experience. This of course requires that supposedly individualistic Americans actually *do* something beyond tsk-tsking what the political and journal classes chat our way about.

In order to die peacefully -- whatever that may mean to you -- you must manifest the resolve to do so. Why? Because the system defaults to unending care in ICUs. Once inside the hospital's double doors it's a bit late in the game to undo the machinations from within the crucible, as an end-of-life hospitalization is experienced.

Most of us spend eons more time planning a weekend outing than we'll ever invest on end-of-life planning, including how to advocate when hospitalized (for any reason). Any patient-family whose members have experienced a loved one's dying while hospitalized knows the overarching likelihood of adding extrinsic systemic shock to a situation already ripe with the intrinsic shock of it happening in the first place.

So how do we choose? How do we know when to choose? How do we know how to choose what to choose? There's very little guidance available.

Based on my experiences during each of my parents' unexpected 3 week terminal hospitalizations, I wrote a book that answers these questions: Notes from the Waiting Room: Managing a Loved One's End of Life Hospitalization. See it at www.AxiomAction.com

Bart Windrum, author/speaker

August 30, 2009 11:05 AM  

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