Saturday, August 08, 2009

Not Quite Death-care. Not Quite Right

Now the last time I got my official score card, the Washington Post was NOT part of the Vast Right Wing Conspiracy. I could be mistaken. Charles Lane - House Health-Care Reform Bill Oversteps on End-of-Life Issues - Undue Influence: The House Bill Skews End-of-Life Counsel.

An interesting review of section 1233 of the health care bill drafted by the House Dems.

This is the section that provides monetary incentives to physicians to have "end-of-life decision counseling sessions with people on Medicare - mostly the elderly.
Though not mandatory, as some on the right have claimed, the consultations envisioned in Section 1233 aren't quite "purely voluntary," as Rep. Sander M. Levin (D-Mich.) asserts. To me, "purely voluntary" means "not unless the patient requests one." Section 1233, however, lets doctors initiate the chat and gives them an incentive -- money -- to do so. Indeed, that's an incentive to insist.

Patients may refuse without penalty, but many will bow to white-coated authority. Once they're in the meeting, the bill does permit "formulation" of a plug-pulling order right then and there. So when Rep. Earl Blumenauer (D-Ore.) denies that Section 1233 would "place senior citizens in situations where they feel pressured to sign end-of-life directives that they would not otherwise sign," I don't think he's being realistic.

What's more, Section 1233 dictates, at some length, the content of the consultation. The doctor "shall" discuss "advanced care planning, including key questions and considerations, important steps, and suggested people to talk to"; "an explanation of . . . living wills and durable powers of attorney, and their uses" (even though these are legal, not medical, instruments); and "a list of national and State-specific resources to assist consumers and their families." The doctor "shall" explain that Medicare pays for hospice care (hint, hint).
Now I am a big fan of hospice, but I think this goes a little overboard.

And the simple fact that this is all aimed at saving money, and that makes it a little creepy.
But Section 1233 goes beyond facilitating doctor input to preferring it. Indeed, the measure would have an interested party -- the government -- recruit doctors to sell the elderly on living wills, hospice care and their associated providers, professions and organizations. You don't have to be a right-wing wacko to question that approach.
Are all hospitals bound to honor DNR orders and living wills, or do any religious hospitals object to not making every effort to save every life? Seems like some might have feelings on that subject, I just don't know.

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