Friday, August 21, 2009

Just Shoot the Old Geezer

Regarding proposed health care reform legislation, pundit Charles Krauthammer ("Kraut" in certain salons) wants to "be honest about death counseling" according to his syndicated column in the Atlanta Journal Constitution, August 21, 2009. In this op-ed, Kraut quickly distances himself from Sarah "death squad" Palin. Her comments on this aspect of the House's proposed legislation clearly proves that Ms. Deathacuda is a cup, saucer, salad plate, butter knife, dinner fork, spoon and water glass short of an entire place setting. This fact makes her the darling of voters who live in a parallel universe called the Paranoid Dimension, aheeeeeeeooooo.

Some of these voters have shown up at the recent and infamous town hall meetings waving posters of Prez BHO altered to make him resemble Hitler. Apparently, Kraut (not unlike my-own-wizened-self), doesn't believe that these voters will be dissuaded from the "death squad" belief so he attacks the end-of-life-counseling provision from a different angle to widen the dissenting audience to include the less creepy elements. While not a fascist plot to euthanize the infirm and helpless, he says, the counseling and attendant outcome (the creation of a Living Will) "mean nothing" at the end-of-days and is, in a strange and illogical flip-flop, a subtle government push toward a less expensive end for the elderly.

In Section 1233 of H.B. 3200, there is a provision allowing for the payment to doctors for their time to meet with Medicare patients and discuss the patient's end-of-life health care wishes. Doctors can do such counseling now but it's a freebie. Kraut asserts that introducing payment into the equation is bad thing. Doctors, he claims, would bring the subject up "whether the patient asked for it or not," because there would be a financial incentive to do so. Such discussion may then lead to the creation of a Living Will and we know what Kraut thinks about those.

Kraut, no doubt, is glad that Terri Schiavo avoided that conversation with her family doctor and let Congress decide about her end-of-life care. Oops, isn't that government involvement in health care decisions? Damn those ideological hard places and contra-logical rocks.

Further, Kraut argues, "Living Wills" are literary, not legal, documents. Here's Kraut's take on his personal Living Will (note that Kraut has one in spite of his professed belief about them): "I've had some good innings, thank you. If I have anything so much as a hangnail, pull the plug." From a literary perspective, and one does write their own wishes in the document, his is but one long cliche. From a pain and suffering perspective, Kraut is apparently deathly afraid of hangnails. Specificity in a Living Will is good but hangnails seem a pretty low bar. Well, we all have our quirks. I am, for instance, morbidly afraid of the "erection lasting longer than four hours" that I hear so much about on the telly. If this condition arises on my deathbed, UNHOOK THE VENTILATOR!

For those of you who think that Charles Krauthammer is the epitome of measured and objective observation, stop reading now, call your real estate agent and ask about buying a lot in a Paranoid Dimension subdivision, aheeeeeeooooo.

The way that most elderly Americans die in 2009 bears little resemblance to the way it occurred even as recently as 1950, thanks to giant advances in medical care. This fact is a double edged blade. American medicine has been successful in lengthening life but lousy at recognizing when life lengthening efforts become negative for the patient, who, at this late stage, often cannot speak on his or her own behalf. American medicine attacks a 1950 paradigm with 2009 technology, it treats people to death. The result is often quite heartbreaking for the family; painful and scary for the dying.

The expense of such care, while high in absolute dollar terms, adds only about 1.1% to the country's total health care spending. Therefore, the issue of counseling with a doctor and creating an Advanced Directive isn't about significantly putting the brakes on costs as Kraut would have us surmise. It is about going through the dying process on one's own terms.

A well-written Advance Directive, updated as frequently as wished and as circumstances change, is the best defense against three things: (1) a dying process that you don't want, (2) unfair pressure on family members to reach consensus about what you would want and (3) pressure from the medical team to take additional action or pull the plug, as they may advise.

An Advance Directive can instruct the medical team to be aggressive and keep a patient breathing for as long as possible, damn the consequences, or it can stipulate that when the hangnails appear, stop treatment. Kraut may want to revisit this particular stipulation as he ages. It is the specificity of the document (current condition, prognosis, quality of future existence, pain tolerance, both physical and mental, etc.) that puts the patient in control. Advance Directives (an umbrella term under which exist both Living Wills and Durable Powers of Attorney for Health Care) are legal documents. The medical team (and the family) would ignore them at their peril.

When surveyed, 90+% of Americans say that when their time comes, they want to "die at home, emotionally and physically pain-free, with dignity and autonomy, unafraid of caregivers and surrounded by loved ones." Currently, 80% of deaths among the elderly occur in an institutional setting, e.g. hospital ICU or nursing home, with the patient often tethered to one or more machines, surrounded by well-meaning and competent technicians (strangers) and suffering one form of pain or another. This is how 4,000 elderly Americans die every day, almost none of them with an Advance Directive.

There are plenty of things in the proposed health care legislation that deserve criticism and revision before we jump off of the unintended consequences bridge. Opposing end-of-life-counseling, however, is a cheap side show (particularly the Ms. Deathacuda version) that should be euthanized.


Observoid of the Day: Money won't buy happiness but it makes being melancholy more bearable.

1 comment:

  1. Boots--

    Glad to see you're still kicking. I didn't see the piece by Mr. Krauthammer (God blesses us in such mysterious ways), I can say I know a thing or two about Advance Directives. (Cue momentous music here). As a chaplain, I've helped, well easily over a 1000, people fill theirs out.

    Funny thing, is they all thought it was a good idea and expressed both thanks and not a little relief at having gotten it done so their loved ones didn't have to make the decision at some catastrophic moment in the future.

    Here in Oregon, which I think we can assume Mr. Krauthammer didn't do any research on, an Advance Directive is a legal document (ORS Chapter 127ff).

    And as for the dying part (despite the infamous Oregon physician assisted suicide law, which only 60 people actually used in 2008), I've been at the bedside of several thousand dying patients as a hospital chaplain. In every case, we have done everything humanly and medically possible to ensure the dying person is comfortable and surrounded by compassionate caregivers. It's a big thing we're into at PeaceHealth.

    Not a death squad in sight. But let's not tell Sarah or Charles. Paranoid folks get so cranky when you present common sense reality to their most tightly held delusions.

    From the West Coast Universe,