Care at the end: Complementary goals

November 3, 2009

After rumors circulated that President Obama’s health-care reform would institute “death panels” for the elderly, Congress quickly abandoned any effort to address end-of-life issues in health-care legislation. It didn’t matter that the rumor-mongering reflected a willful distortion of section 1233 of a House bill that would have let Medicare reimburse physicians for helping patients develop a plan for end-of-life care.

The distortion was clearly motivated by the desire to derail health-care reform at all costs. Those with doubts on that score should consider that, as Amy Sullivan at Time magazine pointed out, in 2003 Republicans passed a prescription drug bill that endorsed end-of-life counseling in virtually the same terms that they now claim will lead to “pulling the plug on Grandma” (to quote Senator Charles Grassley of Iowa).

If those who demagogued the issue actually cared to listen to the elderly in their districts, they would know that most people as they near death especially fear the loss of control. Many fear that they will end their days hooked up to expensive machines and subjected to aggressive treatments when there is no chance of recovery. Many long to die at home, surrounded by family, rather than in a hospital. Above all they want to make their own choices about treatments and to have a doctor who understands their wishes—precisely what section 1233 endorsed.

If those who demagogued the issue actually cared to listen to hospital chaplains and to doctors who specialize in palliative and end-of-life care, they would know that the main threat to the well-being of the elderly and their families is not cruelly rationed care but a medical ethos of blindly trusting technology and avoiding all talk of mortality.

Section 1233 did not spring from the mind of some cold-hearted bureaucrat. It emerged from experts in end-of-life care, including officials at Gundersen Lutheran Hospital in LaCrosse, Wisconsin. Gundersen has been a national leader in humanely addressing end-of-life issues. Hospital officials have encouraged doctors to take the time to discuss death and dying with patients and their families—even when the doctor’s time is not reimbursed. Officials at Gundersen and at LaCrosse’s other hospital have also encouraged residents to develop advance directives for care and to do so well before the end of life, and that effort has made a difference, reports the Washington Post. More than 90 percent of people in LaCrosse have such directives in place, which is double the national average.

Encouraging people to talk about end-of-life care does, in fact, tend to save money, since many people prefer treatments that entail shorter hospital stays and less aggressive measures. Allowing people to die as they wish and avoiding unnecessary expenses are complementary goals. And eventually they will have to be part of health-care reform.