Thursday, July 30, 2009

Krauthammer and 1233

I respect Charles Krauthammer, almost always enjoy what he has to say, and usually learn something from him. I certainly enjoyed the beginning of his recent comments on Section 1233 of HR3200, the House health care bill (emphasis mine):

But on the larger issue here having to deal with end-of-life care, I looked at the language [in the House bill]. There is no requirement that you be counseled, because it would be inherently coercive. If you're dying and a government official shows up and says I want to discuss options including your death, that obviously is going to be kind of a coercion.


Yes! He got it right.

However the rest of his comments had me scratching my head:

But the idea that it is important to do it [end-of-life counseling] years in advance is nonsense. We heard Senator Grassley say this stuff ought to be decided when you're 50 and not when you're 80. What doctor, when he has an 80-year-old with pneumonia, will look at a document signed 30 years earlier and say he [the patient] decided he didn't want to have extra treatment, so I'll pull the plug?


I haven’t heard or read the original Grassley comment so for all I know Grassley really is a fool who thinks people should make up their minds about end of life care at 50 and never change them. Section 1233, though, will pay for patients to review their advance care planning decisions every five years if they wish and will also pay for them to review those decisions if something medically significant changes.

Krauthammer goes on:

The idea of advanced directives (as it is called in the [medical] lingo) or living wills are determinative, is absolutely false. It almost never applies. It only [applies] if you are in a coma or demented, and even in those cases, it's the wishes of the family which almost always override everything in writing.


My first thought was, “What about cases like Terri Schiavo?” Sure enough, Krauthammer had written about the Schiavo case. His March 2005 article began (emphasis mine):

If I were in Terri Schiavo's condition, I would not want a feeding tube. But Schiavo does not have the means to make her intentions known. We do not know what she would have wanted. We have nothing to go on. No living will, no advance directives, no durable power of attorney.


I wonder if anyone would have heard about the Terri Schiavo case if she had prepared a living will or better yet an Order for Life-Sustaining Treatment that stated clearly she absolutely wanted a long-term feeding tube and long-term IV hydration - or absolutely did not.

3 comments:

sifaka said...

you write:[quote]But the idea that it is important to do it [end-of-life counseling] years in advance is nonsense. We heard Senator Grassley say this stuff ought to be decided when you're 50 and not when you're 80. What doctor, when he has an 80-year-old with pneumonia, will look at a document signed 30 years earlier and say he [the patient] decided he didn't want to have extra treatment, so I'll pull the plug?[/quote]
Seeming to think that this is far fetched. Yet you descirbed exactly my father's death. Years before, maybe only 15 not 30 he had an advanced directive which included no antibiotics. I remember talking to him and saying, "But Dad, if you got pneumonia it could kill you, but hte antibiotics could knock it out in 24 hours." His response was. I know, I have lived a wonderful life and if that's the way I go that's it.

15 years later he died of pneumonia and the doctor wanted to treat him with antibiotics, but hisadvanced diredtive prevented it and he died a peaceful death at 83. He feared lingering on so much more than a quick and merciful death.

I think people are a lot more thougtful than you give them credit for

sifaka said...
This comment has been removed by the author.
Elise said...

I think people are a lot more thougtful than you give them credit for

That wasn't where I was going with this. I was trying to address the idea of "should" - or "ought". If Grassley really said end of life care "should" be addressed when you're 50 and not considered again (which is what I think Krauthammer implied) then Grassley is a fool. People should address this issue when they feel ready to do so and re-visit it as often as they feel they need to - including never if they are happy with their original decision. Furthermore, I think Krauthammer left the impression that somehow Section 1233 would create a situation in which people had to make up their minds once and for all about end of life issues when they turned 50 which is not the case.

One of the things that I dislike about those who are wringing their hands and insisting the government will pressure, coerce or cajole the elderly into signing DNR orders is the blithe assumption that old people can't stick up for themselves. Yes, I know some of them are frail and confused and we should do all we can to make sure they're not taken advantage of by anybody. But most old people I've know have been pretty darn sure of what they want and what they don't want.

Just like your father who sounds like a very self-aware guy. I certainly didn't mean to say he was a fool for knowing his mind and sticking with it. I simply meant that anyone who thinks no one should ever change his mind about something as important as end of life care between 50 and 80 is a fool.