Monday, July 27, 2009

Now I can sleep

[I have more to say about Section 1233 of HR3200 and am doing so in a series of (probably) four posts. This is the fourth in the series and I believe it is the last. The first post in the series is here. I highly recommend reading the Jane Galt article linked here before reading this series.

All the posts in the series will be filed under the category “Me And 1233”.

When I began this second look at Section 1233 I anticipated I would end by saying I stood by my original point - that Section 1233 did not require end of life counseling but that I could certainly see why people would consider it a slippery slope, provide incentives, etc. In other words, Section 1233 made me nervous. It no longer makes me nervous. Here’s what changed my mind.

While researching my previous post in this series I learned about Orders for Life Sustaining Treatment (OLST), also called POLST (Physicians OLST) or MOLST (Medical OLST). This is an attempt to make end of life directives more specific and more standard. Rather than just saying “No extreme measures” or “All measures available”, MOLST ask a series of questions about whether the person filling out the form wants CPR or not; wants no IV fluids, short-term IV fluids, or long-term IV fluids; and so on. The questions that appear on MOLST are the very questions Section 1233 suggests be included in any end of life counseling section.

Once I read about MOLST, looked at some of the forms, and understood that Section 1233’s suggestions were part of an attempt to improve end of life care, I looked at Section 1233 more favorably. Then three other pieces of information solidified my favorable impression.

First, MaxedOutMama herself. She said:

We are rapidly approaching the point at which a certain measures, including tube feeding and liquids, are going to be routinely denied to many elderly persons deemed to be close to the end of their lives.

A MOLST can just as easily prevent that as it can cause it. Without a MOLST the patient is at the mercy of whoever has his hand on the off switch. With a MOLST that specifies a patient wants all possible treatment, that person has to think twice about hitting that switch.

Second, the House Republican leadership’s statement on Section 1233. This statement did not claim that 1233 required end of life counseling but - by tying it to a 1977 memo on living wills as money savers - was able to suggest convincingly that:

This provision may start us down a treacherous path toward government-encouraged euthanasia if enacted into law.

I thought this statement was tactically brilliant and told my husband so. He disagreed strongly. Making people afraid of end of life counseling is far from brilliant, he pointed out. End of life counseling, advance planning, a clear statement of what each of us wants is crucial, he said, because we are rapidly approaching the time when medical technology will be able to keep almost anyone in almost any condition alive almost indefinitely - so we’d all better speak up and say whether that’s what we want.

What MaxedOutMama fears - over-fast plug pulling - and what my husband fears - lingering in a sort of living death - have the same cure: informed choice, as specific as possible, on the part of the each of us.

Finally, I found HR 1898: Life Sustaining Treatment Preferences Act of 2009. This bill was introduced on April 2, 2009, and when I read it I realized this was the basis for Section 1233 - large parts of it are word-for-word. It is clearly an attempt to require Medicare to pay for the creation of MOLST; the sponsor’s remarks in the Congressional Record show that. The bill has two Republican co-sponsors including Representative Charles Boustany Jr., (R., La.), a heart surgeon quoted approvingly by Betsy McCaughey. When I read that bill and asked myself if I would have any objection to it if I’d run across it with no preconceived notions, I realized I would not.

I think someone of any age sitting down and figuring out what he or she wants in terms of end of life care is a good idea. I think a MOLST is a good idea. The elderly in this country by and large get the medical services Medicare is willing to pay for. If they are going to get the help they need to develop a valid end of life plan - preferably including a MOLST - Medicare is going to have to pay for it. I no longer consider offering this much-needed medical service to those on Medicare a slippery slope, an incentive to limit care, or anything other than a good idea.

As for whether this good idea is going to save any money, the government may be in for a shock there.

This study by two medical ethicists is more than 10 years old but unless things have changed drastically, it both points out why we need more and more specific end of life planning and explains why it probably won’t save any money:

This study does not support the assumption that, collectively, patients' advance care preferences are less interventionist than actual practices for patients in corresponding scenarios. Nevertheless, these results do support the assumption that life-sustaining treatment decisions do not conform well to individual patients' specific preferences. Progress in end-of-life care should focus on shared decision making at the patient-proxy-physician level rather than on overall life-sustaining treatments utilization.

In other words, some patients who want less end of life treatment are getting more while some patients who want more end of life treatment are getting less. Better advance care planning - MOLST especially - can help straighten out that problem but it’s not likely to save us any money.

Does this mean I support HR3200? Heavens, no. If nothing else the fact that no two people can agree on what the bill says - much less what it means - should make it awfully clear that we don’t understand what this bill will do. Furthermore, to the extent that I do understand it, it seems to me an overly expensive, unnecessarily complicated, and not especially effective means of accomplishing what I consider the appropriate goal: insuring the uninsured. I am not, however, going to lose any sleep worrying about Section 1233.


Greg said...

Lord love a duck, why is it so difficult for us to shuffle off?

Thanks much for your elucidation on all this (I'd like to say I could properly appreciate it).

Good night, sweet prince(ss).

Elise said...

Thanks. And I'll take any appreciation I can get. Good night.

Drive-by reader said...

Now I wonder what my grandpa thinks of this kind of thing. Hmm...

Anonymous said...

I'm a big believer in end-of-life directives. If someone pitched a bill to me in the context of reducing the risk that some faceless hospital personnel would be making most of the choices about things like whether I should be kept alive as a vegetable on a feeding tube, and making sure that the choice would remain firmly in my hands or the hands of my family, I'd react positively.

When I see the same provision in a bill whose ostensible purpose is to push more medical costs onto the government and then find ways to allow the government to spend less money on this new burden it's taken on, I get the heebie-jeebies.

-- Texan99

Jack Reidy said...

Thanks. This further clarifies the thinking on both sides of this important issue. If only our politicians were so reasonable!


Anonymous said...

I have worked in health care for over 20 years and there is a lot more end of life planning now than when I started out. Anyone who's been admitted to the hospital, especially for surgery is asked to consider power of attorney, living will, etc. as part of their admissions process. What is apparently changing is all that paper shuffling will now be a billable procedure. I can see hospital admissions personnel being made to audit charts to see who can qualfy for a new counseling session based on change of condition or if they haven't had one in 5 years. Hospitals and nursing homes should be thrilled with this as it will be just another revenue stream that can be billed to the U.S. Gov. By definition, anyone admitted to a hospital or nursing home has a change in medical status so it is likely that each new admission would trigger a new counseling charge instead of every 5 years.

Elise said...

I have worked in health care for over 20 years and there is a lot more end of life planning now than when I started out.

I always think that's because there's a lot more we can do at the end of life than they're used to be. In other words, there weren't so many choices to be made years ago. Would you agree?

Elise said...

texan99, I can understand those heebie-jeebies, I just don't share them any longer.

Remember the big TARP bill? After it failed the first time, it got loaded up with all kinds of strange stuff like discontinuing the tariff on toy arrows? I poked around a little and found that the toy arrows thing had actually been introduced as a separate bill that was languishing in committee. It got vacuumed up into TARP and was - I assume - the price paid for getting whoever wrote the original bill to vote for TARP.

I suspect that HR3200 just vacuumed up every health care bill (and every half-baked health care idea) laying around - that's why the thing is so, so long.

I actually think Obama was foolish to try to sell the health care bill on cost-cutting grounds. It left the door wide open for claims just like this. I've been thinking a lot about this lately and I may have more to say about it in a future post.

BTW, glad you dropped by.

Elise said...

Drive-by reader, if you ask him I'd be interested to hear what he says.

Everyone in my family older than I am is dead but I think they'd think this:

My grandmother would say her family should make the decisions.

My mother would want as little intervention as possible.

My aunt would want everything except CPR.

I think it would be nice if they had all gotten to say what they wanted and had someone pay attention.

Elise said...

Jack - thanks. Being called reasonable is a high compliment.