Here's the Truth, Granny
by Judy Bachrach
AUGUST 11, 2009 TAGS:
If you happen to own a radio or have access to the Internet, you’ll likely have learned of Congress’s latest piece of proposed health care legislation, which contains within it a provision that is either unrepentantly wicked or incredibly humane. “An ORDER from the government to end your life,” as one web site would have it -- or a calm, educative moment between doctor and patient. It all depends on who’s doing the talking.
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And, as it turns out, everyone is talking. Adherents of the health care bill claim the provision is necessary to clear the air about end-of-life choices for elderly or desperately ill people who are in need of clarity. Detractors, a large group that includes extremist pro-lifer Randall Terry and his many voluble friends on talk radio, insist that the undeclared, sneaky purpose of this bill is basically to save money and (this above all) “kill Granny.”
To help you sort through all the complicated issues of Section 1233 (yes, that’s the dull name for the explosive provision), Terry has a video on the subject, helpfully entitled KILL GRANNY AND SAVE YOUR INHERITANCE. As the title implies, it is his contention that any attempt to inform anyone very old or terminally ill about the medical possibilities open to them is intended not to help the patient make end-of-life decisions, but to improve the economic upside for Granny’s heirs. (Sample Terry-video quote: “She’s got a little nest egg there, and it’ll be yours when she’s gone…”)
Here’s the problem. Right-wingers aren’t the only rabid dissenters from the bill. Democratic strategists, fearful of the political fall-out, are pointedly refusing to set the record straight by rebutting some of the more outrageous attacks on the proposed legislation. Over the weekend, even the Washington Post’s editorial writer Charles Lane weighed in, declaring in a column that “Section 1233 is not totally innocuous.” Why semi-dangerous? Because, Lane points out, it was attached to a bill designed to keep Medicare costs down. That means, he insists, that the bill “addresses compassionate goals in disconcerting proximity to fiscal ones.”
A proximity, in other words, that Granny has every reason to fear! The next time she goes to the doc for a hearing aid, she’ll be told it’s time to croak!
So let’s examine in a cooler, more studied fashion what the fuss is all about these days and how exactly Section 1233 would address end-of-life choices for the elderly or the terminally ill. Young or old, ill or robust, it’s about time we do address such choices. Because right now, as things stand, we can be sure of nothing in our final days.
First off, we are living in a country where only one-fifth of the population has what’s known as a Living Will or Advance Medical Directive: meaning a document that, in the event of a terminal diagnosis, specifies our wishes concerning various medical interventions (or non-interventions). Secondly, and this is where it gets especially messy: Even if you have such a document, there’s no guarantee your written wishes will be carried out.
As Jane Brody writes in her excellent Guide to the Great Beyond: “…in the heat of the moment doctors often make value judgments and in doing so may purposely or unknowingly violate the tenets of the patient’s living will.” [Emphasis mine]. Right now, she adds, physicians fail to honor about one in four of these documents.
So what Section 1233 would do, if passed, would be to institutionalize the idea that it is the patient – not the doctor and not the government – who has the last word on how to die, when to die, in what circumstances to try to ward off death, and in what circumstances to accept it.
How would such legislation accomplish all this? Once every five years, according to the proposed bill, a doctor can initiate a fairly specific discussion with a patient on end-of-life issues. Does the patient, in the event of a terminal diagnosis, want hospital care or hospice care? To be resuscitated if the heart stops? When things go completely downhill and death is likely at hand, does the individual want only palliative pain-killing medication or would she prefer to have physicians throw every medical marvel at a killer disease?
Medicare would reimburse the doctor for such a consultation. That’s what has Lane and others so outraged: Show Dr. Needle a few federal bucks, they say, and he’ll show Granny the exit door. In fact, he’ll color that door green by telling her that Medicare pays for a large portion of hospice care (“Hint, hint,” observes Lane). A fistful of cash, in Lane’s words, “gives [doctors] an incentive – money” -- to lay all this out. “Indeed that’s an incentive to insist.”
The illogic of such assumptions defies belief. Let’s see now… How can doctors make the most money? By having a once-every-five-years talk with an elderly patient and getting reimbursed by the government for those 20 minutes? Or by keeping that patient alive for as long as possible, with as many medical interventions as possible, whether or not those procedures will ease the patient’s symptoms, cause her more pain, make her healthier, or even extend her life? (Answer to the last question: A study published two years ago in the Journal of Pain and Symptom Management found that hospice care actually prolongs the life of the terminally ill -- by 29 days. That’s what doctors, and patients, and editorial writers, and legislators need to learn.)
“My father’s doctor actually talked my father out of accepting hospice care,” Susie Madrak, a writer, tells me. When her father, a retired bookkeeper, was diagnosed with pancreatic cancer, she says, that doctor informed him, “Oh, you don’t want to go to a hospice; they’re a little free with the morphine!”
Madrak recalls thinking, “Isn’t that the whole point?”
Bowing to his doctor’s suggestion, her father spent his last days in a hospital where, his daughter recalls, she had to back the physician up against a wall – “oh hell, yes, literally, I backed him into a corner” – to get him to prescribe her father the morphine she felt he needed. And even then, she adds, the morphine pills were prescribed for him only “on request.” As he was by then incapable of speaking, such requests never came. A morphine IV drip was installed only after considerable family pressure was exerted.
How do you feel about the proposed congressional bill on health care with the controversial provision? I ask Madrak.
“Of course I support it! It’s horrifying to me that they’re using this into scaring old people into thinking they’re going to be killed.” And then Madrak says something with which no one can disagree:
“We have this really strange way of dealing with death in our society.”
And, as it turns out, everyone is talking. Adherents of the health care bill claim the provision is necessary to clear the air about end-of-life choices for elderly or desperately ill people who are in need of clarity. Detractors, a large group that includes extremist pro-lifer Randall Terry and his many voluble friends on talk radio, insist that the undeclared, sneaky purpose of this bill is basically to save money and (this above all) “kill Granny.” To help you sort through all the complicated issues of Section 1233 (yes, that’s the dull name for the explosive provision), Terry has a video on the subject, helpfully entitled KILL GRANNY AND SAVE YOUR INHERITANCE. As the title implies, it is his contention that any attempt to inform anyone very old or terminally ill about the medical possibilities open to them is intended not to help the patient make end-of-life decisions, but to improve the economic upside for Granny’s heirs. (Sample Terry-video quote: “She’s got a little nest egg there, and it’ll be yours when she’s gone…”)
Here’s the problem. Right-wingers aren’t the only rabid dissenters from the bill. Democratic strategists, fearful of the political fall-out, are pointedly refusing to set the record straight by rebutting some of the more outrageous attacks on the proposed legislation. Over the weekend, even the Washington Post’s editorial writer Charles Lane weighed in, declaring in a column that “Section 1233 is not totally innocuous.” Why semi-dangerous? Because, Lane points out, it was attached to a bill designed to keep Medicare costs down. That means, he insists, that the bill “addresses compassionate goals in disconcerting proximity to fiscal ones.”
A proximity, in other words, that Granny has every reason to fear! The next time she goes to the doc for a hearing aid, she’ll be told it’s time to croak!
So let’s examine in a cooler, more studied fashion what the fuss is all about these days and how exactly Section 1233 would address end-of-life choices for the elderly or the terminally ill. Young or old, ill or robust, it’s about time we do address such choices. Because right now, as things stand, we can be sure of nothing in our final days.
First off, we are living in a country where only one-fifth of the population has what’s known as a Living Will or Advance Medical Directive: meaning a document that, in the event of a terminal diagnosis, specifies our wishes concerning various medical interventions (or non-interventions). Secondly, and this is where it gets especially messy: Even if you have such a document, there’s no guarantee your written wishes will be carried out.
As Jane Brody writes in her excellent Guide to the Great Beyond: “…in the heat of the moment doctors often make value judgments and in doing so may purposely or unknowingly violate the tenets of the patient’s living will.” [Emphasis mine]. Right now, she adds, physicians fail to honor about one in four of these documents.
So what Section 1233 would do, if passed, would be to institutionalize the idea that it is the patient – not the doctor and not the government – who has the last word on how to die, when to die, in what circumstances to try to ward off death, and in what circumstances to accept it.
How would such legislation accomplish all this? Once every five years, according to the proposed bill, a doctor can initiate a fairly specific discussion with a patient on end-of-life issues. Does the patient, in the event of a terminal diagnosis, want hospital care or hospice care? To be resuscitated if the heart stops? When things go completely downhill and death is likely at hand, does the individual want only palliative pain-killing medication or would she prefer to have physicians throw every medical marvel at a killer disease?Medicare would reimburse the doctor for such a consultation. That’s what has Lane and others so outraged: Show Dr. Needle a few federal bucks, they say, and he’ll show Granny the exit door. In fact, he’ll color that door green by telling her that Medicare pays for a large portion of hospice care (“Hint, hint,” observes Lane). A fistful of cash, in Lane’s words, “gives [doctors] an incentive – money” -- to lay all this out. “Indeed that’s an incentive to insist.”
The illogic of such assumptions defies belief. Let’s see now… How can doctors make the most money? By having a once-every-five-years talk with an elderly patient and getting reimbursed by the government for those 20 minutes? Or by keeping that patient alive for as long as possible, with as many medical interventions as possible, whether or not those procedures will ease the patient’s symptoms, cause her more pain, make her healthier, or even extend her life? (Answer to the last question: A study published two years ago in the Journal of Pain and Symptom Management found that hospice care actually prolongs the life of the terminally ill -- by 29 days. That’s what doctors, and patients, and editorial writers, and legislators need to learn.)
“My father’s doctor actually talked my father out of accepting hospice care,” Susie Madrak, a writer, tells me. When her father, a retired bookkeeper, was diagnosed with pancreatic cancer, she says, that doctor informed him, “Oh, you don’t want to go to a hospice; they’re a little free with the morphine!”
Madrak recalls thinking, “Isn’t that the whole point?”
Bowing to his doctor’s suggestion, her father spent his last days in a hospital where, his daughter recalls, she had to back the physician up against a wall – “oh hell, yes, literally, I backed him into a corner” – to get him to prescribe her father the morphine she felt he needed. And even then, she adds, the morphine pills were prescribed for him only “on request.” As he was by then incapable of speaking, such requests never came. A morphine IV drip was installed only after considerable family pressure was exerted.
How do you feel about the proposed congressional bill on health care with the controversial provision? I ask Madrak.
“Of course I support it! It’s horrifying to me that they’re using this into scaring old people into thinking they’re going to be killed.” And then Madrak says something with which no one can disagree:
“We have this really strange way of dealing with death in our society.”
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