Wednesday, January 5, 2011

"Don't Ask, Don't Die" Health Ruling

Michael Williams was pretty healthy at age 84 but knew he was slowing down. His hip replacement was working well in his walks around his retirement home. His wife had passed away two years before and his children were helpful but had busy lives of their own.

One evening he attended a course by his local hospice on how to get ready for the inevitable - how to approach end-of-life planning. Michael found this interesting but more than a bit confusing. Did he need two forms or one? What rights was he giving up with a Power of Attorney for Health Care? How could he communicate his wishes to his doctor and children? What would happen if his heart stopped and 911 was called?

The speaker encouraged Michael and others to have a visit with their doctor to discuss what their wishes would be. Michael felt that he had lived a full life and did not want to be kept going with "tubes and shocks". He really feared being attached to a ventilator and being kept alive when he couldn't speak, walk, or relate to his loved ones.

Michael knew that there was some controversy during the Presidential race of 2008 about "Death Panels". He didn't want to government involved in the decision about the way he might die, but he did want to be able to talk things over with his physician and felt that this should be covered like most other office visits.

In December of 2010, Michael read that a regulation had been placed in the voluminous Medicare rules that would allow a Medicare approved visit for an end-of-life discussion with his doctor. So he called early in January of 2011 and was informed that this regulation had been removed and that such a visit would not be covered by Medicare. So Michael waited and hoped the confusion might clear. Was the government telling him not to ask and not to die? Didn't he have a right to the information to direct his own destiny?

Comment: It would appear that Medicare's Dr. Donald Berwick was over-ruled by the politicians in the Medicare ruling reversal. The reason isn't that obscure. The Obama advisers are afraid that the "Death Panel" accusations might give too much ammunition to opponents of the recently passed Health Care Reform Act. Although there may be political reasons for denying Medicare coverage for end-of-life planning discussions with one's physician, good medicine dictates that a patient's autonomy is controverted when informed consent is bypassed. Would Michael have a hip replacement without knowing the benefits and burdens of the procedure? Likewise should he have CPR, feeding tubes, and other interventions without the important discussions with his doctor?

My hope is that over time this apparent "Don't Ask, Don't Die" ruling will be overturned and we will return to having Medicare acting more in the patient's and society's best interests. Ironically, the government is interfering with good medical practice in disallowing Medicare coverage for end-of-life discussions. It has now been shown in several studies that advance planning improves the patient's quality of life and that their wishes about life support are respected. Also, interestingly, advance planning can not only save patients and families unnecessary pain and suffering, it can generate large cost savings for Medicare. The argument that advance planning is a slippery slope to euthanasia is both facetious and politically disingenuous.

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