Feeding fear about end-of-life care
Boston ? I am as happy as anyone at signs of an economic recovery. But I confess to having mixed feelings about the resurgence of the wing-nut industry.
We now have “The Birthers” manufacturing myths that President Obama was not born in the United States and therefore is serving illegally. These products arrive in my inbox faster than I can press “block sender.”
They are just following the business plan of those earlier entrepreneurs selling the idea that Obama had killed his grandma. Consider the scare-biz Internet scribe who penned the memorable line: “Obama flies to Hawaii to visit his grandmother and just a few days later she winds up dead. Coincidence?”
But now the industry has ratcheted up from accusing Obama of killing his grandma to accusing him of trying to kill your grandma.
The campaign of the moment is based on a small provision in the health care bill that would allow Medicare to reimburse doctors for time spent consulting with patients about their end-of-life choices.
This modest idea was willfully distorted by people such as Betsy McCaughey, the former lieutenant governor of New York, who said that the bill would “absolutely require” end-of-life counseling that “will tell them how to end their life sooner.” Republican leader John Boehner offered the same flawed product, saying, “This provision may start us down a treacherous path toward government-encouraged euthanasia.”
Their views were also sold by right-wing franchise operators. Laura Ingraham warned that government bureaucrats would “come to an old person’s house” — yeah, house calls! — for scary death chats. Fox News analyst Peter Johnson called it a “kind of our 2009 ‘Brave New World.'” And Randall Terry, the Zelig of the pro-life movement, said this was an attempt to “kill Granny.”
Panic is their most important product. The bill doesn’t really mandate anything. It simply assures that a talk about advance care planning will be covered for the patients and families who want it. As Obama told a woman at an AARP forum, “It strikes me that that’s a sensible thing to do.” But who would trust someone who offed his grandma?
All in all, Fearmongers Inc. plays on the notion that advance directives are a sneaky way of cutting costs by cutting life short.
Well, here’s what we know: One-quarter of all Medicare dollars are spent in the last year of life, much of it in the last month. We don’t know yet whether it will cost less (and how much less) for patients to choose high-quality palliative care. It surely isn’t the cheap fix to the health cost spiral.
But we have some other hints. In a study of terminal cancer patients at the Dana-Farber Cancer Institute in Boston, those who had end-of-life conversations spent about one-third less in their last week than those who didn’t. And they had a better quality of life and death.
Yes, those who didn’t talk about options had more aggressive treatment. They ended up in intensive care and/or on ventilators or were resuscitated. They not only had a worse quality of death by any measure, they left their families in more distress, and here’s the kicker: They didn’t live any longer.
As the study’s author, Holly Prigerson, said, “Usually saving money comes at a cost to society or the patient and family. In this case it would appear to be a win-win.” The patients who got more expensive treatment, she added, “were not buying anything that any informed consumer would want.”
Conversations about dying are never easy. Only about 20 percent of Americans have advance directives.
This cultural silence lingers over a false and stark choice between “treatment” — the word we use to describe aggressive procedures — and fear of abandonment. Families may feel that if they aren’t doing “everything,” they are doing nothing. Patients may see the alternative to medical care as no care.
We confuse life-prolonging and suffering-prolonging treatments. We don’t always hear about palliative care and hospice. This is precisely why we need to encourage these conversations.
Some people will choose “everything.” Others will choose comfort care. But if we train and reimburse clinicians for the fine art of communicating, we’ll have an informed choice. And that’s what this teeny little clause in the great big health care bill does. It enables granny and grandpa and us to say how we want to die.
So may we declare the scare biz bankrupt? Oh no, what’s that I see on the horizon? “Obamacare Will Mandate Free Sex Change Operations.” More wing nuts for sale.