Friday, August 14, 2009
THE DEBATE over health reform has veered into a peripheral and misleading discussion of whether it includes a scheme to pressure senior citizens into pulling the plug. The most extreme misrepresentation has "death panels," as former Alaska governor Sarah Palin colorfully put it, deciding who is too old or too disabled to merit treatment. This is a distorted interpretation, to say the least. The debate threatens sensible policy on end-of-life discussions and in the separate realm of reforming the health-care system.
First: It makes sense for everyone to think about end-of-life issues, and the earlier in life the better. If you want every last heroic measure to be tried to extend your life, you can say so. If you have a different vision, you can spell that out. You will be doing your relatives and yourself a favor if you express yourself while you are still healthy. You can always change your mind.
Second: It makes sense for doctors to encourage their patients to think about these issues, preferably while patients are still relatively young and relatively healthy. That's the intent of the now-controversial measure inserted into the House version of health-care reform; it would allow Medicare to reimburse physicians for the time they spend discussing these issues with their patients. Since 1990, hospitals, nursing homes and similar institutions have been required to inform patients of their rights to accept or refuse treatment and to execute advance directives specifying their wishes in case they are incapacitated. Last year, Congress -- with little if any controversy -- included such "end-of-life" planning among the services covered in seniors' initial "Welcome to Medicare" checkup.
Third: The issue of end-of-life planning should never get mixed in with the issue of cost control in health care. Such planning is a virtue, as we said, in itself. Cost control is a virtue, too, but not to be achieved by persuading people to limit their end-of-life care. Tucking the measure in question into a bill that focuses substantially on controlling costs may have been a mistake. The sensible thing might be to set this measure aside for separate consideration, as the Senate Finance Committee apparently is inclined to do, according to Sen. Charles Grassley (R-Iowa).
As it happens, there is evidence, though inconclusive, that advanced directives might save some costs. A study of 603 patients with advanced stages of cancer, published this year by Harvard researchers at Dana-Farber Cancer Institute, found that the final week of health costs for those who had discussed end-of-life treatment with their doctors was 36 percent lower than for those who did not have such talks.
But here's the more important finding: Patients who hadn't discussed treatment options did not live longer, but they had a "worse quality of life" in the final week, more likely to be in intensive care or on a ventilator. Yet a recent AARP survey of people 50 and over in Massachusetts found that, though 89 percent of seniors believed it very important to get honest answers from their doctors about end-of-life issues, only 17 percent had discussed such issues with their doctors. Indulging in demagoguery on this issue -- suggesting, for example, that encouraging physicians to discuss advance directives with their patients is starting "down a treacherous path toward government-encouraged euthanasia," as House Minority Leader John Boehner (R-Ohio) asserted -- could have the effect of consigning more patients to unnecessarily uncomfortable deaths.