Hospice eNews
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What
the Media Said about End-of-Life Care This Week
Week of March 7, 2005
…a service of
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DYING SOONER
MIGHT HELP SAVE MEDICARE
* The New York Times columnist Daniel Altman, in an article entitled “How to Save Medicare? Die Sooner,” says that one way to contain Medicare costs is to let people die sooner. While Medicare costs in the last year of life have remained steady at about 28%, and thus isn’t a factor in the recent ballooning costs of Medicare, it’s still a reasonable place to look for cost cutting, says Dr. Gail R. Wilensky, senior fellow at Project HOPE.
The problems with letting people die,
Altman says, are the difficulties in identifying when someone is likely to die
and identifying the kind of end-of-life care that may not be of much value. Dr.
David O. Meltzer of the
Wilensky suggests that better coordination of care could cut down on the extra tests and treatments made by “unusual number[s] of specialists and other doctors visiting the patient.” She recommends the use of evidence-based medicine, where care is based on documented cases and statistics, as a way of discouraging doctors from recommending treatments that are probably futile. Another option is the use of gatekeepers, administrators who choose which procedures patients could have, but several have suggested that the public would not agree to that. Dr. Arnold S. Relman, Harvard professor emeritus, says that a “complete revamping of Medicare’s payment system” is needed.
Another alternative is to push the use of hospice care, but Wilensky says that we don’t know whether or not it saves money. Meltzer says the lack of information on that subject should be the main target. “We just woefully underinvest in health-related research,” he says. “The Medicare program has really very, very little money to fund research to help improve itself.” (The New York Times, 2/27)
JAMA READERS
TAKE ISSUE WITH SHARED DECISION-MAKING
Drs. Jeffrey R. Waggoner, of
Waggoner also calls McNutt’s statement that patients will learn to accept the responsibility of choosing treatments “arbitrary at best.” He says that patients bring strengths and weakness to bear in the face of terminal illness and that appropriate care should work with these, not demand change.
McNutt responds to Waggoner, saying, “The physician can only guide the patient on how to go about choosing; there is no guarantee about what that choice will be.” He says that his point is “that to make a choice one must understand the ramifications of that choice, irrespective of how any individual may internalize the specific outcomes. The goal of the process is to inform the patient about what is known, not to lead to a uniform set of choices.”
Silviera and Feudtner disagree with McNutt by saying that “scant empirical evidence” exists for the superiority of McNutt’s method, or that patients prefer it over others. They question his assumption that the decision-making cannot be shared with anyone else, noting that a spouse may have something to say about preferring sexual disability or death as consequences of prostate treatment. They also call McNutt’s method “neopaternalistic” – the physician is no longer dictating the treatment but is dictating the method by which the patient should choose.
In response to Silviera and Feudtner, McNutt says, “We should not be eager to tolerate the variety of ways patients work through decisions unless those ways include reflecting on what is known, what has been studied in a sound manner, and what others have experienced.” “Medical decision-making is not coping,” he says, “it is about reflecting on the best evidence. My experience with patients who have been given multiple opinions by multiple physicians tells me that one of the best means of coping is knowledge and a full understanding of the consequences that are being faced. Compassion, dignity, and caring are essential. However, these attributes do not ensure informed choice; science must be included.” (JAMA, 2005;293:1058-59)
FILM DISTORTS
EOL DECISION-MAKING
“The Oscars are
over, but unless doctors and medical ethicists step in to use the film as an opportunity
to educate the public, I am very afraid that this film [Million Dollar Baby] is
going to cause a great deal of suffering for dying patients and their
families,” ICU physician James J. Murtagh writes in The Atlanta Journal-Constitution and The New York Sun. Murtagh calls the premise of the film “dead
wrong,” since Baby could have refused the ventilator by saying that she didn’t
want it.
Even more ludicrous, Murtagh says, are the
“talk-show and op-ed debates that have followed it… Nobody seems to have grasped a key fact: This is a total non-issue in American
hospitals today.” He urges “all of
us to ignore the medical distortions contained in this film — and to treat it
as an opportunity to explore the deep and searching questions that will face us
at the end of life.”
Debra Jarvis,
hospital chaplain at the Seattle Cancer Care Alliance and NPR commentator, concurs with Murtagh. In an NPR
interview, she also points out that disability activists object to the premise
that disabled people cannot live fulfilling lives. (The Atlanta Journal-Constitution, 3/1; The New York Sun, 3/3; NPR’s All Things Considered, 2/25)
PAS NOTES
* Speaking
at the President’s Council on Bioethics, Dr. Herbert Hendin, medical director of
the American Foundation for Suicide Prevention, examined the results of the
laws allowing euthanasia in the
* Bill
Colby, attorney for Nancy Cruzan’s family, says that five minutes of discussing
with your family what you’d want done if you were in a persistent vegetative
state could save your family a scenario such as Terri Schiavo’s is enduring. In Colby’s op-ed in USA Today, he
recommends a written power of attorney for health care, as well as discussions
with spouses, parents and siblings so that all know what kind of care you would
want. (
* David
Prueitt was a terminally-ill
* In one
of 11 new motions filed by Bob and Mary Schindler on behalf of their daughter,
Terri Schiavo, they ask a
* An
editorial in the
OTHER NOTES
* “Last Wishes; For some facing death, final fulfillment comes in works that will outlive them,” is the name of an article in Time Magazine. The article profiles the choices in living made by several persons near the end of their lives. After doctors told her that chemotherapy had not contained her breast cancer and that she had less than two years to live, 31-year-old Stephanie Williams began the novel she’d always wanted to write. Her sister Laurie says she “never wavered” over the writing and publishing of the book, even editing it during weeks of intensive care. The final result, Enter Sandman, was called “remarkable” and “compelling” by The Boston Globe. Williams got to see it in print three weeks before her death. (Time Magazine, 3/7)
* The Ethics Forum, at the website of American Medical News, looks at the blurring of lines between palliative, regular and aggressive care. Two cases explore common barriers to hospice and palliative care. See www.ama-assn.org/amednews/2005/03/07/prca0307.htm for the article. (American Medical News Website, 3/7)
* The
February issue of the AACPI newsletter is online at www.aacpi.org.
Click on “Pain Forum E-Newsletter” in the left column. The articles report on pain initiatives in
*
* Senator
Charles Grassley (R-Iowa), chairman of the Senate Finance Committee, and a number of charity watchdogs are
calling for “sweeping reforms” of the non-profit sector. The recommendations call for harsher
penalties for executives who “engage in self-dealing,” mandatory audits or
financial reviews of non-profit organizations and greater disclosure to the
IRS. (