Tuesday, August 3, 2010

Letting Go of Death Panels

Cross-posted from National Review Online.


UPDATE: National Review Online has posted an audio version of this article. So, if you’re washing the dishes and you feel like listening to someone read this article on your behalf, this mp3 file is for you:



I’m a great admirer of the thoughtful, literary style of Atul Gawande. He writes sincerely and movingly about the trials and tribulations of modern medicine. It’s when he tries to extrapolate public-policy recommendations from these stories that he falls flat, kind of like a Steinway piano whose middle C is badly out of tune.

His most recent article, titled “Letting Go” and published in the August 2 issue of The New Yorker, is exemplary of his work. In the article, Gawande tells the stories of several patients, young and old, who are dying — typically of cancer — and how doctors, nurses, patients, and their families struggle with the challenge of facing death.

As he notes, end-of-life care was a prominent element of the Obamacare debate. “Twenty-five per cent of all Medicare spending is for the five per cent of patients who are in their final year of life, and most of that money goes for care in their last couple of months which is of little apparent benefit.” Why is this a matter of concern? Because Medicare is a taxpayer-funded entitlement, spawned by Congress 45 years ago last Friday. But Gawande thinks that certain politicians have got it all wrong:
The subject seems to reach national awareness mainly as a question of who should “win” when the expensive decisions are made: the insurers and the taxpayers footing the bill or the patient battling for his or her life. Budget hawks urge us to face the fact that we can’t afford everything. Demagogues shout about rationing and death panels. Market purists blame the existence of insurance: if patients and families paid the bills themselves, those expensive therapies would all come down in price. But they’re debating the wrong question. The failure of our system of medical care for people facing the end of their life runs much deeper.
By “deeper,” Gawande means that patients and their caregivers aren’t trained to face death; instead they’re trained to fight on, adding more and more treatments, even if many of those treatments are futile. Of course, these problems are rare in other parts of the world. In Britain’s National Health Service, for example, terminally ill patients are incorrectly classified as “close to death” so as to allow the withdrawal of expensive life support.

But there is something to be said for dying with dignity and for making considered decisions about how much medical intervention is enough. What Gawande doesn’t get — what he calls “demagoguery” — is the understandable fear that Americans have that, in a state-run system, those decisions won’t be theirs. We only have to look across the pond to see how that could play out.

Gawande believes, as we all do, that the practice of medicine would benefit from patients’ thinking ahead about end-of-life care. He cites the example of La Crosse, Wisc., where, since 1991, anyone admitted to a hospital, nursing home, or assisted-living facility has been required to fill out a form asking: “Do you want to be resuscitated if your heart stops? Do you want aggressive treatments such as intubation and mechanical ventilation? Do you want antibiotics? Do you want tube or intravenous feeding if you can’t eat on your own?” Gawande notes that the mere act of asking patients to think about these questions in advance led to more humane, and more effective, treatment later on. It’s a good idea, one that other hospitals could learn from.

But to Gawande, it’s not enough that other hospitals adopt such procedures on their own. A provision in Obamacare was to provide government funding for doctors to have end-of-life discussions with their patients; to Gawande’s dismay, “it was deemed funding for ‘death panels’ and stripped out of the legislation.” The obvious question doesn’t seem to occur to him: Why do we need a government program to pay doctors to have thoughtful conversations about their patients’ eschatological desires — something they should be doing already, and that doesn’t cost a dime?

Amazingly enough, there are ways to improve the quality of end-of-life care in America that don’t involve a government program. Gawande knows this, for he writes compellingly and often about the successes of people like the doctors in La Crosse.

But it is a constant struggle for Gawande to see what is in front of his nose: that such improvements come not from Olympian government officials, throwing lengthy pronouncements down from D.C. office buildings, but from the accumulation of thousands of small innovations by individual doctors, nurses, and administrators.

One of the great slanders of the last year was that conservative opposition to Obamacare’s end-of-life provisions was demagogic and dishonest. It is true that we often try too hard to extend life at times when it is futile to do so. It is true that, thanks to unwise government policy, we often expect care we don’t need, because we are insulated from its price.

There are legislative reforms that can help address these problems. But they involve reducing, not expanding, government control of the health-care system. They involve letting patients decide for themselves, with the aid of their doctors and their families, how best to negotiate their last days on earth. If a free country can’t be about that, it can’t be about much.

16 comments:

  1. You ask why doctors don't have these conversations already because they "don't cost a dime". But a doctor's time is money. The provision in the health care bill stated that a doctor could have a half-hour (or however long) conversation and bill that time to Medicare. Now he has to do it for free - he can't be reimbursed for that time. So now we have to rely on the doctor's willingness to donate his time.

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  2. Hi Anonymous,

    You make a fair point: time is money, and adding these conversations will reduce the number of patients a physician can see. But how many minutes does it take to do what La Crosse does?

    I would say that a larger problem is that medical students, at least when I was in medical school, weren't trained to talk to their patients about end-of-life care. As a result, we don't think of end-of-life conversations as part of the standard of care, when they should be. It just seems to me that physicians shouldn't have to be paid extra to ask patients how they wish to be treated.

    If that means we need more doctors (which we should), then by all means, let's train more doctors.

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    Replies
    1. That's bc talking to patients about end-of-life care is practice during residency, not in medical school.

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  3. " But how many minutes does it take to do what La Crosse does?"

    A lot, if you are going to do it right. Incentives matter. If you want docs to do this, which is to the benefit of the patient, incentivize them.

    I think the death panel demagoguery was one of the sleaziest political moves I have ever seen, though I will admit this is a subject very dear to me. If nothing else passed but this provision, it would have been a worthwhile start as a health reform bill. Those on the right who are knowledgeable about health care should have immediately responded to this and shot it down. We desperately need to address end of life issues. This was a good start. It is the main reason I stopped reading most right of center health writers for a while, other than Suderman and the main econ blogs. If you guys were unwilling to cal out such blatant lies, harmful at that, you lose credibility. I have calmed down and am now reading more on the right again, but I will never vote for anyone who used death panel talk.

    Steve

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  4. Hi Steve,

    Thanks for expressing your point of view. I think this is one of those issues where liberals just don't understand what conservatives are upset about, and vice versa.

    I think this is a great subject for a follow-up post -- so I will write one, on why conservatives are freaked out about death panels. I don't expect anyone's mind to change on the fundamental issue, but hopefully it can help liberals understand that conservatives, rightly or wrongly, are reacting honestly, rather than demagogically.

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  5. To say conservatives are freaked out about "death panels" in a discussion regarding end of life care unfortunately undermines everything else you say. The bill contained nothing that any sane individual (particularly a physician) could possible interpret as a "death panel". If you want to have a discussion about compensation for physicians time and end of life issue honestly then that phrase needs to be eliminated and those that use it ignored.

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  6. Avik
    For disclosure, I am a centrist, a tad left leaning, but a neutral listener/engager nonetheless.

    I am following the hubbub back and forth between you and Aaron, Austin, etc.

    I am a doc that does practice palliative care, and have a reasonable understanding of the dying process and what is involved in family issues and the complications that arise from emotional turmoil. This obviously stems from the patient and family perspective.

    As I read your column above, what struck me was the comment you wrote about med school. Please forgive, I mean no venom, but that surprised me. Your words as I processed them seemed to emanate from a non-clinician (you know, when a professional thinks, "this person needs to walk a mile in my moccasins," etc., they dont have an idea of what doing x, y, and z, are really like). Just for context, can you tell me a bit about your clinical experience or life in the death and dying trenches?

    As as aside, when death is at the front door, I have always found that regardless of political affiliation, folks of all stripes are profoundly equivalent and the questions they ask, the emotions they wear on their sleeves, etc reveal no ideological ties. We are all humans, not conservatives or liberals. Everyone wants guidance and a hand to hold. How you want docs to put the time in to do it, well, I guess you have your feelings. I just know from reading above you are on the wrong track and your prescription is to propagate more of the same. I am sure you will disagree, but I felt the need to write and state it.

    As far the town in Wisconsin, it is a rarity, and not something to be replicated easily--a bad test case in my book. See this similar post on my feelings in that regard: http://community.the-hospitalist.org/blogs/wachters_world/archive/2010/07/23/berwick-pronovost-and-the-non-scalability-of-charisma.aspx

    I can assure you, the energy and inertia that brought about that "revolution" wont happen in many places. Again, we may cordially disagree.

    Thanks
    brad

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  7. Hi Anonymous (or is it Aaron?)

    I think one difference between liberals and conservatives is their view as to the unintended consequences, and natural evolution, of state control of institutions and industries. This is one thing I will try to walk through in my post on the subject.

    I would also submit that it is unwise to presume that tens of millions of people who disagree with you do so out of dishonesty or ignorance. They might be wrong, but it's worth at least trying to understand their point of view.

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  8. Hi Brad,

    Thanks for introducing yourself, and for your thoughtful comments. I think the post you cited from The Hospitalist made a lot of appropriate points about the importance of leadership and high-quality management: which is why the left sometimes goes overboard in criticizing effective leaders for how they are compensated.

    On the question of biography: I haven't walked a mile in your moccasins, so you are more than welcome to point that out. I'm happy to learn from your experiences and your perspective, and I am open-minded about what to do. I went to medical school (at Yale), but the extent of my clincial training was my med school clerkships. I didn't do any postgraduate training. My undergraduate degree was in molecular biology (at MIT). My father was a molecular endocrinologist, so I grew up around science and medicine.

    After med school, I was recruited into the investment world, and I have spent the last ten years as an analyst and investor in healthcare companies, with an emphasis on the biotechnology industry. I spend an enormous amount of time going to medical society meetings and other scientific conferences, in order to learn about the latest developments in every field of medicine, so I keep abreast of what is going on in a wide range of medical specialties.

    While I would certainly defer to your clinical experience, I would point out that my compatriots in the financial and technological side of things also have their frustrations about others who haven't walked a mile in *our* moccasins. In particular, we are constantly disappointed by pleasant-sounding but unwise legislative and regulatory initiatives, which end up doing more harm than good because they haven't been well thought-out.

    If you feel you need to be paid by Medicare in order to spend the time discussing end-of-life questions with your patients, I respect that. I certainly appreciate that you have economic disincentives from doing so now, and so I understand where you're coming from.

    I was prompted to write the piece in large part because of Gawande's dismissal of conservative objections as "demagoguery." I think that conservatives have a genuine and legitimate discomfort with state-sponsored end-of-life initiatives. As I wrote in previous comments, I promise I will flesh this out further in an additional post.

    Thanks for your thoughts,

    Avik.

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  9. Will appreciate a follow up. I read the initial bill and the relevant part on physician payment. If you can explain how paying a doc to discuss end of life issues equals death panels, that would be appreciated.

    Steve

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  10. Avik
    Thanks for you civil response. I can see we will perhaps learn something from each other. In your response, yes, please differentiate "state-sponsored" EOL discussions and demagoguery from those that would stem from govt sponsored plans.

    I am fearful by your choice of words ("state sponsored," a loaded and demagogued term on its own) that you area already approaching this from a biased angle, and not one from a concerned conservative.

    There is a big difference between paid by Medicare, and "state sponsored", if you know what I mean....comrade :).

    Brad

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  11. Brad F said: "Just for context, can you tell me a bit about your clinical experience or life in the death and dying trenches?"

    This is precisely the arrogance that opponents of further government intervention into healthcare are concerned about. If you practice palliative care, you help people who are dying (i.e. they cannot be cured). You are a witness to the process and hopefully can provide them with some physical comfort but you have no greater wisdom regarding the ultimate decisions that should be made than the person who is dying or any of their loved ones who are going through the experience with them. There are tens of millions of Americans who have experienced the agony of watching a loved one pass away from cancer, Lou Gehrig's (ALS), Alzheimer's etc. They have detailed experience and knowledge about the costs and benefits of treatment. They know what the process entails. As a doctor, you hopefully have information regarding the treatment options and the prognosis for each of those options. However, you seem to think that because you are a "clinician" you have some greater wisdom that leads you to know what they should do. You don't. That is the liberal arrogance in you. If someone is diagnosed with lung cancer and they have a 50% chance to extend their life by 12 months if they undergo chemotherapy and they will have to take mortgage out on their house to pay for it and they have a daughter who is 3 months pregnant, it is their decision as to whether or not they want to experience the agony and expense of chemo therapy in exchange for a chance to see their grandchild. Neither you, nor Obama, nor Dr. Berwick nor any other arrogant liberal is wise enough to make that decision on behalf of any patient.

    As for the EOL provisions in the original version of the Obamacare bill, you are falsely stating those are the basis for the legitimate concern about health care rationing. Sarah Palin used the term "death panels" and liberals use her and her ineloquent term as a bogeyman to divert the argument.


    It is clear that liberals believe that they know better and that they should decide the quantity and quality of healthcare we should all consume. Canada's single payer system has outlawed the provision of health care outside the government system and the government system decides how many MRI's or colonoscopies or back surgeries will be provided in a given area in a given period of time. The NHS in Great Britain uses the NICE commission to determine the cost/ benefit of given treatments for categories of individuals. The New York Times ran a story last year about a man with cancer in his kidneys and NICE's rejection of his request for treatment with a cancer drug available in the US. NICE determined that the likely benefit (the additional life expectancy) to the patient was not worth the cost of the drug. It is disgusting to many people that a government bureaucrat would have the right, not to mention the gall, to assign a value to someone's life expectancy. It is not a decision for the community boards established by Obamacare, it is not a decision for the blue ribbon panel that Obama proposed last year when he was interviewed by David Leonhardt of the NY Times; it is not for knuckleheads like Dr. Berwick to make.

    Obama, Barney Frank, Jan Schakowsky, Russ Feingold etc. have all explicitly stated on video that they want to put private insurance out of business and establish a single payer system. Obama has also said that in his esteemed opinion we spend too much on health care and that Obamacare will "bend the cost curve". Medicare will bankrupt this country, but the failures of liberals to adequately plan for and fund the Medicare program is not an argument for increased government intervention in the entire health care system.

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  12. Not Aaron, but do read his blog. I will admit writing my earlier comment about "death panels" bit hot under the collar. I am a family doc who tries to deal intelligently with this and believe that we get what we pay for. If we refuse to pay for end of life discussions and even demonize the subject we will continue to get out of control spending for terminally ill patients (I'm sure that between you and Aaron you can argue those numbers more effectively than I).

    I think we need a healthy debate on this and health care in general but would once again rant that the use of "death panels" is inflammatory. It starts an argument over a nonexistent portion of the recent bill and from there on part of your audience goes deaf to the rest of your point of view. We need you, we need Aaron and we need you both and anybody else with good ideas to argue facts, opinions and theories honestly so we can figure out how to best fix this health care mess.

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  13. Anonymous.
    Sorry you feel that way. I am not a liberal, firstly. Secondly, I think you misconstrued my question to Avik. I did not mean it arrogantly, and I think Avik got that. He was very civil and polite. I had a legitimate interest in his medical background.

    Oh well. Sorry I got you bothered, but sometimes a query is just a query.
    Brad

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  14. "There are tens of millions of Americans who have experienced the agony of watching a loved one pass away from cancer, Lou Gehrig's (ALS), Alzheimer's etc. They have detailed experience and knowledge about the costs and benefits of treatment. They know what the process entails."

    No they do not. Few people know what it costs. Few people know ahead of time what it will be like to end life on a ventilator. Most avoid even thinking about it. I ask them.

    Steve

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