Thursday, August 27, 2009
Only Strengthens Reasons for Concern
By Dave Andrusko
"If President Obama wants to better understand why America's discomfort with end-of-life discussions threatens to derail his health-care reform, he might begin with his own Department of Veterans Affairs (VA). He will quickly discover how government bureaucrats are greasing the slippery slope that can start with cost containment but quickly become a systematic denial of care." From "The Death Book for Veterans," by Jim Towey, which appeared in the Wall Street Journal August 19, 2009.
Although Jim Towey's column has stirred the proverbial hornet's nest, my hunch is that not enough people are aware of the growing controversy over what is afoot at the Department of Veterans Affairs (VA). According to Towey (the one-time director of President George W. Bush's Faith-Based Initiatives, among other things), the VA has brought back to life a death initiative into which Bush tried to drive a stake back in 2007. All this, needless to say, is being pooh-poohed by the Obama Administration.
Towey's Wall Street Journal piece (available at http://online.wsj.com/article/SB10001424052970204683204574358590107981718.html) charges that a 52-page "hurry up and die" workbook/primer titled Your Life, Your Choices: Planning for Future Medical Decisions "presents end-of-life choices in a way aimed at steering users toward predetermined conclusions, much like a political 'push poll.' For example, a worksheet on page 21 lists various scenarios and asks users to then decide whether their own life would be 'not worth living.'"
This "hurry-up-and-die message is clear and unconscionable," Towey writes. "Worse, a July 2009 VA directive instructs its primary care physicians to raise advance care planning with all VA patients and to refer them to 'Your Life, Your Choices.' Not just those of advanced age and debilitated condition--all patients. America's 24 million veterans deserve better."
for the rest of this article, please visit: http://www.nrlc.org/News_and_Views/Aug09/nv082409.html
Friday, August 21, 2009
For more description, see the Wall Street Journal article:
Friday, August 14, 2009
Tuesday, August 11, 2009
ADVANCED CARE PLANNING PROVISIONS MUST NOT PRESSURE PATIENTS TO REJECT LIFE-SAVING CARE
National Right to Life strongly encourages the execution of a pro-life advance directive, the Will to Live (See http://www.nrlc.org/MedEthics/WilltoLiveProject.html). However, the pro-life fear is that efforts to push patients and prospective patients to prepare advance directives may in practice become a means of persuading or pressuring them to agree to less treatment as a means of saving money.
Central to the Health Care reform bills is the concept that cost cutting measures will be sufficient to make up for financing shortfalls. One of these measures is the promotion of advance directives.
There have been several recent studies showing how advance directives and end of life conversations generally yield cost savings.
A 2009 Archives of Internal Medicine study concluded, “Patient-physician discussions about [end of life] wishes are associated with lower rates of intensive interventions.”[i] The mean cost of care was 35.7% less for patients who reported having end-of-life discussions compared with for patients who did not in their final week of life. “We refer to the end-of-life discussion as the multimillion-dollar conversation because it is associated with shifting costs away from expensive, …., to less costly comfort care….” noted Dana-Farber's Holly Prigerson PhD[ii].
A recent JAMA study reaches a similar conclusion that, "On the other hand, patients who reported having end-of-life discussions received less aggressive medical care and were more likely to receive hospice services for more than a week."[iii]
Aside from the many stand-alone bills related to advance directives this term in both houses, there are three separate provisions dealing with advance directives in the House legislation. 1) There is the main 1233 provision.[iv] There are also two other amendments, one requiring private and public health care plans to give potential enrollees the option to establish advance directive; [v] and the other to empower the Secretary to spearhead a public education campaign, toll-free telephone hotline, and clearinghouse to promote advance directives and other advance care planning. [vi]
What is particularly disturbing about this “cost-savings” provision of the bill is that it appears to follow President Obama’s call this past spring for “a very difficult democratic conversation” about “those toward the end of their lives [who] are accounting for potentially 80 percent of the total health care bill out here.”[vii]
It is also extremely troubling that Compassion and Choices, the principal group that promotes physician assisted suicide throughout the country[viii] is not only aggressively promoting these provisions, but claims responsibility for the inclusion of the main provision.[ix]
 This provision allows assisted suicide and euthanasia to be promoted as an option in the places where it is legal (Washington, Oregon, and Montana).
[i] Health Care Costs in the Last Week of Life Associations With End-of-Life Conversations. Arch Intern Med. 2009;169(5):480-488.
[ii] Dr. Prigerson was the senior author of the study.
[iii] Wright AA, Zhang B, et al. Associations Between End-of-Life Discussions, Patient Mental Health, Medical Care Near Death, and Caregiver Bereavement Adjustment. JAMA. 2008;300(14):1665-1673.
[iv] Section1233 of H.R 3200, “America’s Affordable Health Choices Act of 2009” provides for Medicare reimbursement for consultations about “advance care planning” between health care providers and their patients when they enter Medicare, every five years thereafter, and if they become seriously ill.
[v] Amendment offered by Mr. Hill in Energy and Commerce titled “Information on End-of-Life Planning.” offered July 31, 2009.
[vi] Amendment offered by Ms. Baldwin in Energy and Commerce titled “Programs to increase awareness of advance care planning issues: part S—programs to increase awareness of advance care planning issues.” offered July 31, 2009.
[vii] April 14 interview, published in the New York Times Magazine April 29, 2009.
Jennifer Popik, J.D.
Robert Powell Center for Medical Ethics - NRLC
For Media, contact:
Communications Department at (202) 626-8825
Monday, August 10, 2009
With Congress preparing for floor votes on health care restructuring this Fall, we must guard against the grave danger of rationing life-saving medical treatment, food, and fluids.
Since its inception, the pro-life movement has been just as committed to protecting older people and people with disabilities from euthanasia as to protecting unborn children from abortion. We have long recognized that denial of treatment, food and fluids necessary to sustain life against the will of the patient is a form of involuntary euthanasia, and thus have fought to protect the vulnerable from rationing of health care, whether by health care providers such as hospital ethics committees or by the government.
All versions of the health care restructuring bill provide for premium subsidies to help the uninsured obtain health insurance. The problem is that the proposals under serious consideration to date fail to ensure a sustainable method of financing these subsidies (See NRLC’s webinar at http://nrlcomm.wordpress.com/2009/06/13/hcrwebinar/ and also www.nrlc.org/HealthCareRationing.describeplan.html). Indeed, a substantial part of the subsidies, under current proposals, would be paid for by “robbing Peter to pay Paul” – reducing Medicare funding for older people in order to cover the uninsured. The dangerous consequence is that in a few years, having over-promised and under-funded, the government will be faced with the choice of adding other means of revenue or else (and far more likely) in some way imposing rationing.
The companion piece describes how “comparative effectiveness” research included in the legislation could be used to accomplish such rationing.
When the Kennedy bill was considered in the Senate Health, Education, Labor and Pensions Committee, several important anti-rationing amendments sponsored by pro-life Senator Mike Enzi (R-WY) were adopted. However, a critically important amendment to prevent “comparative effectiveness” from being used for rationing was defeated (see http://www.nrlc.org/press_releases_new/Release062209.html). Moreover, a provision in the Kennedy bill reported from the committee gives Secretary of Health and Human Services Kathleen Sebelius unconstrained authority to issue regulations governing doctors, hospitals and other health care providers who want to be paid by qualified insurance plans with the vague objective “to improve health care quality”– authority that could be used to require them to deny so-called “ineffective” treatment to their patients.
Through the good offices, in particular, of the staffs of pro-life Senators Enzi and Chuck Grassley (R-IA), NRLC has been able to negotiate language to be included the comparative effectiveness portion of the bill planned to be brought before the Senate Finance Committee in September that would forbid use of comparative effectiveness data to deny treatment discriminatorily based on disability, age, or terminal illness. Since no such language is included in the Kennedy bill or House legislation, however, there is no guarantee that this protective provision will be included in any bill finally passed by Congress. Moreover, if the bipartisan group of six Senators does not agree on a compromise bill by September 15, Democratic Senate leaders have warned they may bring the Kennedy bill to the Senate floor under a procedural maneuver, called “reconciliation,” that would permit many portions of it to pass with only 51 votes – meaning that Senate Republicans and centrist Democrats could be cut out of the process and the negotiated anti-rationing language might not be part of the bill brought to the floor.
The House legislation, as reported from the Energy and Commerce Committee, contains provisions to promote advance directives like “living wills,” including:
1) Medicare reimbursement for consultations about “advance care planning” between health care providers and their patients when they enter Medicare, every five years thereafter, and if they become seriously ill;
2) requiring private and public health care plans to give potential enrollees the option to establish advance directives; and
3) a public education campaign, toll-free telephone hotline, and clearinghouse to promote advance directives and other advance care planning.
Advocates of such measures frequently cite the cost savings if, as they expect, this promotion results in more directives rejecting life-saving treatment. “We refer to the end-of-life discussion as the multimillion-dollar conversation because it is associated with shifting costs away from expensive . . . care like being on a ventilator in an ICU, to less costly comfort care…,” says Holly Prigerson of Boston's Dana-Farber Cancer Institute. National Right to Life strongly encourages the execution of a pro-life advance directive, the Will to Live (See http://www.nrlc.org/MedEthics/WilltoLiveProject.html). However, the pro-life fear is that efforts to push patients and prospective patients to prepare advance directives may in practice become a means of persuading or pressuring them to agree to less treatment as a means of saving money. Moreover, governmental promotion of advance care planning must not include the “option” of assisted suicide. Especially in the Senate, NRLC is working to address these concerns through negotiations and, if necessary, by preparing amendments to be offered in the Senate Finance Committee and on the Senate floor.
It is critically important that pro-life citizens make their voices heard while Senators and Representatives are at home during August, and after they return to Washington in September. The contemplated restructuring of America’s health care system will affect the life – and death – of every American.
--Article Published in July/August 2009 NRL News
“Facing the Challenge of Health Care Rationing” by Burke J. Balch, J.D., director, Robert Powell Center for Medical Ethics
Sunday, August 9, 2009
As one medical journal article describes it, “The basic idea underlying the QALY [Quality-Adjusted-Life-Year] is simple: it assumes that a year of life lived in perfect health is worth 1 QALY (1 Year of Life × 1 Utility = 1 QALY) and that a year of life lived in a state of less than this perfect health is worth less than 1. . . . By moving away from a purely biological model . . . a need arises to focus on areas such as the individual's ability to operate in society [and] disability.” Some measures have “negative . . . scores for health states perceived as being worse than death.”
In a featured piece in the July 19 New York Times Magazine, Princeton bioethicist Peter Singer openly advocated government rationing of health care, using QALYs. He made it clear that society should be more willing to withhold treatment from those who are old and those with disabilities. “The death of a teenager is a greater tragedy than the death of an 85-year-old, and this should be reflected in our priorities,” he wrote. “[S]aving one teenager is equivalent to saving 14 85-year-olds.” Similarly, “If most would . . .choose 6 years of nondisabled life over 10 with quadriplegia, but have difficulty deciding between 5 years of nondisabled life over 10 with quadriplegia, then they are, in effect, assessing life with quadriplegia as half as good as nondisabled life.”
In one example in the medical literature, an attempt was made to assess different quality adjusted life year scores for each of the following: “no physical disability, limp, walk with crutches, and need a wheelchair.” In another, the authors wrote, “[I]t may be judged that one year of life with a moderate disability is equivalent to 0.75 years of life at optimal health.”
The assumptions built into the use of quality-adjusted life years are often inaccurate. As Hayden Bosworth of the Duke University Medical Center documents, “Patients who have not experienced a stroke . . . or individuals at risk for future stroke . . . respond with low [quality of life] estimates for physical impairments. Yet it is clear that patients who actually experience a high level of impairment as a result of a stroke provide high estimates of their quality of life.”
How could comparative effectiveness research using quality-adjusted-life-years be used to deny treatments needed by people with disabilities? Mark Pauly, a professor in the Department of Health Care Systems at the Wharton School of the University of Pennsylvania, advocates “a bottom-up strategy in which the plan set a target level for spending growth and then used cost-effectiveness analysis to choose the set of new technologies whose cost fit within the limit and which maximized the number of new QALYs delivered. At the limit, a technology would be in the package only if its value of dollars per QALY were lower than that of all excluded technologies.”
--Article Published in July/August 2009 NRL News“Facing the Challenge of Health Care Rationing” by Roger Stenson