If I Were President

My family and I visited our nation’s capital over Easter weekend.  About 9 months ago I put in a request through our state senator for a tour of the White House.  After submitting all the necessary background information so that the Secret Service could vet us as a security risk (I do have shifty eyes, after all) we were given an appointed time for our tour of the “people’s house.”  After going through the security screening we were allowed entrance into the public areas of the structure and were free to roam through rooms of various colors: the green room, the red room, the blue room.  The only rooms we failed to visit were the most famous: the oval office is off-limits for fairly obvious reasons, and the Lincoln bedroom was unavailable for an overnighter—it turns out I am two administrations too late and a million dollars in campaign contributions short.

The President was in California at the time of our visit, but we managed to catch a glimpse of the presidential dog, Bo, as he was being walked around the grounds by the official dog-walker (probably some secret service guy being punished for falling asleep on the job).  Despite my attempts to catch up with the “first dog”, he managed to walk away before I had a chance to challenge him about his birth certificate.

The timing of our trip proved to be quite propitious for my little daughter, whose 3rd-grade class had just finished a detailed study of all the presidents.  She can now name each in order and dish out such pearls such as which president kept an alligator as a pet and which one had a habit of getting stuck in the bathtub.  She was surprisingly well versed in the history of the White House and its occupants and proved to be an adept tour guide.

As part of their assignment, my daughter’s class had to come up with a law they would enact if they were in charge.  “If I were president,” my daughter, the budding activist, wrote, “I would pass a law requiring a new tree to be planted for every one that is cut down.”  This got me thinking about what kind of laws I would make if I were the Commander in Chief.

Mind you, I’m not naïve enough to believe that in our politically partisan environment the head of our executive branch has enough power to enact any law she or he dreams up, so maybe I’ll rephrase my line of daydreaming: “If I were the omnipotent emperor of our land what one law would I enact that relates to our nation’s healthcare?”

The answer I came up with?  Death panels.

Of course, I am not referring to real death panels—the term that conjures up teams of government officials huddling over hospital beds deciding who deserves to live and who merits a pull of the plug.  What I mean is the provision in the healthcare reform law that was pejoratively derided as “death panels” but was actually intended to provide funding for end-of-life counseling by a doctor for any patient deemed in need.

Throwing aside the political rhetoric on the matter, here’s how I understand that portion of the proposed law.  Right now if a primary care doctor has a patient nearing the end of life (even if that person remains healthy now) the doctor cannot be reimbursed for the time spent counseling the patient on issues such as “do not resuscitate” preferences and advanced directives.  A doctor can bill for physical exams and preventive screening measures, but when it comes to the long discussions about what patients’ end of life preferences are a busy family doctor would go broke having an hour-long discussion about such weighty matters and being able to bill only 15 minutes’ worth of time.

This may not seem like a big problem to many of you, but if you stop to consider how complicated dying really is you’ll very quickly see the rub. Thanks to the explosion of modern technology we now have an amazing array of ways to make you suffer before you die.  A 90-year-old chronically debilitated patient coming through the emergency room with a heart attack and cardiac arrest will by default receive the same care as a 30-year-old.  She’ll be whisked off to the cath lab where we’ll use stents to open the blockage.  If she does poorly on the cath table we may end up placing a temporary pacing wire in the right ventricle and a balloon pump in the aorta.  She’ll stay for days in the ICU, possibly on a ventilator and on various intravenous medications, while we wait to rouse her enough to determine how much cognitive damage she’s suffered.  We’ll probably cool her body temperature for a couple of days and induce an artificial coma to aid in her recovery.  After that, she’ll languish until she either mounts a miraculous recovery or slowly slips toward the failure of her liver, kidneys, heart, and brain.

This process is about as automatic as you get.  We in the medical establishment are like Energizer bunnies, automatically programmed to keep on going and going, ordering every test, procedure, and surgery that has even the most remote chance of promoting recovery.  Such a system works well with the young healthy victim of a car crash or rare illness, but when applied to the geriatric population—whose bodies are already frail and lacking necessary reserve—our aggressive approach to medicine rarely extends anything more than the hospital bill.

Just last week I sat outside the room of a dying patient listening as the family members debated and argued about what sort of care their mother should receive—how much more should they put her through?  When do they start backing off?  The saddest part was that the patient was destined to die regardless of what decision the feuding family members made.  Their debate would really only determine how much more suffering we’d inflict and how much more stratospheric her bill would be.

The proposed legislation would have dramatically improved situations like these.  Dr. Paul Kettle, a geriatric specialist in Philadelphia, summarized this best in his editorial in last year’s Journal of the American Medical Association:

People like their physicians to talk with them.  People are generally in favor of physicians getting paid.  But the concept of physicians being paid for time to talk with patients and their families about advance directives somehow generated into the fear of decisions about life and death being controlled by the government.  The idea was torpedoed not because it was a bad thing, or because people didn’t want it, or because it wasn’t needed. . . . the idea was transformed successfully into a negative sound byte (sic) with a memorable catchphrase.

As doctors, we owe it to our patients to do more than just treat illness.  We are also responsible to help shepherd our dying patients and their families through the incredibly complicated maze of modern medical care.  While I’ll never get the chance to sit in the Oval Office and pass my law, maybe my daughter will.  Perhaps then we’ll get more end-of-life communication along with our new trees.