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.
Dr.Eric Van De Graaff, MD As president, what would you do about the vast quantities of lawsuits that lawyers will bring against doctors and hospital administrators? You know it will happen! The dye has been cast against doctors and hospitals. You have money and you are percieved filthy rich and and undeserving of your fortunes! see the regulatory nightmare and demise of private aviation and commercial avition. The doctors are NEXT!!!
I suspect the family of the patient, and the difficulty of letting go has a lot to do with what looks like MD pride. I cannot imagine a more difficult task than asking a family member if their fight should perhaps be over. I did that to a friend once. He did not forgive me quickly. Thank you for your insight. All the people I know who've chosen hospice are really glad they did. Though difficult I believe acceptance and the opportunity to say goodbye are precious gifts.
Death panels for lawyers would be a good start. :) Maybe when a person signs up for medicare, they also fill out the forms for their advanced directives. Problem solved, whats next?
There may be a variety of reasons hospice and palliative services are not offered soon; however, it is my opinion that these services are not offered sooner due to the fact that MD's generally focus on curing a patient and ways to increase life span...this is the doctor's job and what they set out to do. Some MD's may view referring a patient to hospice as a failure on their part. Based on these goals, it only makes sense that their focus is different and they may continue to push treatment, when in reality comfort care would be more appropriate. Again, this is my opinion and I do not want to stereotype all doctors. I do not see a downside to palliative and/or hospice care but I do know that some people have associated these services with "giving up", which is not the case at all when you truly understand hospice philosophy. Also, for hospice, life sustaining treatments are no longer a part of the care plan, which often times is a scary thing for patient’s to discontinue. Instead the focus is on comfort and pain management. It all depends on perspective. In my opinion, these services allow individuals to embrace a natural part of life and to find closer.
I like Laurie and Erica's comments. Is there a down side to Hospice and Palliative Care Options ... Why are these options not offered sooner?
I think it would be in everyone's best interest to start this type of discussion with our patients/families AT FIRST, instead of AT LAST........... Thanks for the interesting comments, everyone!
I recently had to watch my 86 year old aunt suffer through every other day dialysis treatments because her children were only told that without it she would die,They actually thought she would improve with the dialysis! Doctors failed to mention that she infact was going to die either way but how much suffering could she endure before her kids decided 'that's enough'. With my advice, hospice was called in for a consult and it was smooth sailing but my Aunt and her family trusted the family doctor to guide them. Death Panels, probably no, but paying doctors to talk to patients about end of life definately yes.
One option to minimizing the above mentioned problems: utilize the palliative care and hospice services, which are readily available and trained in these specific areas. Informational visits are available and free of charge, so the patient's and family are able to become educated, prior to coming on service.
Linda Lund Rn, BSN
Ditto the above comment...thank you Dr. Van De Graaff! My mother-in-law is now 90 yrs old and has gotten pretty frail and believe me we are thinking about all these things.
I could write a book about your post. I have been a Hospice RN for Alegent health for 4yrs. Prior to this I was blessed to work on the Oncology floor at Bergan. I think it is imperative of all physicians to understand and know that medicine and machines can only do so much. If a patient is failing or declining that MD needs to talk about quality of life and guide families to help them make the most informed decision along with the patient if they are able to part of this decision. Families trust their PCP and look to them for advice. I can say from a Hospice perspective many of our patients come onto service when they have days to hours left. If more physicians would embrace eol as the natural progression of a failing body we would be able to get patients onto service sooner. By doing this we have more time to educate families and patients about what we do and how the natural progression to EOL evolves. I can say from all my yrs of being a nurse I have never had 1 family member come back to say that Hospice was not the right choice. It was the perfect choice and the memories they have of their loved one in the final months to days were some of the best. It is very sad to me that so many patient die in the ICU units and never had that chance to fulfill their bucket lists or get home for that final time. Laurie Villotta RN,BSN Alegent Hospice
Interesting. Why not a "Death Panel" that decides what's best for the patient based on disease state and age? I know it's not that simply but, as Americans, why do we want to live forever? Is it worth going down this path to be in a hospital/nursing home with people the patient doesn't know to see their kids/grandkids a few more times? Medicare spends 30% of its budget on beneficiaries in their last year of life. No wonder Medicare has been in the red since 2008. The new healthcare legislation will cost a total of $1.1 trillion (by 2021) to get another 34 million Americans insured. Can money be more important than life? What if it's your mother's health in question? Tough problem to solve for the nation
Mary Fischer Golda
Well, until someone finds a cure for death, you have my vote...as long as you can pass a citizenship test.
I would vote for you!! I also enjoy your blog. I know I speak for the mass majority of people, in that they would not shed a tear for a Doctor to not be able to bill someone. But being "in" the medical field, I understand how things work and you are not just billing for money in your pocket. I'm not sure if you billed, say one thousand bucks,(for what ever procedure) how much really makes it to your pocket to bring home after you spit it up with all the out streached hands, insurance, office staff, gov. tax and so on, and so on. And you did go to school for about 50yrs. so you should get paid, and paid well! The death squads, if everyone made up the living will/advanced directives, it would be a good thing, most pt's say "I don't want to be on the machines". I just don't think the gov. should say who lives,(gets the expensive procedure/med.) or who doesn't(your to old).
Dr Van De Graaff - Thanks for a great read! You make many valid points in your thoughts on this subject. One could respond at length to each one individually but suffice it to say that the whole end of life issue will eventually touch each of us personally. The physician, no matter what speciality, usually seeks to heal body, mind and soul and it is not unreasonable to expect some compensation for those services which are rendered. As indicated above, with the advancements and technology in providing health care today, it also emphasizes the need for everyone to make his or her personal advance directive known, both in a written document and to those people who would have to ultimately make those decisions if we become unable to do so for ourselves.