Thursday, August 06, 2009

Just the Facts

I have been over to The Huffington Post to look at a version of the health care bill released by the Democrats. Now, I haven't read the whole thing, but I did read the part that was of most interest to me, and is being painted by some number of folks as state sanctioned euthanasia, or its equivalent.

To wit,


(1) IN GENERAL.--Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended--

(A) in subsection (s)(2)--

(i) by striking ''and'' at the end of subparagraph (DD);
(ii) by adding ''and'' at the end of subparagraph (EE); and
(iii) by adding at the end the following new subparagraph:

P. 425

''(FF) advance care planning consultation (as defined in subsection (hhh)(1));''; and

(B) by adding at the end the following new subsection: ''Advance Care Planning Consultation ''(hhh)(1) Subject to paragraphs (3) and (4), the term 'advance care planning consultation' means a consultation between the individual and a practitioner described in paragraph (2) regarding advance care planning, if, subject to paragraph (3), the individual involved has not had such a consultation within the last 5 years. Such consultation shall include the following:

''(A) An explanation by the practitioner of advance care planning, including key questions and considerations, important steps, and suggested people to talk to.

''(B) An explanation by the practitioner of advance directives, including living wills and durable powers of attorney, and their uses.

''(C) An explanation by the practitioner of the role and responsibilities of a health care proxy.

''(D) The provision by the practitioner of a list of national and State-specific resources to assist consumers and their families with advance care planning, including the national toll-free hotline, the ad-

P. 426

vance care planning clearinghouses, and State legal service organizations (including those funded through the Older Americans Act of 1965).

''(E) An explanation by the practitioner of the continuum of end-of-life services and supports available, including palliative care and hospice, and benefits for such services and supports that are available under this title.

''(F)(i) Subject to clause (ii), an explanation of orders regarding life sustaining treatment or similar orders, which shall include--

''(I) the reasons why the development of such an order is beneficial to the individual and the individual's family and the reasons why such an order should be updated periodically as the health of the individual changes;

''(II) the information needed for an individual or legal surrogate to make informed decisions regarding the completion of such an order; and

''(III) the identification of resources that an individual may use to determine the requirements of the State in which such individual resides so that the treatment wishes of that individual will be carried out if the individual is un-

P. 427

able to communicate those wishes, including requirements regarding the designation of a surrogate decisionmaker (also known as a health care proxy).

''(ii) The Secretary shall limit the requirement for explanations under clause (i) to consultations furnished in a State--

''(I) in which all legal barriers have been addressed for enabling orders for life sustaining treatment to constitute a set of medical orders respected across all care settings; and

''(II) that has in effect a program for orders for life sustaining treatment described in clause (iii).

''(iii) A program for orders for life sustaining treatment for a States described in this clause is a program that--

''(I) ensures such orders are standardized and uniquely identifiable throughout the State;

''(II) distributes or makes accessible such orders to physicians and other health professionals that (acting within the scope of the professional's authority under State law) may sign orders for life sustaining treatment;

P. 428

(III) provides training for health care professionals across the continuum of care about the goals and use of orders for life sustaining treatment; and

''(IV) is guided by a coalition of stakeholders includes representatives from emergency medical services, emergency department physicians or nurses, state long-term care association, state medical association, state surveyors, agency responsible for senior services, state department of health, state hospital association, home health association, state bar association, and state hospice association.

''(2) A practitioner described in this paragraph is--

''(A) a physician (as defined in subsection (r)(1)); and

''(B) a nurse practitioner or physician's assistant who has the authority under State law to sign orders for life sustaining treatments.

''(3)(A) An initial preventive physical examination under subsection (WW), including any related discussion during such examination, shall not be considered an advance care planning consultation for purposes of applying the 5-year limitation under paragraph (1).

P. 429

''(B) An advance care planning consultation with respect to an individual may be conducted more frequently than provided under paragraph (1) if there is a significant change in the health condition of the individual, including diagnosis of a chronic, progressive, life-limiting disease, a life-threatening or terminal diagnosis or life-threatening injury, or upon admission to a skilled nursing facility, a long-term care facility (as defined by the Secretary), or a hospice program.

''(4) A consultation under this subsection may include the formulation of an order regarding life sustaining treatment or a similar order.

''(5)(A) For purposes of this section, the term 'order regarding life sustaining treatment' means, with respect to an individual, an actionable medical order relating to the treatment of that individual that--

''(i) is signed and dated by a physician (as defined in subsection (r)(1)) or another health care professional (as specified by the Secretary and who is acting within the scope of the professional's authority under State law in signing such an order, including a nurse practitioner or physician assistant) and is in a form that permits it to stay with the individual and be followed by health care professionals and providers across the continuum of care;

P. 430

''(ii) effectively communicates the individual's preferences regarding life sustaining treatment, including an indication of the treatment and care desired by the individual;

''(iii) is uniquely identifiable and standardized within a given locality, region, or State (as identified by the Secretary); and

''(iv) may incorporate any advance directive (as defined in section 1866(f)(3)) if executed by the individual.

''(B) The level of treatment indicated under subparagraph (A)(ii) may range from an indication for full treatment to an indication to limit some or all or specified interventions. Such indicated levels of treatment may include indications respecting, among other items--

''(i) the intensity of medical intervention if the patient is pulse less, apneic, or has serious cardiac or pulmonary problems;

''(ii) the individual's desire regarding transfer to a hospital or remaining at the current care setting;

''(iii) the use of antibiotics; and

''(iv) the use of artificially administered nutrition and hydration.''.

What is the noise all about? There is nothing sinister in this language. What it attempts to do is establish a legal requirement for the health practitioner to communicate to the patient or the patient's advocate what all the options are. This is especially crucial with the terminally ill or those facing a potentially life-ending procedure. By legally mandating that the practitioner have the conversation, the result is that the patient or advocate has all the facts and options available to them. Whether or not the patient pursues further medical treatment is the patient's choice. See again at the top of Page 430, this clause:

(ii) effectively communicates the individual's preferences regarding life sustaining treatment, including an indication of the treatment and care desired by the individual;

As a former hospice volunteer, and having lost 3 family members to cancer, I know that not everyone desires to spend their last moments hooked up to machines and struggling to hold onto every minute of life they can. Some would prefer palliative care and support for them and their families as they face the end of their lives. Each patient still has that option before them, but the important part of this section in the bill is that the patient knows there are options and can state their preferences.

Too often doctors failed to discuss end of life care as a viable option. My mother's doctor just wouldn't go there, he used 'quality of life' as his code for 'terminal cancer.' Mom signed an advance directive to avoid being hooked up to machines in a futile attempt to keep her alive. The ER doctor treating her at the end told my sister she could override that directive if she wanted to. The result would have been a significant medical intervention on a patient that the ER doc acknowledged was in cardiac failure and unlikely to survive anyway. My sister honored Mom's wishes.

Many doctors want nothing to do with hospice or, as an alternative, want hospice to occur in a hospital setting, which is not what hospice is about. And frankly is not a good use of hospital resources unless you need a new revenue stream. In a profession that counts its victories among the living, accepting that death will defeat your medical prowess must be more than a little disheartening. If this section survives then the patients of the future can at least expect a fuller explanation of what their rights are and the options available.

That is a far cry from claims that this section supports euthanasia.

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