Sunday, August 09, 2009

Guest post by skylanda: The most assinine distractor in the health care debate

Sarah Palin calls it “evil.

Randall Terry of the tired old pro-life machine Operation Rescue calls it the “Kill Granny” clause.

The well-organized anti-reform conservative arms would have you believe that if the Obama health care package passes, government-sponsored panels will be convened to decide if seniors get life-saving treatments or get to die in the gutter.

That these panels appear nowhere in the actual bill seems to have no bearing on the panic flamed by the Randall Terrys and Sarah Palins of the debate.

That uninsured patients already live by the de facto, unacknowledged death-panel approach to care seems not to have entered into the debate.

That the origin of these myths lies in a clause that offers reimbursement to physicians who set aside visits for a sit-down talk about end-of-life care – something physicians already do, largely unpaid, every day – seems to stem the tide of rancor not at all.

As a primary care physician, let me lay out the case for full and just reimbursement for appointments dedicated to what (to steal from the right wing) amounts to “death care.”

In the last six months, I have taken care of a patient with advanced dementia whose daughter cares for her at home. The family is congenial but financially stricken, and tension remains over the matriarch’s care and the use of her remaining resources. The treatment for advanced dementia is minimal and mostly palliative, and we continue to pursue that at every visit, as well as a few minor other issues. But at every visit, I also ask the family (nay, plead with the family) to hammer out what their and the patient’s wishes are on the day that something unpleasant happens: pneumonia, a hip fracture, what have you. Do they want all measures taken? Do they want palliation over putting an elderly person through risky surgeries and pain that cannot be explained to a brain that has passed beyond the era of comprehension? And if the patient “codes” – heart stops beating in a manner that can deliver oxygen, lungs stop pulling air – do they want rib cracking chest compressions, shocks to the heart, a tube down the throat that will likely never come out of a her alive on the off chance she makes it coughing and sputtering through an ICU stay, or do they want to let her go?

I have broached the subject briefly at roughly every other visit with this family as they have dawdled along in their decisions as their elderly mother gets more ill and functional at every visit; this sounds something like, “Have you thought any more about what you might want for her care if something happen to her and she has to be hospitalized?” I do not get reimbursed for this; I bill under the diagnosis of dementia, we review and adjust some meds, and the talk comes as an afterthought. To my knowledge Medicare does not allow me to bill a visit to sit down and have a comprehensive talk about these issues currently; under Obama, it would…once every five years. These visits would be voluntary to the patient. They would be paid by Medicare. The outcome would be that the wishes of the patient would be documented and – in the best case scenario (barring the interference of family, the most frequent cause of unfulfilled end-of-life wishes I have seen) – honored. In medicine, we call this “patient-centered care;” it’s all the rage these days, or at least we like to talk about it like it is.

I want to be cared for in my death; I would put money on it that you want to be cared for at that final stage of life too. Most Americans die in hospitals with aggressive interventions still running at the bedside; when polled, most Americans express a firm desire to die at home, in the care of family with the support of the home health services like hospice (notably, finances and ethics are not at war here). Adequate, compassionate, dignified care requires some planning and some dedicated time to set aside the diabetes and the dementia and the aches and groans of the aged (and their families) to talk about the what-ifs and the what-thens of what will inevitably come for every one of us.

But these objections, these “kill granny” media campaigns, they are distractors. They are ways of mobilizing the AARP generation against a reform that is fundamentally beneficial to them: shoring up the enormous social and private financial burden that is healthcare in America is a fundamental part of rebuilding a flagging economy that at present threatens the stability of a retiring generation. By riling up seniors against the straw man of non-existent “death panels” and “kill granny” clauses, the right has shrewdly – and incredibly callously – used one of the most vulnerable cohorts to shoot their own selves in the foot.

Because, of course, the end is all economics. The neo-con right will always place private free-marketeering (in this case, the right of insurance companies to make a buck or two or a couple billion banking on your medical needs) over community health, and are entirely without conscience in doing so. The odious stink of money in the kill-granny media storm should turn any good Christian’s stomach; that Palin and Terry and their ilk wallow in it should be a good sign about the green face of the god that they worship most: capitalism.

That is not to say that there is no solid grounds on which to object to the Obama health care plan; there are many, on which I shall not even get started (ok, wait, I will: lack of a single payer plan, for one). But this red herring of death panels and kill granny tells far more about the media figures that promulgate the myth the health care plan itself. And it is not a pretty picture it paints.

Cross-posted from my infrequently-updated blog, Loose Chicks Sink Ships.