Conservatives have been pushing the meme that the healthcare plan supported by the president will require elderly Americans to meet with government representatives to discuss how they wish to die. Taking it further, Republican extremists like Rush Limbaugh and Sean Hannity and even some in Congress have translated this to mean that the government is going to euthanize old people.
What the health plan authorizes is coverage of end-of-life (referred to as "Advance Care Planning") consultations with physicians for those who elect to have them.
These conversations between a patient and his/her physician or healthcare team involve the physician giving the terminal patient a realistic outlook on his/her prognosis and outlining the options that are available, which might include last ditch medical treatments or hospice care.
From the Think Progress Wonk Room, here are examples of the conservative effort to scare our nation's elderly:
Laura Ingraham: Old people could be visited in their homes and essentially be told " all right, sweetie, you’ve had a good life...I don’t want a government bureaucrat telling him what kind of treatment he should consider to be a good citizen. That’s frightening.
Rep. Virginia Foxx (R-NC): [Americans will be] put to death by their government.
Rush Limbaugh: The bureaucratic going to make the decisions. You aren’t. And it’s in the House bill. Once you reach, I don’t know what the age is, every five years, it’s in the sixties, every five years some counselor shows up.
Sean Hannity: In other words, they would mandate that those who get government care literally could be pushed to refuse care.
For decades, oncology researchers have studied the effect of end-of-life discussions on patients with cancer.
In the 1950s and 190s, it was standard practice for physicians not to tell terminally ill patients their prognosis because it might make them depressed.
Although hiding patients' condition from them is no longer recommended practice, it is still common for physicians to be less than up front with terminal patients about their condition:
From a 2001 study:
In 23 percent of the cases, physicians said they would not give the patient a precise prognosis, even if asked. In only 37 percent of cases would the doctor communicate his best guess at probable survival. In 40 percent of the cases, physicians said they would intentionally provide an inaccurate estimate, usually suggesting that the patient would live much longer than the doctor really expected.
A more recent survey found that things are not much better than they were in 2001; while physicians now routinely tell patients they are going to die, the majority do not tell patients when:
Although 98% said their usual practice is to tell terminally ill patients that they will die, 48% specifically described communicating terminal prognoses to patients only when specific preferences for prognosis information were expressed. Forty-three percent said they always or usually communicate a medical estimate of time as to when death is likely to occur, and 57% reported sometimes, rarely, or never giving a time frame.
In January 2008, Bishop Eli Sgreccia, president of the Pontifical Academy for Life, had harsh words for physicians who are less than honest with their terminally ill patients and suggested that end-of-life discussions are good for patients' spiritual wellbeing:
Bishop Eli Sgreccia...criticized doctors for engaging in a "conspiracy of silence" concerning informing terminally ill patients that they are dying, Zenit.org reported today.
[He] insisted that such silence "hinders the patient from preparing himself for detachment and death."
"It is necessary that the clinical truth be positively articulated with anthropological truths, with the global meaning of life," he said. "The dying contribute maturity and value even to those who are at their side. They become teachers of life. We take with us all the acts of love that we have been given. Our spiritual life does not disappear but flourishes; it is enriched in eternity."
How do terminal patients feel about end-of-life discussions? A team of US researchers interviewed 608 patients with advanced cancer and fewer than 6 months to live to find out.
Overall, 79.3% "want[ed] to know life expectancy."
One of the most surprising results of this study was the fact that only 50.5% believed themselves to be terminally ill. Despite their desire to know their prognosis, only 1/3 of the patients had "end-of-life" discussions with their physicians.
Overall, 26% of the 608 patients said they valued life extension over comfort and 20% wanted to do everything possible to extend their lives.
The investigators matched the 124 patients who had end-of-life conversations with 124 patients who did not so that both groups had roughly the same demographics (age, race, sex, marital status, religion), the same type of cancer, and the same health status.
They found that both groups were very similar in how they felt about end-of-life care, with 19.4% in each group wanting "everything possible to extend life for a few days" and slightly more in the group who had end-of-life conversations preferring not to die in intensive care (42% versus 38%).
After the patients died, formal caregivers (doctors/nurses) and informal caregivers (friends/spouses) were questioned on the patients' "overall quality" of life in the final week before death.
Patients who reported EOL conversations with their physicians at baseline were less likely to undergo mechanical ventilator use or resuscitation or to be admitted to or die in an ICU in the final week of life. They were more likely to receive outpatient hospice care and be referred to hospice earlier. Patients who reported EOL discussions had less physical distress in the last week of life than those who did not, but the 2 groups did not differ in psychological distress, quality of death, or survival time.
Medical costs in the last week for the people who had end-of-life conversations were $1876 compared with $2917 for patients who did not--a 36% decrease.
Despite the extra costs, the patients who had more treatment did not live longer and actually had more physical distress in the last week of life. They were not happier, and they were more likely to die in the ICU--a place where many patients said they did not want to die.
A more recent study that involved only patients with metastasized lung cancer (who have fewer than 2 years to live) found that only half of them discussed hospice care with their physician in the first several months after diagnosis. Of the patients who died within 2 months of being interviewed, only 53% had conversations on hospice care with their medical provider.
End-of-life conversations help patients with terminal disease; they do not harm them:
Researchers interviewed 332 pairs of dying patients -- all of whom had advanced cancer -- and their informal caregivers. The median time from enrolment in the study to death was 4.4 months.
At the start of the study, 37 percent of the patients said they'd had end-of-life discussions with their doctor. Contrary to expectations, these talks did not increase the rates of depression or worry.
And those patients who did have such talks with their physician had lower rates of ventilation (1.6 percent versus 11 percent); resuscitation (0.8 percent versus 6.7 percent) and admission to the intensive care unit (4.1 percent versus 12.4 percent). These patients also enrolled in a hospice earlier; longer hospice stays were associated with better quality of life, while aggressive medical care had the opposite effect, the study found.
President Obama responded to critics on this provision at a recent meeting with the AARP, whose spokesperson noted that Medicare does not currently cover end-of-life conversations between patient and physician:
Obama made clear the intent was to "simply make sure that you've got more information, and that Medicare will pay for it." In his response, Obama stated, "But understand what the intent is. The intent here is to simply make sure that you've got more information, and that Medicare will pay for it." Obama later added: "So, if Medicare is saying you have the option of consulting with somebody about hospice care, and we will reimburse it, that's putting more power, more choice in the hands of the American people, and it strikes me that that's a sensible thing to do."
CONCLUSIONS:
- Most patients with terminal illness want to talk with their physicians about their prognosis and end-of-life care.
- Conversations between terminal patients and physicians about advance planning issues:
a. Reduce healthcare costs
b. Reduce the patient's physical distress in the last week of life
c. Decrease the likelihood that the patient will die in ICU
d. Result in better quality of life
- Having end-of-life conversations does not:
a. Hasten the patient's death
b. Cause mental distress
Many patients with no hope of recovery undergo painful or unpleasant treatments because they do not realize how close death lies.
My boyfriend's grandmother developed leukemia in her 70s. She underwent multiple rounds of chemotherapy. Her physician said she could have more chemotherapy but that it was unlikely it would extend her life and it would make her sick. He told her if she went off the chemotherapy, however, she would likely have better quality of life for the last 1 to 2 months of her life.
His grandmother decided to forego the chemotherapy, and for the last 2 months of life, she had more energy than she'd shown in awhile and was more engaged in the activities she loved doing and spent more time with her family. Then, she suddenly became very ill and died two days later.
This was her choice, and all her family members agreed after her death that it was the right one. Without such end-of-life discussions, patients do not know what all the options are and accept treatments that make them ill but offer no benefit. Terminal patients deserve to know all their options, and it is almost criminal for conservatives to orchestrate a fearmongering campaign to scare our nations' vulnerable elderly into opposing a public health care option, by trying to spin a provision to cover patients' end-of-life conversations with their physicians as a plot to kill the elderly.
Perhaps what conservatives really oppose is giving people the option to make informed choices about death; they made it clear with the Terry Schiavo case that they do not want people to have the option to forego measures that wring the very last second out of life, regardless of the quality of that life.
**UPDATE**
For those who want more information and another link, a helpful Kos poster provided a link to a news release on some of the proposals mentioning this topic at Congressman Earl Blumenauer's Website.