Monday, September 21, 2009

Death Panels and all that

Like Mike Doonesbury this morning, I had thought all the Death Panel furor was behind us. But if Gary Trudeau thinks it's still a current topic, and Newsweek gives it featured coverage (The Case for Killing Granny, Rethinking end-of-life care, Sept. 21, pages 36-40 and page 8), it may be useful to review it one more time for those gullible enough to believe that we old-timers are about to be shut out of the system and left to die. That's deliberate nonsense. The facts are:
Living wills (or advance medical directives) have been around for years. My own was first notarized in June 1997, and I update it as "still valid" and sign it every year or two to show that my mind hasn't changed. I make sure my own doctor and any hospital I go to has a copy.
The reason doctors and hospitals advise people to do this is so that the your personal desires are on record even if you are later found unconscious, or are unable to communicate, or have relatives telling the medical attendants to do this or do that regardless of your own stated wishes.
You may state that you want everything done to keep you alive, or want Hospice care, or want to let nature takes course, or any degree of treatment in between. It's up to you. But unless your desires are recorded while you are still conscious and of sound mind, the doctor or hospital will have nothing to go on.
My own advance directive says, in part, "If I am disabled by [for example] stroke, dementia, or cancer, I do not wish my life prolonged artificially. If there is no reasonable chance of recovery or fully conscious existence, then let my dying process take its natural course without tube or IV feeding, radical surgery, extended use of a respirator or other resuscitation measures. Relief of pain and/or routine nursing care are OK. I do not want my medical care to threaten bankruptcy of my family and heirs.
"In particular, I do not want attorneys, judges, doctors, or ethics committees quibbling about my intent or wish. What I want is to go to my Maker when my time comes, with what measure of human dignity is possible."

The difference between a "Death Panel" and a Living Will is who makes the decision - a nameless bureaucrat, or you yourself?

As a doctor, I have seen people kept alive for a few extra days while they are dying of incurable, painful cancer or other disease, and their medical costs keep building up to loss of home and all the family's funds, only to prolong the pain or keep the heart beating, but with no useful outcome. But without instructions to the contrary, doctors do what they can to keep a person alive.
President Obama's Health Plan encourages doctors to counsel patients on how to make their wishes known. It's still a matter between only you and your doctor.

Wednesday, September 9, 2009

The President's Medical Plan Speech

I listened carefully to the President's address this evening, both as a retired doctor and as a senior citizen now living on a moderate fixed income. In general, it was well received; even the Republicans stood and applauded at several points.
He laid out the main actions and the reasons. Skeptics on both sides will say "not enough detail", but he emphasized the results he was seeking: against the law for insurance companies to refuse coverage of pre-existing conditions, against the law to drop insurance or raise the premium when a client's treatment is too expensive; everyone can keep their present policy if they like it, and their present doctor too. There will always be details to work out, and I expect modifications will be necessary after the plan has been in operation a few months or years.
Most people's first reaction will probably be "How can the nation pay for all the extra care when the 45 million uninsured get coverage?" But the fact is, these 45 million are already here, already getting care, in the Emergency Room—the only place required to take care of them—but an ER visit is ten times the cost of a doctor's office visit.
You don't believe that cost ratio? Google the comparative prices. What I found was $170 for the average first office call, and from $1,000 to $2,000 for an average ER visit, tests, and treatment included in both. Sometimes the severity of the case demands ER care, but moving the headaches, colds, and minor injuries into the doctor's office can save billions per year.
Opponents like to quote the figure one trillion dollars over the next ten years as the increased cost of the President's plan, but that's 100 billion per year. Savings from over-testing, over treating, and over use of the ER could easily cover that.
My first reaction to Congressman Boustainy's rebuttal was that I thought the President covered all those points, but then I realized Mr. Boustainy would have had to write his speech before he heard the President, who had finished only about five minutes earlier. The only differences I can see are the Republican wish to make insurance purchasable across state lines (which I like) and their desire to "Press the reset button and start over" which would send us back to square one.
The biggest savings in present medical care I see are (1) tort reform with resultant easing of over-testing and over-treatment, and (2) lifting the ban on competitive bidding on pharmaceutical contracts. Downsizing the "donut hole" is useless if drug prices get upsized the next day.
Overall an excellent speech, and substantive. More later.