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Bring On the Death Panels

One of the things I hear patients talk about when they mention Obamacare is the “death panels”..as they sneer these words they look to me for some knowing and indignant nod of agreement at this latest oppressive government outrage.

Unfortunately, they are again disappointed in me because I stop them in their tracks when I intone…”We need the death panels…the death panels are a very good idea…I’m all about the death panels !”
The term “death panel” conjure up some white coated tribunal of indifferent doctors ..hired guns as it were …strangers who will chose who lives and who dies. Which grandma still has a little life in her yet. Whom to refuse fourth line chemotherapy. Which sick little baby will be tossed off the side of the mountain as the ancient Spartans used to do with children who did not seem whole and well. Cruel, Arbitrary and Indifferent ! Who could be comfortable with those decisions?!
Swap out the word “independent” for “ indifferent “ and I am actually down with the plan. You will be as well once I have explained things from my standpoint. When you really think about it, and I don’t blame you if you haven’t been preoccupied with this subject… who better than to decide on your medical fate than a professional medical team of independent experts. This isn’t about the death panel randomly picking out people at Destiny USA for harvesting like some grim reaper Halloween pageant. This whole issue is about what to do at the end of meaningful productive life. This is about not torturing Grandma during her final days despite the well meant desires of their family.This is not just about what makes economic sense. Frankly I think economics should not factor into the equation in any way shape or form at all but you can’t be ignorant of the financial issues. WNET news reports that “Medicare, the health insurance program for the elderly, spends nearly 30 percent of its budget on beneficiaries in their final year of life. Slightly more than half of Medicare dollars are spent on patients who die within two months.” That’s a staggering amount of money and sadly it’s usually poorly spent. Way too many grandmas spend their last few days on Earth in some oddly lit room full of strangers and stranger equipment…often tied up to the bed or some equipment , sedated lest they pull on their life support. One tube going in here and another tube coming out there Never well enough to have meaningful communication with their family. Dragging out the inevitable process from hours to days if you allow nature to take its course to weeks or even longer if “all measures are taken” to keep grammie going . I’m sorry but that’s just not right!Gustave_Doré_-_Death_on_the_Pale_Horse_(1865)
Although I am sure Obamacare’s underlying concerns are financial I view the Death Panels from a more moralistic standpoint. Sometimes enough is enough. Just because you can artificially prolong someone’s life doesn’t mean you should. My sister who is a doctor in Florida once approached my mother with consternation and although I wasn’t there I imagine a little indignation as well…”Mom” she decried .” Do you know that your health care proxy…your first born son ….Bud..(meaning me) ….has told us that if you were demented and in a nursing home and had pneumonia ….he would withhold antibiotics ..he would just let you die ! “ My mother responded ….”That’s precisely why HE is my proxy and YOU are not ! “ I know Momma wouldn’t want to be kept alive under those circumstances…and I have the conviction to honor HER wishes. Not impose my own.
That’s always one of my founding principles…do what the patient would want…not what I would do or what the family wants….What would the patient want had they still had the capacity to tell us? WWMW..What would Momma want ? That actually makes it easier for me. I feel better when I am honoring the known wishes of the patient. Having said that I also feel there is a place for an independent evaluation of the end of life situation.
There comes a time…and it’s almost always involving the hospital…when the question has to be raised ….Are we doing too much? Have we gone too far?.. I think there is a place for an independent panel to weigh in on this issue. If it’s obvious that we are dealing with a possible end of life issue I think we should call a “Code White” Although we can work out the details later it would be, I think, relatively easy to convene a panel of independent doctors who can evaluate the situation and the patient and weigh in on the appropriate use of advanced life support. Mind you these people would never have the last say in what happens to the patient but they would determine whether insurance of any kind should pay for the care.Clinicians_in_Intensive_Care_Unit
So I could envision this scenario…..Your mother has advanced dementia and hasn’t been able to say the names of her kids in years or live independently. She gets pneumonia and is hospitalized. She does poorly despite usual hydration and antibiotics…and the questions become….should she go to the ICU for closer monitoring?…should she be fed by a tube since she is not eating well? ….How many tests and procedures to put her through ? CODE WHITE …is called an within a day a panel of doctors would have reviewed the chart and examined the patient and would be able to weigh in as to what’s the most appropriate thing to do. At that point they would not say what could or could not be done but would say what would be covered by insurance. It’s OK to say “Keep Momma alive at all costs !” But it’s also OK for a panel of experts to say …”We feel that aggressive care is not appropriate but It’s fine if you want to proceed but it’s not going to be covered by insurance and its 5,000 dollars a day for the ICU and can we have 3 days stay in advance.?!” . Of course there is the risk that these oversight doctors will be incentivized to cut short care to reign in finances but what we have now is just as bad….No cost control whatsoever and even worse …no routine evaluation of the appropriateness of care. You rightly fear a government that will devalue lives but I see every day where we , from an understandable combination of love and regret and fear , put our loved ones through procedures that rob them of their dignity and deny them a comfortable reflective peaceful passing. We can do better…we must do better and the Death Panel conversation is a good place to start.If this article does nothing else but get you to make sure Momma has a Health Care Proxy and someone both knows what Momma wants but has the strength to carry out HER wishes then I have been of service…

Until next month…get well …stay well….

Dr. Barry