Death Panels and Advanced Care Planning
A recent article in the Journal of the American Medical Association, JAMA, discusses the need for effective public health announcements to encourage people to explain their end of life wishes and their values, goals and preferences. It has been well established that physicians are reluctant to discuss end of life choices with their patients and the norm has been to put it off until the patient is in advanced terminal disease when it is, indeed, more difficult to discuss. Studies have also shown that the majority of patients said they would choose to forego futile care but few are presented with this option.
The failure to have this conversation at an appropriate time may end up having the patient frightened and confused and unable to have a meaningful discussion after being fully and intelligently informed about the risks of further treatment and the progression of their illness and the physicians frightened to raise the subject late in the game and give their patient the impression that he or she is being giving up on.
Legislation was proposed in recent Health Reform bills requiring physicians to “offer” to discuss advanced health care planning was met with chants of “Death Panels” in the media partly as a result of prior vice presidential candidate Sarah Palin’s claim’s of “Death Panels.” She based this on President Obama’s choice for Chair of the NIH Department of Bioethics and concurrent, and seeming conflicting position, as White House Office of Management and Budget - Ezekiel Emanuel. Emanuel has forthrightly stated that young children and elderly should not receive basic health care, not only in times of epidemics or pandemics but in general as it applies to scarce medical (economic) resources. This was easy fodder for Palin’s accusations of death panels in proposed health reform legislation.
In the JAMA article Drs. Terri Fried and Margaret Drickamer; argue for public health announcements to urge advance care planning.
“Delivering these messages will require broad outreach,such as through the use of public service announcements.…Although the process of personal participation in ACP should take place on the clinical level with an individualized interaction between patient and clinician, the process of encouraging participation in ACP must occur on the population level
This will be difficult especially t this time because of recent increased mistrust of government proposals. In my view the trust exists between physicians and their patients and thus the answer lies in vigorous efforts to educate medical students and physicians in the need for, and the methods of discussing advanced care planning at an appropriate time.
It's amazing how little reading comprehension you seem to possess for a self-proclaimed "blogger". Dr. Emanual's report you allude to was written by TWO OTHER DOCTORS as well, and explains the ethics behind deciding how to use limited resources on specific populations. Are you so naive as to assume that every single need can always be met in every circumstance? And he NEVER stated anything like "young children and elderly should not receive basic health care", THAT is a great example of conservative ignorance run rampant. CONGRATS.
The “two other doctors” that you refer to in your comment are Govind Prasad, a PhD student and law school student, who hopes to get his PhD and law degree in 2014, and Alan Wertheimer, PhD, a philosopher, who works at the National Institute under Dr. Emanuel. So, any implication in your comment that these “two other doctors” are medical physicians, who deal, or who have dealt, with the patients is misplaced.
Emanuel and “authors” also deal with what they label the “complete lives system.” This “system” makes decisions of allocation not based on traditional ideas of triage but rather scale the receipt of medical care based on their criteria of the patient’s productive value to society, based upon the investment society has made on their behalf as well as their stage of personality development.
For example:
“Adolescents have received substantial education and parental care, investments that will be wasted without a complete life. Infants, by contrast, have not yet received these investments. Similarly adolescence brings with it a developed personality capable of forming and valuing long-term plans whose fulfillment requires a complete life.”
They distinguish between “public health emergencies.”
“When implemented, the Complete Lives System produces a priority curve on which individuals aged between roughly 15 and 40 years get the most substantial chance (to receive medical care), whereas the youngest and oldest people get chances that are attenuated.”
Dr. Emanuel favors gauging the receipt of medical care predicated upon his philosophy of the “continuation of the polity”:
“– those that ensure healthy future generations, ensure development of practical reasoning skills, and ensure full and active participation by citizens in public deliberations – are to be socially guaranteed as basic. Covering services provided to individuals who are irreversibly prevented from being or becoming participating citizens are not basic and should not be guaranteed. An obvious example is not guaranteeing health services to the patient’s with dementia.” (Emanuel article in The Hastings Report 1996). (Emphasis mine).
Accordingly, Dr. Emanuel does state that the elderly and very young youth should not be guaranteed basic medical care in his “complete lives system.”
This post that you are referencing “Death Panels and Advanced Care Planning” discussed a Journal of the American Medical Association which urged physicians to have discussions of end of life care. This would be one way to reduce spending on futile medical care. Emanuel’s statements made unfortunate fodder for the vituperative ravings of Sarah Palin who waved a flag of fear about “death panels.”
Emanuel provides a good discussion of the problems in defining basic medical care in his article on “Where Civic Republicanism and Deliberative Democracy Meet.” He quotes Amy Gutmann: “The remaining question of establishing a precise level of priorities among healthcare and other goods is appropriately left to democratic decision making.”
This argument is based on majority rule, which Emanuel describes as “extremely dangerous” suggesting that efforts to ensure universal access will always flounder on the fear that guaranteeing any healthcare to all citizens means guaranteeing all available services.”
Emanuel agrees with Dan Callahan in focusing on what the “goals of medicine” are. This presumes that medicine has a “goal.” – and if so, who defines it. If we define the goals of medicine as that which satisfies the expectations of all consumers of medicine, we leave ourselves in an impossible corner. If we define the goal of medical care to provide the care of careful and prudent physicians who apply their learning and skill and utilizing the growing technological advances - then, perhaps, that will be more in line with what the public should expect.
That care, however, requires appropriate guidance from physicians to their patients as to what is the proper scope of necessary medical care. For this to occur there needs to be legitimate communication between doctor and patient.