End-of-Life Choice, Palliative Care and Counseling

Posts Taggedhealthcare

Overtreatment Is Taking a Harmful Toll

By Tara Parker-Pope
The New York Times
August 27, 2012

When it comes to medical care, many patients and doctors believe more is better.

But an epidemic of overtreatment — too many scans, too many blood tests, too many procedures — is costing the nation’s health care system at least $210 billion a year, according to the Institute of Medicine, and taking a human toll in pain, emotional suffering, severe complications and even death.

“What people are not realizing is that sometimes the test poses harm,” said Shannon Brownlee, acting director of the health policy program at the New America Foundation and the author of “Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer.”

“Sometimes the test leads you down a path, a therapeutic cascade, where you start to tumble downstream to more and more testing, and more and more invasive testing, and possibly even treatment for things that should be left well enough alone.” More

Putting Patients First

Patient care and healthcare should be synonymous — right?

At Compassion & Choices, we believe that healthcare should be all about patient care, especially at the end of life. But too often, policy debates on care at life’s end focus on everything but the patient.

How is it possible to leave patients behind?

Just look at the healthcare insurance reform debate. Right now, as administrators in Washington, D.C., hammer out the new law’s implementation details, insurance industry executives and lobbyists push to make sure their interests come first. That’s why Congress focuses so much attention on who gets reimbursed for what and how, which federal agency oversees which part of the act, and what each section of the bill means for the industry.

Few people and organizations ask, “How can we make sure patients get what they want and need?” And even fewer advocates work to make sure that patients’ wishes are honored at the end of life.

Time and again, we see the focus shift from patients to process when care at the end of life is legislated and regulated.

Watch this short video to see what I mean. It’s from “Living Well at the End of Life,” a National Journal panel discussion I recently joined in Washington.

Compassion & Choices has renewed its commitment to work for healthcare policy that is centered on patients, not process. I’m thrilled to announce that we now have a Washington, D.C., policy office to amplify our voices in the Capital — the voices of our supporters, patients and families.

Staff in our new Washington office will track legislation as it develops and educate Congress and regulators about end-of-life issues. Our priorities will be front and center during the debates that matter most. And we’ll make sure that patients aren’t forgotten when legislators discuss healthcare at the end of life.

This is a major step forward for Compassion & Choices and our movement. The debate over our issues will never be the same and I am very excited about this milestone.

Sierra Vista Chooses Community Over Catholicism

Last week Sierra Vista Hospital, in rural Southeast Arizona, abandoned its affiliation with the Catholic Carondelet Health Systems. One year into a 2-year trial period, reality apparently hit home. The hospital board could no longer ignore daily picketing by concerned citizens, growing discontent of physicians barred from delivering high quality medical care and mounting evidence that strict doctrinal enforcement undermines a community’s trust in its medical provider. An informative PBS story (see the bottom of this post for the video) 4 days prior may have influenced board members as well.

Compassion & Choices supporters were especially concerned that end-of-life wishes be heeded and honored. Thus, we enthusiastically join Cochise Citizens for Patient Choice in celebrating this victory for quality care and patient self-determination. I hope this signals the start of a trend among hospitals to avoid mergers binding them to religious doctrine.

Over the last century Catholic institutions grew, prospered and assumed an ever greater market share in the healthcare industry. Today more than 600 Catholic hospitals deliver care to 1 in 6 patients in the United States each year. Since 1971 these hospitals have followed written doctrinal direction from the National Conference of Catholic Bishops, which in turn follows the Vatican.

A publication called Ethical and Religious Directives for Catholic Healthcare (ERD) lays it all out. Until recently hospitals could interpret the ERD according to their own conscience, and they usually found ways to meet the needs and expectations of their communities. But the local bishop is final decision-maker and an increasingly conservative hierarchy is flexing its doctrinal muscle across the nation. This leaves hospitals with a stark choice: buckle under pressure from Catholic authority or break the shackles of Vatican oversight.

The tension plays out in different ways.

Last May Bishop Olmstead of Phoenix terminated the church’s 116-year relationship with St. Joseph’s Hospital for terminating a woman’s pregnancy to save her life. The hospital, its parent corporation, Catholic Healthcare West, and the Catholic Health Association all backed the decision of Sister Margaret McBride, who led the hospital’s ethics committee. Now she is excommunicated, Mass no longer occurs in the hospital chapel, and the community knows its hospital will not allow Bishop Olmstead to obstruct a life-saving procedure.

Similarly, St. Charles hospital in Bend, Oregon, refused to accede to demands from Bishop Robert Vasa to stop performing tubal ligations for women seeking to limit their pregnancies. Founded by nuns 92 years ago, St. Charles is no longer a Catholic health center and delivers about 250 tubal ligation services per year.

But in Texas, Bishop Alvara Carrada stopped tubal ligations at St. Michael’s and Trinity Mother Frances Hospital in 2009. Now women who give birth there by caesarean section must endure the risks and inconvenience of a second surgery, at a different facility, to have their tubes tied. Exposing patients to unnecessary surgical risk falls below the standard of care in every community.

For Compassion & Choices, the chief hazard of the ERDs is the stipulation that advance directives are valid so long as their instruction does not conflict with Catholic teaching. Since the local bishop interprets and enforces Catholic teaching, it’s uncertain how a person’s wishes might be viewed should the need arise. Compassion & Choices offers a Dementia Provision as an advance directive addendum, and it seems almost certain to run afoul of recent Catholic teaching on tube feeding.

Catholic dogma and community medical expectations are on a collision course. Hospitals serving diverse communities cannot shoulder the weight of strict ERD enforcement as America’s population ages and vests itself in end-of-life choice and control, as new technologies to treat infertility emerge and as therapies developed with embryonic stem cell cultures come on line.

To me, the most striking aspect of these events is how totally tone deaf Catholic leaders are to growing disenchantment with their edicts. They care not at all that Catholic hospitals deliver healthcare to Lutherans, Presbyterians, Jews, Muslims, Buddhists and Atheists as well as Catholics. They demand Catholic doctrinal adherence from all.

Catholicism’s place in American society has changed dramatically over the past twenty-five years. The hierarchy has exaggerated its political power by extracting obedience from Catholic elected officials and controlling their votes. But the criminal cover-ups and harboring of public menaces have decimated its moral authority.

The PBS story features Bishop Weinandy, executive director for the Secretariat of Doctrine, and Richard Dorflinger, Associate Director, Secretariat of Pro-Life Activities, both at the US Conference of Catholic Bishops. Weinandy defends Bishop Olmstead’s preference for a woman’s death over a pregnancy termination with this: “If you directly said the mother could not live unless we aborted the child then that would be contrary to Gospel values and the teaching of the church.”

That may be a reason enough for Weinandy and Dorflinger, but it shocks the conscience of most Americans and conflicts with their expectations for responsible health care. The Washington Post offers an example from the ranks of Catholic moral theologians. It cites Rev. James Bretzke of Boston College, “who supports the directives but said he might now hesitate if a female relative sought some care at a Catholic hospital.”

When Reverend Bretzke’s hesitation spreads to a critical mass of alert healthcare consumers, as it did in Sierra Vista, I predict Catholic healthcare institutions will do the right thing. In increasing numbers they will reject their assigned role as enforcer of Vatican doctrinal ideology, and serve their communities instead. If not, purchasers of healthcare — patients, employers and insurance carriers — will shun them in the marketplace, preferring providers unencumbered by obedience to dogma that harms patients.

Watch the full PBS episode. See more Religion & Ethics NewsWeekly.

Healthcare Reform and the Price of Torture

In this country we usually torture people before we allow them to die of whatever is killing them — cancer, emphysema, the multi-organ failure of diabetes or heart disease.

Like the episodes of military torture from which our nation is recovering, medical torture reflects a culture and a set of assumptions. Reform is not about just identifying a few “bad actors” and weeding them out. Our medical-industrial complex follows a cultural paradigm to do as many things to people near death as is medically possible. Our broken system rewards that paradigm with fee-for-service payments.

Standard routine is to torture those in the process of dying by inflicting upon them a host of toxic chemicals, invasive machinery and painful surgeries. It’s the American way of dying — agonized and prolonged imprisonment in an intensive care unit, pinned down under a maze of tubes and machines, enduring one medical procedure after another, unable to hold or be held by loved ones.

It’s an American tragedy, really. Every player in the medical-industrial complex is in on it.

Oncologists entice their dying patients into bearing one more, experimental round of chemotherapy almost certain to intensify toxic symptoms without extending life. Surgeons repair the fractures and amputate the limbs of people clearly only a few weeks from death. The newest medical specialists, “hospital intensivists” deftly thread tubes into failing hearts and attach ventilators to decrepit lungs. Much of the pain they inflict does nothing but monitor the chemistry and pressures of internal crevices and gather the information necessary to thwart a body trying to shut itself down.

Hospitals build bigger spaces and place ever more complicated technology at the fingertips of aggressive specialists. Behind the scenes pharmaceutical companies and medical equipment manufacturers produce the instruments, devices and chemicals of torture. And insurance companies pay by the procedure, feeding the bloated growth of an industry.

What is the price of all this? At Compassion & Choices we focus on the human costs. We expose how much end-of-life care merely prolongs a miserable dying process. We work to break the pattern of expectations and behaviors that rob people of dignity, peace and comfort at the end of life. We work for changes in law and policy to help those who reject futile heroics to die at home, with hospice care. We show how families can face loss and sadness together, close at the bedside of their dying loved one. We know the greatest price of end-of-life torture is the human cost.

But no one can ignore the fiscal cost of a system run amok. We cannot reform our healthcare system without addressing the fact that it is driven by profits. Medicare, as a public system, is the only source of comprehensive data on expenditures. Approximately 5% of Medicare beneficiaries die each year and in 2006 30% of the Medicare expenses were for their end-of-life care. 10% of all Medicare costs occur in the final 30 days of life. Most of the money goes toward intensive care and treatments intended to extend life, like feeding tubes and mechanical ventilators.

Here’s the irony. These exorbitantly expensive tortures do not even serve their goal. The authoritative study on this came out this March. Its conclusion:

Analysis demonstrated that higher medical costs in the final week of life were associated with more physical distress in the last week of life and with worse overall quality of death as reported by the caregiver. There was no survival difference associated with higher health care expenditures at the end of life.

How do we reform this profit-centered industry and remake it into a patient-centered one? How do we deliver the comfort care and supportive services people truly want and need at the end of life?

Like all cultural shifts, it must start with the people. The people — you — deserve to be able to choose a healthcare plan driven by what patients need, not what profit demands. You deserve a system that pays your doctor to talk with you about peaceful endings when death is imminent. One that pays for hospice care in the home as readily as it pays for intensive care in the hospital.

Raise your voice. Make your views known. Talk to your own doctor and to your family. Take action with calls to members of Congress and letters to local news outlets. Ask for healthcare reform to include payment for your doctor to talk to you about your end-of-life wishes. We make it easy for you here. Tell them you reject torture at the end of life for yourself and you resent the needless torture of others. Joining together, let’s change the American way of dying.