Facing death rationally

Published in the Tampa Tribune, January 3, 2011

Sarah Palin made headlines last year when she accused President Obama of planning "death panels" for the elderly in his quest to curb the cost of health care. The ensuing political uproar for "pulling the plug on grandma" led Congress to drop the plan for end-of-life counseling in the final health care bill.

But such counseling would be allowed under a new Medicare rule. Starting Jan. 1, "voluntary advanced care planning," including talking about advance directives compelling doctors and families to forgo certain medical procedures, can become part of a patient's annual physical examination and will be paid for by Medicare.

Critics say it is another attempt to limit health care options for the elderly and will lead inevitably to rationing. 

But aside from the quiet -- even sly -- way the rule was approved and how supportive members of Congress tried to keep it under raps, this is a sensible regulation. It offers not end of life advocacy, but an opportunity for information -- a moment between doctor and patient to talk about the care the patient would want as he or she faces death.

And with the cost of health care ever rising, Americans need to have an uncomfortable conversation about death. President Obama should lead that conversation, no matter how emotional it becomes.

No one likes to think about it, but death comes to all of us eventually, and part of that reality is understanding that extending life--but not the quality of life--a matter of days or weeks through expensive medical interventions may not be worth it, especially if the patient doesn't want it.

The fact is the chronically ill and those nearing death account for potentially 80 percent of the total health care bill. So just as estate planners advise clients to write living wills and sign advance directives, doctors and nurses are similarly equipped to advise patients about the options they face. The patient, then, makes the decision.

In 1984, then-Colorado Gov. Richard Lamm made his controversial remarks about the elderly having a "duty to die." He explained at the time he wasn't talking about beating up on elders, but even then he predicted the cost of health care would rise to unprecedented levels. He hasn't changed his mind.

"We treat death as if it were optional," Lamm said during a speech at DePauw University. "People talk about the right to die, as if we have the right to refuse to die. Once we stop treating death as an enemy and recognize it as an inevitability, we can save massive resources. We must look rationally at the phenomenal amount of resources we spend on the last few weeks of peoples' lives to only prolong suffering.

"We are not wealthy enough to base our health care system on the assumption that we can give everything that genius has invented to all of the people out there. I believe clearly that the United States must ration medicine."

It's not a pleasant nor popular concept, but let's not forget that rationing already takes place every time an insurance company, Medicare or Medicaid refuses to pay for certain procedures.

Lamm has a valid point. None of us can escape death, and when faced with the inevitable, patients must begin considering whether the cost of treatment, both fiscally and physically, is worth it.