In the past two weeks, The Washington Post published two op-ed columns on the end-of-life provision in the House's health reform bill, one by Post editorial writer Charles Lane and the other by house conservative Charles Krauthammer.
The proposal would permit Medicare to pay doctors for discussing issues of death and dying with their patients. But the two columns, each built on fundamental misunderstandings of the legal, ethical, and medical issues that surround those nearing death, do a profound disservice to those who face painful end-of-life decisions.
In his Aug. 8 column ("Undue Influence: The House Bill Skews End-of-Life Counsel") Lane conjures theoretical government-approved scripts where doctors manipulate unwilling patients into premature death. On August 21, Krauthammer echoed the message in a column shamelessly headlined "The Truth about Death Counseling." Both were filled with errors of fact, logic, and judgment.
The documents this bill encourages doctors to discuss with their patients--living wills and other advance directives-- are in no way limited to requests to "pull the plug." Living wills may contain any instructions a patient chooses. One may write an advance directive requesting that absolutely every possible measure be taken to prolong life. You can use a living will to request a feeding tube or a ventilator, just as you'd use it to ask that no extraordinary measures be taken to prolong your life. There is not a syllable in the House bill that in any way changes this.
Lane suggests that doctors will scramble to hold end-of-life consultations once they are compensated for them. I only wish. The real problem is that too few doctors feel comfortable discussing terminal illness with their patients. It is hard to believe that for an extra few bucks, doctors will suddenly leap at the chance.
Similarly, he implies that enrolling in hospice is a way to accelerate death. Nothing could be more wrong. Indeed, extensive research suggests that many hospice patients live at least as long as those suffering similar illnesses but receiving "standard" medical care. Once enrolled in hospice, a patient's overall health often improves, since their pain is better managed, and they are more likely to eat and drink appropriately, take the correct medications, and receive assistance from social workers, chaplains, and volunteers.
Krauthammer's argument is even more curious. A physician himself, he writes that making your end-of-life wishes known at a relatively early age is foolish because "the relevant question is what you desire when facing death not what you felt sometime in the past when you were hale and hearty." His implication: Wait until you are about to die, then say what care you want.
The problem, as Krauthammer well knows, is that many of us don't get such efficient notice. We may suffer a severe traumatic brain injury in an auto accident at 25. Many of us will slide into dementia, or suffer a sudden debilitating stroke. It may not be possible to make your wishes known as you near death. That is exactly the point of advance directives.
But my biggest concern about these pieces is Lane's suggestion that ignorance in the face of death is better than knowledge. As consumers, we demand full transparency. We spend hours comparing prices and product reviews on the Web. Yet, when it comes to terminal illness, some argue that learning about our options is somehow dangerous. The libertarian in many of us worships at the god of choice. Yet choice without good information is no choice at all. Especially when it comes to matters of life and death. Family, clergy, and lawyers are important resources. All this bill says it that doctors are too.
Interestingly, when given both information and choice, people's decisions may surprise the critics of the House bill. As I mentioned in an earlier post, euthanasia has been legal in the Netherlands for a quarter century. But, when patients discuss end-of-life options with doctors and family members, they rarely choose suicide. It may, in fact, be the very act of talking out these options that discourages euthanasia.
By contrast, consider the following all-too-common event I witnessed. In the middle of the night, a 93-year-old woman suffering from Stage IV lung cancer and congestive heart failure is admitted to an American hospital's Intensive Care Unit with severe breathing problems.
Once she is stabilized, a doctor, nurse, and social worker gently tell her that she is extremely ill and faces two choices. The staff can make her as comfortable as possible but take no extraordinary measures to keep her alive. In that case, she was told, she would die quietly within a day or two. Alternately, she could choose to be hooked up to a ventilator, a machine that would pump oxygen through her body when her heart and lungs no longer could. The doctors described what life on a ventilator would be like (pretty awful) and told her that, with the machine, she might live another month or two.
What, they asked, did she want to do?
The House bill is a modest attempt to encourage people to have that conversation with their doctors long before that awful moment. For the life of me, I can't understand why anyone would be opposed to that. Or why The Post persists in using its op-ed page to mislead people on this critical issue.