To save an individual or to not save an individual, this is the question at hand. Many uninformed Americans are up in arms over the notion of the government forcing the elderly Medicare patient to make an advanced directive. Healthcare reform as a whole has been a highly debated topic as it should be, but there are many aspects of the new healthcare reform bill that have their own energized debate. An advanced directive is one of them, but the debate should not prey upon people’s most basic fears.
Up until now the topic of advanced directives had taken a back seat in the news. Prior to the healthcare reform bill, the last time advanced directives had so much media attention was the Terri Schiavo case. Wikipedia defined the Terri Schiavo case as a seven-year long legal case that revolved around whether Terri Schiavo, diagnosed as being in a persistent vegetative state (PVS) for several years should be disconnected from life support. Fierce critics and avid supporters have all stated their opinions in one form or another.
The uninformed public is left to decide, who’s right and who’s wrong. I intend to explain each side, give real life examples, and educate my reader so they can decide for themselves. Does the public really understand what an Advanced Directive is? In my experience, many patients and families do not understand. Northwestern Memorial Hospital defined advance directives as, “legal documents with written instructions regarding your medical care wishes and preferences. A living will and a medical power of attorney are important documents within advance directives.
A living will describes your end-of-life wishes, whereas a power of attorney allows you to select a family member or friend, designated as an agent, as your medical decision maker. ” Advanced directives indicate one’s desire for such services such as analgesia (pain relief), antibiotics, hydration, feeding, and the use of ventilators or cardiopulmonary resuscitation. The term “Advanced Directives” has become increasingly more difficult for the public to understand recently due to the terminology being flung around, for example: death panel, physician assisted suicide, mercy killing, suicide, and euthanasia.
Sarah Palin is responsible for the “death panel” reference. On August 12, 2009, she posted on Facebook the following statement. “The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama’s death panel so his bureaucrats can decide, based on a subjective judgment of their level of productivity in society, whether they are worthy of health care. Such a system is downright evil. The idea made popular by Sarah Palin and New York’s former Attorney General Betsy McCaughey is that the government would make it mandatory for all Medicare recipients to undergo end-of-life counseling sessions “that will tell them how to end their life sooner”. These so-called “death panels” would essentially be a way for our government to decide who was worthy of receiving expensive medical care and the elderly and frail would be at the bottom of that list. These poor elderly and sick people would be “killed off” if our government had their way.
This claim was made by Betsy McCaughey on the Fred Thompson radio show on July 16th, 2009. This is a false claim, because a version of the bill included a provision to pay for end-of-life consultation during the patient’s initial visit (Welcome to Medicare visit) to the doctor as a newly enrolled Medicare participant, and every five years following that initial visit, or if a new diagnosis has been determined. These proposed consultations would not be mandatory and would be patient-led, meaning that patients get to choose their path of care, not the physician.
Patients may refuse without any penalty, but many will bow to white-coat authority, according to Charles Lane of The Washington Post. The doctor’s part in the consultations would be to present all available treatment options to the patient, including hospice and palliative care. These consultations are also meant to discuss the important task of planning ahead with advance directives or living wills – something adult patients of all ages should be considering. The intent is for the patient to have the opportunity to learn about end-of-life options and choose the treatment plan that suits their personal goals, beliefs, and peace of mind.
This program that the government has set up focuses on Medicare patients, but advanced directive forms are easily obtained for adults of any age. The previous provision required hospitals and nursing homes to help patients with Advanced Directives or living wills if patients requested them. Every state has a boiler plate Advance Directive form online; one may also be obtained through an attorney, or a physician. From a Palliative Care physicians’ standpoint, Dr. Ashok Choithani from St. Luke’s Medical Center reported to me during an interview that, “Many physicians today are reluctant to discuss end-of-life care.
They may fear that bringing up options to discontinue aggressive care or go with hospice care will be viewed as a failure on their part to “fix” the patient. Unfortunately, this sometimes means that patients continue to get care that is uncomfortable, sometimes dangerous, and possibly futile without ever knowing they have another choice. ” Modern medicine has become so good at keeping the terminally ill alive by treating complications of underlying disease that the inevitable process of dying has become harder and is often times prolonged unnecessarily.
Therein lies the conflict, and in comes the nurse’s role to advocate for their patients best interest. Who will be responsible for these consultations? With only fourteen hundred certified palliative care physicians in the country there is not enough man power to accept such a responsibility. Primary care physicians need to see a patient every fifteen minutes in order to make a living. Medicare only pays 10 cents on a dollar, so even though Medicare is willing to now reimburse physicians for their time spent many physicians that I have spoken with say that it just not worth their time.
According to Charles Lane of the Washington Post, “This provision in the health care reform bill would have helped facilitate important discussions between patients and their doctors so patients can make their wishes known. This would not have been our government’s way of rationing health care or limiting what care the frail and elderly are entitled to receive. ” It is not hard to imagine end of life care and health care decision making as one of the most gut wrenching and emotional decisions individuals and families have to make.
I have personally had the opportunity to play a role in numerous instances where a patient of mine had an advanced directive, and also on the opposite side where the patient had no directives and the family of the patient had to make all those gut wrenching medical decisions. Prior to any invasive medical procedure, hospital staff is required to ask the patient if they have an advance directive and if not they are asked if they would like to fill one out. Having an advance directive can make all the difference.
Here are two examples of patients where one had an advanced directive and the other did not. Patient number one did not have an advanced directive, and during her surgery she sustained a massive heart attack and a stroke. The physicians said that she’d never regain normal brain function and would be dependent on a ventilator and many IV medications. She had to be resuscitated later that same day, ribs were broken and more life sustaining medications were needed to be started in order to keep her alive.
The family was approached and wanted everything done for her, even though she would never wake up, walk, or live a productive life again. Now she’s dependent on a ventilator and a dialysis machine and a multitude of medications to keep her alive. Not once did the family think about what the patient would have wanted; they were only struggling with the thought of losing their mother. Now she assumes a continuous assault on the body, and the ability to lie in a bed dependent on machines until her body cannot take anymore and no amount of medical intervention will help her.
She has a prolonged and painful death. How horrible this scenario is to watch, not only for the family but for the medical staff caring for her. Patient number two had an advanced directive. He has end stage cancer and does not want any heroics or means to keep him alive. As his disease progresses and takes over his body he is made comfortable with pain medication and various other medications to help keep him from experiencing nausea and various unpleasant side effects from his disease. He enjoys the rest of his time with his loved ones, and dies a peaceful, quality, and painless death.
The family is happy that he is now no longer in pain and that he died the way he wanted to. They can now begin the grieving process. Had the family and physicians known what patient number one wanted, they could have had the option to proceed with all the heroics or let her die naturally and peacefully. The family would not have been left with the burden and guilt of these very tough choices and the outcomes that inevitably developed. Lane reports, that only about a third of Americans have a living will or advanced directives expressing their wishes for end of life treatment.
A study of 4. 7 million Medicare enrollees found that 30 to 35 percent of Medicare funds are spent on patients with chronic illnesses during the last two years of their lives (The Dartmouth Atlas Project, 2006). These costs represent a sizable opportunity for savings, particularly if monies are being spent on procedures and treatments that do not comply with patient wishes, reports Fay Rozovsky, author of Consent to Treatment: A Practical Guide.
Recently The Los Angeles Times reported a study of 3,746 deaths; researchers found that 42. % of patients had faced treatment decisions near the end of their lives, but that more than 70% of those people had lacked the ability to make choices because of their mental or physical health. Among that same group, the majority — 67. 6% — had advance directives. Ultimately they had a voice in their treatment when their voice couldn’t be heard. This is such an important topic within the Healthcare Reform bill because the potential cost savings will help to keep the largest healthcare plan in the country, Medicare from being exhausted. The use of Advanced Directives could save 6% of all Medicare spending or 24 billion dollars.
The house legislation has debated about $540 billion dollars in savings over the next ten years, according to Senator Arlen Spector of Pennsylvania. Statistics show that 27% of Medicare expenditures occur during a person’s last year of life, and a tremendous percentage of medical costs occur in the final month, weeks, and days. The average cost of one day spent in the Intensive Care Unit is ten thousand dollars. According to Andrew Stern, last year alone Medicare spent $40 billion more than it should have on end of life care, due to the inefficiencies of many hospitals.
Today 34. 8 million Americans are 65 years old or older. This number will double by 2050 to about 72. 2 million, with a 240% increase in the population age 85 years old or older. The baby boomer generation is getting older and I speculate that this is the cause of such a tremendous increase. It is also important for individuals who do have an advanced directive to keep it easily accessible. According to the Journal of the American Medical Association, studies have found that caregivers have access to patient’s living wills as infrequently as 16 percent of the time.
They sit in desk drawers, bank safety deposit boxes, or computer hard drives. In the middle of an acute medical crisis these documents have little value if they cannot be easily located. Solutions for increasing accessibility are available for just this type of situation. Electronic Health Record or EHR is one solution. This system would allow patients to make, update, or revise their advanced directive documents with software date and time stamping new versions so the current version replaces all previous advanced directives.
It would also be easily accessible for medical professionals who would need to access it for use at any point in time. The final decision on the EHR solution has not been finalized rather is currently being discussed. The final healthcare reform bill that President Obama signed on March 23, 2010 won’t be in full effect until late 2014, although some pieces may be in place sooner according to the AARP website. I personally believe that the advanced healthcare portion of the recent healthcare reform bill is a blessing in disguise.
If society accepts an individual’s choice to preplan their own funeral, then why not allow individuals the choice to either prolong their life or to die a natural and peaceful death. Some individuals do believe that physicians should not play God, rather let God decide on when it’s their time to go. Facing one’s mortality may not be an easy task, but with the guidance and education of a specially trained health care professional an adult may choose the choice they are most comfortable with.
As a registered nurse in an Intensive Care Unit, I believe that an adult of any age should have an advanced directive. We cannot pretend that nothing will ever happen to us, because the unexpected can happen and I have seen this many times. Just once would I like to invite everyone to visit an ICU, and then contemplate their own individual wishes. For those who know nothing about healthcare reform and advanced directives, I encourage them to educate themselves before making choices. Remember that knowledge is power, and your voice is your own.