In a recent interview on Long Island, Sarah Palin reiterated her now infamous claim that 2010’s Affordable Care Act (ACA) would bring about the formation of “death panels.” In Palin’s dystopic fantasy, death panels are ambiguously composed bodies of bureaucrats charged with the task of deciding who lives and who dies based on “subjective judgment of [a person’s] ‘level of productivity in society.’” The enduring invocations of Palin’s words illustrates the level to which her brand of rhetoric can pollute our public discourse. The tragedy, however, is not that our debates grow increasingly vitriolic. Rather, in the case of the death panels, the true disappointment lies in the continued avoidance of discussions that address some of the most crucial and poignant issues at play in American health care.
The term “death panel” was coined in response to a proposed section of the ACA that would allow physicians to be reimbursed by Medicare for time spent discussing end-of-life issues with their patients. The conversations were to remain optional, and would be slated to occur every five years unless a patient grew significantly ill, at which time the frequency of reimbursable consultations could increase. The content of the discussions would center around clarification of a patient’s desires in the event of a medical emergency: would an individual like to receive CPR in the event of cardiac arrest? Invasive ventilation? Who will make decisions when the patient loses the capacity to do so? The questions asked in such conversations are not necessarily profound. The value of careful end-of-life planning is, however, quite remarkable.
In his 2010 New Yorker article “Letting Go,” Atul Gawande eloquently traverses the medical and personal landscapes of end-of-life decision making. Recounting his own patient experiences, Gawande illustrates how heart wrenching discussions regarding patient wishes are all too easily avoided as illness progresses and curative options begin to run low. When terminal medical crises finally occur, the patient is rarely able to provide input. The default instinct of the family and the medical establishment is often to fight for prolonged life until the last shard of hope is lost amongst beeping machinery and myriad protruding tubes. Curtailing the “more is always better” approach and ensuring patient autonomy requires advanced planning as death grows nearer.
In support, Gawande cites revealing data. A 2004 study by Aetna found that when individuals were given the opportunity to use hospice care in conjunction with standard medical treatment near the end of life, their usage of standard medical care went down, while their overall satisfaction scores went up. A 2008 study of terminal cancer patients found that 6 months after death, the relatives of those who had experienced less aggressive end-of-life treatment were less likely to suffer from depression. In La Crosse, Wisconsin, a policy change that brought about routine discussion of end-of-life issues lead to reduced in-hospital death and a subsequent decrease in end-of-life health care expenditures. The economic implications of end-of-life issues cannot be avoided, as 25% of medicare spending is devoted to the 5% of patients in the final year of life. In Gawande’s work, a portrait emerges of a situation in which those who approach the end with preparedness often pass in a more peaceful manner, leaving behind less beleaguered loved ones and a more financially solvent health care system.
The decisions made when the end nears are unrivaled in complexity. The content of end-of-life discussions, however, was never intended to be the province of the Affordable Care Act. The ACA aimed to provide only for that which Gawande shows to be sufficient: the mere occurrence of these conversations. In their interpretive leap, conservatives of Palin’s leanings painted with the broad brush of conspiracy. The furor caused the measure to be dropped from the ACA, but in January, Barack Obama quietly rectified the omission through a medicare regulation.
Despite the regulatory resolution, we must wonder at the ultimate damage done by such instances of fear mongering in the delicate debates on human health and disease. We must examine our attitudes toward end-of-life care as we strive to mold a compassionate and sustainable health care system in America. While differences of opinion are critical, there is no room for sensationalist lies. As this and other health care issues enter the public view, we will be well served to approach the discussion using the analytical and judicious consideration that underpins medical inquiry itself.
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