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Cassidy: In defense of 'death panels'

Photo Credit: Illustration by Tim Foley

The country now awaits a decision from the U.S. Supreme Court on the constitutionality of the Affordable Care Act. It's unfortunate that resources have been spent to challenge and defend Obamacare when no rational alternative is available to address America's dysfunctional health care system -- particularly when there are still many compassionate and cost-effective steps that need to be taken to make health care reform even better.

As a former health fraud and patient abuse investigator with expertise in Medicare and health insurance, I was better prepared than most to advocate for my elderly father in the last few months of his life. But still, it was heartbreaking to watch this proud man, who then weighed less than 125 pounds, hold out false hope for recovery because his doctors sidestepped telling him that he had months, not years, to live.

Granted, doctors are faced with a dreadful dilemma. If they tell their patient that there is little hope for a cure, then what?

Do they delay seeing the patients in the waiting room in order to spend enough time discussing treatment options with a single gravely ill individual? Or do they postpone the uncomfortable discussion by scheduling the next appointment for three months in the future and prescribing an improbable treatment? In my father's case they chose the latter.

There could have been another choice for my father and his physicians if doctors had the option to refer patients for a Medicare covered end-of-life consultation. This proposed benefit would have allowed a health care provider to talk with a patient about important advanced directive issues such as living wills, as well as palliative care and hospice services covered by Medicare. But that benefit was removed from the health care reform law due to the hysteria caused by false and reckless rumors that a voluntary consultation by a physician about end-of-life options was a "death panel."

My father was a retired New York City Police detective commander. In the last months of his life, he kept a log of his health issues just like a detective on surveillance. I sat with him on many occasions as a nurse or lab technician took his hand to draw blood. They would look at his fragile fingers and apologize. He would say thank you. When they stuck the needle in his finger, he never winced, and said thank you again.

He trusted his doctors would keep him alive for a few more years. He very much wanted more time with his family and friends. Nonetheless, as a frequent visitor to gravely ill relatives and friends in hospice settings, he valued palliative care as a compassionate approach to help dying patients control how they spend their remaining days. He even recommended that I address hospice in my book on elder care, and helped me write that chapter.

Yet, hospice was not discussed by his doctors until three weeks before his death, when he had a routine appointment with his geriatrician. She knew immediately, by looking at his frail and hollowed body, that he was near death. She asked him if he would accept hospice. He said yes.

 

Hospice care is a benefit provided by Medicare and many other insurers when doctors estimate that their patient's life expectancy is six months or less. The hospice philosophy accepts the approaching death of a patient and attempts to provide a comfortable and pain-free evironment for the patient at home or in a health care facilty.

But according to several research studies, most doctors avoid conversations about hospice with their patients. For example, a study conducted by the journal Cancer surveyed 4,188 physicians about how they would talk with a hypothetical cancer patient with four to six months to live. Many of the respondents said they would discuss prognosis, but only 26 percent of the responding doctors said they would discuss hospice.

Understandably, many physicians may be hesitant about discussing hospice because they're concerned they might frighten a patient and his or her family. It's a justifiable concern, and all the more reason the subject should be addressed by a physician who is skilled at communicating all of the treatment and end-of-life options available to a patient.

Ironically, accepting hospice care does not necessarily reduce a patient's life expectancy. A study published in the New England Journal of Medicine in 2010 found that lung cancer patients receiving palliative care actually lived longer than those receiving standard oncologic care, even though patients who spent more time in hospice received less chemotherapy.

Hospice was a difficult choice for my father, but once he had made it, he was relieved that his ordeal was finally over. The hospice team of doctors, nurses, social workers and home health aides helped him live the final weeks of his life in relative comfort.

The last night of his life, a hospice volunteer who was also a New York City police officer carried my father to a hospital bed in his living room. My father enjoyed talking about their mutual experiences in various precincts throughout the city. The next day my father died peacefully in his own home.

No matter what decision is reached by the Supreme Court about the Affordable Care Act, Americans must insist that their political leaders come to their senses and take steps to restore the end-of-life-discussion benefit that was removed from Obamacare. And this time, rather than limiting the Medicare coverage to once every five years, they should let physicians decide without time constraints when their patients would benefit from the consultation.

Not only would this service reduce the number of pointless, painful and expensive medical procedures performed in a patient's final weeks, it would improve the quality-of-life for seriously ill Americans and the people who love them.

Thomas M. Cassidy is a clinical associate professor at the School of Social Welfare at Stony Brook University and the author of "Elder Care: What to Look For, What to Look Out For!"

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