Overuse or Humane?

The following article appeared on page A - 11 of the San Francisco Chronicle

Health care reform: What is costly overuse, what is humane?
Katherine Dowling Schlaerth
Wednesday, July 29, 2009

President Obama has impressed me once again with his multifaceted talents.

Citing his grandmother's hip-replacement surgery as a personalized experience, he has made his case to deny aggressive and costly end-of-life care, and his concepts have been embodied in HR3200, "America's Affordable Health Choices Act of 2009," rocketing its way through Congress.

All of us would agree that putting a dying person through painful and useless procedures not only costs a lot, but also interferes with normal developmental tasks of the end of life, such as putting one's financial and spiritual house in order and saying goodbye to loved ones. To quote President Obama, we must correctly inform families who might otherwise approve of "additional tests or additional drugs that the evidence shows (are) not necessarily going to improve care." My problem, as a physician who has practiced medicine for decades, is that I just can't predict with certainty what is end-of-life care, nor can I determine for another individual the meaning of "quality of life."

I recall cases like that of the nonagenarian WWII veteran, comatose for days with multiple organ failure, who with the help of a loving family and dedicated ICU nurses walked out of the hospital, brain intact, to live a few more years.

I've seen "terminal" cancer patients kept alive long enough to hold a new grandbaby, and a 2-year-old's cancer-ridden body sustained for the weeks it took for his heartbroken parents to finally come to peace with his passing.

This current legislation, however, seeks to prevent such costly overuse of health resources through a program of "advance care planning consultation," wherein those on Medicare, or their families, could meet with a "practitioner of advance care planning" every five years, or sooner if illness supervened. Such an adviser need not be a physician, either.

This specialist would discuss care issues such as "the individual's desire regarding transfer to a hospital ... the use of antibiotics and the use of artificially administered nutrition and hydration." The discussion may, in fact, be triggered if "there is a significant change in the health condition of the individual, including diagnosis of a chronic, progressive, life-limiting disease."

I would be loath to talk a person on dialysis or in a wheelchair from a stroke into forgoing antibiotics for a pneumonia that may itself be treatable.

HR3200 has created tiers of administrators, who do not necessarily have medical experience. They will attempt to facilitate your end-of-life care, probably with the assistance of the electronic medical records each medical facility will shortly be required to use.

These and other provisions of the health choices act frankly scare me. As a physician, I took an oath long ago to put my patient's interests above all else, but provisions in the bill have a quality of coerciveness that make me wonder if I can fulfill my oath. Certainly they bear deeper inspection than possible during the brief monthlong look-see President Obama wants lawmakers to give this 1,000-page bill before passage.

Katherine Dowling Schlaerth is a practicing physician and associate professor emeritus of the University of Southern California School of Medicine.