Archives for June 2012

The stampede of media interest in the critical issue of health care policy in the United States has once again gone dormant — what “issues of the day” don’t, any more? — now that the lawyers have fled the Supreme Court chambers. Count on the whole thing resurfacing in a maniacal frenzy in about June, when the court renders a judgment.

During the recent wave of attention to the Affordable Health Care Act ( “Obamacare” is a transparently derisive label snatched up by a lazy media), I started posing a simple query about health-care policy choices on a number of platforms, from Facebook to the comments section of the Washington Post and New York Times.

Here’s the pitch:

Can anyone refute the theory that all of our national health-care choices fall under one of the following three broad propositions?

1) We can find a way to cover everyone — “health care for all.”

2) Or we accept “free riders” on the system — Most of us pay for insurance, but those who choose not to still receive health care (via the George W. Bush “emergency room” health plan).

3) Or we choose, as a society, to go back on our previous commitment to providing health care to those who need it, when they need it — turn people away from emergency rooms. (This was the choice of the cheering crowd at a Tea Party-sponsored GOP candidates’ “debate” in September. I wonder how many of those who relished the prospect of letting the uninsured die realize that the law mandating such compassionate action, the Emergency Medical Treatment and Active Labor Act, was signed into law by their hero Ronald Reagan in 1986.)

To date, I have not gotten one response that falls outside those three basic choices. There are minor variations such as kicking the issue back to the states, but the choices remain the same even at that level.

I’ve tried to contact the Mitt Romney campaign several times asking for clarification of what the candidate would do about health care, noting that I am an Extremely Important Journalist. My credentials must not be up to snuff.

But looking at his website, I see that Romney’s plan is to kill off the ACA and send the issue back to the states. Further, he would “promote free markets and fair competition” — I guess that means we’d all have the privilege of continuing to pay for 26 percent overhead in the private insurance sector (per the Journal of American Medicine), rising profits, higher premiums and more uninsured. A bright future.

Hey, I admit it: the ACA is a miserable piece of political sausage, ground by craven, money-mad politicians and contaminated with blood, bone and hair to protect the profits of private health-care barons. Still, it’s better than what we had before, and, so far as I can tell from his rather vague promises, what Romney would give us.

When a President Romney gives states the authority to ignore the ACA while he seeks to have it repealed, he will transport us back to the good ol’ days when parents couldn’t cover their children aged 18-26 on their health-care plans and those with dreaded “pre-existing” conditions, no matter how mild or inconsequential, were routinely rejected by most insurers, which presented a Hobson’s choice of crazy expensive plans or going uninsured.

A lot of people who “hate Obamacare” actually like a lot of its provisions. But mostly, they don’t know what the law contains, and they’ve gotten hung up on abstract notions of “freedom” and “liberty.” They are enraged by the piece of the legislation that’s gotten the most attention, the individual mandate. You’ve all heard, of course, that this idea originated with the conservative Heritage Foundation and was the linchpin of, ahem, Romney’s health-care reform in Massachusetts.

You’ve also heard of the radical notion that anyone who drives should be covered by insurance to protect the rest of us. And, if you paid attention to the recent Supreme Court arguments, you also heard justices cleverly inquiring as to whether the principle behind the mandate would allow the government to compel us all to eat broccoli.

The best rejoinder I’ve seen to that is “What Makes Health Care Different,” a succinct, rational op-ed piece by software company CEO Donna Dubinsky from the April 6 Washington Post (http://wapo.st/HomfFG).

Even as she blows the bogus broccoli baloney away, Dubinsky takes the Obama solicitor to the woodshed for missing a critical point in his arguments.

“(T)he court forgot that the private insurance market does not function as a normal market. If you are not employed and you want to purchase insurance in the private market, you cannot unilaterally decide to do so. An insurer has to accept you as a customer. And quite often, they don’t,” she writes.

She goes on: “The government muffed its response. There are two simple limiting conditions, both of which must be present: (1) it must be a service or product that everybody must have at some point in their lives and (2) the market for that service or product does not function, meaning that sellers turn away buyers. In other words, you need something, but you may not be able to buy it.

“Can the government force you to eat broccoli? This proposition fails on both counts. Nobody must eat broccoli during their lives, and the market for broccoli is normal. If you want broccoli, go buy it. Nothing stops you.”

I’m truncating her elegant, pellucid argument, but you get the idea.

All those rabid opponents of the ACA, most of whom are no less appalled by the idea of single payer — that’s public health insurance, not public health care or “socialized medicine,” and don’t let anyone tell you otherwise — are beholden to abstractions at the expense of real-world solutions.

And plenty of them seem to suffer from permanent teenage-itis: Insurance? I don’t need no stinking insurance! I’m indestructible. But if I do need, you can pay for me … deal? We live in bizzarro world when professed personal-responsibility conservatives are indignantly upholding the rights of leeches.

But perhaps I’m wrong. Do you have a solution that doesn’t involve universal coverage, free riders, or death in the streets? Let’s hear it.

Email: claybonnyman@yahoo.com.

After the Camera ran last week’s column, “End of Life, Part 1,” I was deeply moved and gratified by the many responses I received from readers. Many of them told personal stories — some positive, some disastrous, all heartbreaking — about complications at the end of life for someone they love.

I heard about horrible situations in which medical personnel, for whatever reasons, refused to honor the patient’s and the family’s wishes to withdraw treatment. I heard from one who told the story of her beloved brother, who was on a ventilator but fully conscious — and who instructed his family, via eye blinks, to allow him to die in peace.

Other readers were astonished to learn that, unlike on TV, CPR rarely works and typically results in painful injuries.

And if there was a thread running through them all, it was simply that they want to know more about how, if possible, to ensure their wishes will be honored when the time comes for them to die.

To that end, I was privileged to interview Kim Mooney, director of community education for HospiceCare of Boulder and Broomfield Counties, one of the oldest hospice organizations of its kind in the United States. Kim has been working to educate people about end-of-life issues for decades, talking about the critical importance played by communication when it comes to expressing your wishes.

But when her mother died recently, that message really came home for her. Unlike most of us, Kim’s mom had talked to her family about her wishes over the course of a lifetime. When it came time for her children to come together and make medical decisions for her and talk about quality of life, “we knew exactly how to treat her and support each other. There was some kind of sanity in the middle of difficult choices.”

Her mother, by nature cheerful and upbeat, was wise enough not to be in denial about the certainty of her death one day. And so she talked about what she wanted all along, knowing “it was going to be part of what we deal with,” Kim says.

And, of course — after all, Kim was both her daughter and an expert — she made sure she had written her wishes down in black and white.

“She taught me a lot about how I want to die,” Kim says.

So: How would you like to die?

There are two things you should be doing to make your friends, family and medical team aware of your wishes:

Make sure you’ve completed two key documents, the Medical Durable Power of Attorney for Healthcare Decisions and an Advance Directive for Medical/Surgical Treatment.

But don’t let it stop there. Make sure you have comprehensive conversations with all who might have to make decisions about your care, explaining carefully to them your values and your wishes.

(There also is a new form, but it’s targeted at a narrower category of patient, the Medical Orders for Scope of Treatment, or MOST. I’ll address that below.)

“We can never say 100 percent that this will work,” Kim says. “But doing this will close a lot of gaps, especially if you have been clear with people.”

The durable power of attorney allows you to designate the person who will make decisions on your behalf should you be unable to. It’s important not only that your health-care agent be informed of your values and wishes, but also that you notify family members of your choices and be sure that they know how you want to be treated.

“Everyone who is over 18 needs to do this. It’s a simple form but it requires a serious commitment to self-reflection and good communication. However, you don’t need a lawyer to complete one which is one of the reasons many people delaying completing one,” Kim says.

The Advance Directive for Medical/Surgical Treatment, once known only as a “Living Will,” now allows you to give clearer directives to your care team regarding when and if you’d like artificial nutrition and hydration withdrawn or what to do if you are in a “persistent vegetative state.” But the form encourages you to go far beyond that by attaching further directions: Do you want to be in hospice? Do you want antibiotics, blood transfusions, dialysis?

“All these choices should be based on thought-out conversations with your family, based on the essence of you and what you consider to be quality of life,” Kim says. “The whole thing is underpinned by what your values are: Is it important for me to stay independent, meaning I don’t want someone to have to clean me? Do I want to be able to hold my grandchildren?”

Because there are many misinformed people and politicians willing to use the issue for demagoguery, some are uneasy about all this, thinking if they don’t opt for “everything,” they’ll die in pain. But as Kim says, comfort, respect and palliative care are always a given, regardless of your choices.

The MOST form is an important new physician’s order, but it’s not for everyone. It’s designed for “patients in motion” — the terminally ill, frail elderly people, patients who are more likely to be in frequent contact with doctors — those with immediate and serious medical concerns. It is a “CPR directive designed to follow the patient around in every setting, including an ambulance,” Kim says. In Colorado, the form is bright green so hopefully it will be immediately visible when it is needed.

With the MOST, you can request not to be put through a (likely painful and futile) attempt to resuscitate you, given antibiotics or placed on a ventilator. (Or, if you choose, you can request all those interventions — it’s up to you.)

Through HospiceCare, which is deeply invested in community education, Kim has spent two years educating doctors, emergency personnel, nurses and the public at large about how the MOST works. Like the forms intended for the general population, MOST can — and should — spur conversation.

Even many doctors have traditionally been reluctant to engage in conversations that acknowledge the reality of death. But, as Kim says, “If you think it’s hard to talk about the end of life now, guess what happens when you don’t?”

To download the most current Medical Durable Power of Attorney and Advance Directive forms, you can go to irisproject.net.

On May 5, HospiceCare of Boulder and Broomfield Counties will present a free five-hour training on how to prepare your end-of-life documents and open up conversations with friends, families and medical personnel. For more information, call Kim Mooney at 303-604-5214 or email her at kimmooney@hospicecareonline.org.

Email: claybonnyman@yahoo.com.

It was a nightmare Rick, his wife, and their family thought they had guarded against. But after Rick’s father in law became short of breath and an ambulance arrived, the Parker, Colo., family was dragged down into America’s maddening morass of misguided medicine when it comes to end-of-life care.

It actually started seven years ago (I’ve agreed to use Rick’s first-name only because of the sensitivity of these issues) when the older man’s heart stopped.

He was revived, but doctors informed the family of numerous complications, and he was admitted to hospice care. As is sometimes the case with hospice patients, his condition improved. He was far from 100 percent, but he was discharged from hospice.

However, because of his ongoing complications and an up-close experience with the revive-at-any-cost mentality, he and his wife filed “advance directives” with the hospital asking that “he not be resuscitated again, because of the emotional cost to him and his wife,” Rick says.

When he became short of breath a couple months ago, the family did call 911; he needed help, but didn’t appear to be in crisis. (After all, just because a patient has a “do not resuscitate” order doesn’t mean he or she shouldn’t be kept comfortable in non-life-threatening situations.) for But then, his heart stopped, and the 72-year-old man was revived no fewer than eight times in the ambulance and hospital, despite the family’s wishes.

At the hospital, anguished and stressed, when doctors provided contradictory information — first that he was brain dead, next he was “responsive” — the older man’s wife decided to wait until morning before making any decisions about discontinuing care.

In the morning, another doctor showed up and said, “I’m sorry, we made a mistake,” Rick says. The doctor acknowledged to the confused family that the older man had, indeed, been brain dead.

“I asked why did you bring him back eight times then?” Rick says. “He says, ‘No good reason.'”

Worse, the older couple had taken pains to file documentation of their express legal wishes with the same hospital, asking that the man not be resuscitated.

The medical team had even consulted the older man’s file, but either had failed to see, or worse, ignored the family’s clear advance directive.

To Rick, who used to work as an emergency medical technician, the whole painful episode — his father-in-law eventually was “allowed” to die — reminds him of people he saw in the medical world who have “almost a God complex. … There are times they get so wrapped up in what they’re doing that they don’t stop to consider the ramifications to individuals and families.”

Sadly, such situations are more common than many think, says Dr. Merle Miller, a physician with HospiceCare of Boulder and Broomfield Counties, who worked as an emergency room doc for 20 years. (Dr. Miller was not involved in the above case.)

“Paramedics tend to be driven by protocol, and if there is any doubt, they resuscitate,” Miller says. “And that can start a cascade of events.”

In her practice, “I’m not one of those people who needs a piece of paper that’s been stamped and signed,” she says. She communicates directly with family members and wishes more emergency personnel would consult their “medical backup” before plunging into something that could cause a tragic cascade.

The roots of most of our misconceptions about resuscitation go deep in American society. Entertainment and media have badly skewed our notions of success and promulgated the false impression that medicine can rescue us at every turn.

“The pendulum has gone too far toward this resuscitate mentality, and I think TV is part of the problem,” she says.

On “House,” “ER,” and other shows, resuscitation is shown as normal, and successful 75 percent of the time, according to a 1996 survey by the New England Journal of Medicine. In fact, among the chronically ill and elderly, the success rate is an underwhelming 1 to 3 percent. Overall, the rate hovers around 18 percent, with the best success rates for younger, healthy people who experience sudden heart arrhythmia in a setting where help is immediately available.

And did you know that, done right, CPR will probably snap a good number of your ribs? CPR is only done with someone who is dead or almost dead, not whenever they are having a medical emergency.

The problem, at the deepest level, is our death-denying culture. Miller, who grew up in the African nation of Congo, saw death regularly: “It was visible, and not uncommon.” In 21st century America, few people see death up close, and many of us consequently have deluded ourselves into believing that medicine can — and should — keep us living far beyond our otherwise likely sell-by date.

Physicians today run the whole gamut from being very aware of these issues and of the equally important potential trauma to the families to physicians who have had no professional education and very little experience in dealing with the outcomes of end-of-life choices. But doctors, more than anyone, also know all too well that the massive interventions they inflict on us — typically at our own, misguided request — are a “cure” worse than the “disease” of human mortality. I urge you to look up “How Doctors Die,” an essay by physician Ken Murray of the University of Southern California.

“Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone,” Murray writes. “They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen — that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR.”

Some physicians and institutions understand all this; others don’t. In other words, every situation is individual, contingent on how decisions are made.

Murray writes candidly about all that intervention we think we want.

Most doctors, he writes, have seen ” ‘futile care’ being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs.”

And guess what? Those who elect hospice and palliative care, blessedly free from such brutalities, actually live longer, statistics have found.

With yet another round of “debate” about the Affordable Care Act (Obamacare to those who diss and dismiss it), the know-nothings are bound to start spouting demagoguery about “death panels” and such nonsense.

But the truth is, much of the medicine we inflict on ourselves, particularly at the end of life, causes more pain and suffering … for both the living and the dying.

“If you go to the hospital, you are offered a whole spectrum of treatments,” Miller says. “People don’t always realize that they have any choices” — including the choice to say, “No thanks.”

Coming up next: Kim Mooney, an expert in advance directives, will discuss how to protect your family against situations like that faced by Rick’s family.

Email: claybonnyman@yahoo.com.

When I traveled to Israel in 1996, things were pretty calm. Minus a couple brief side trips to Jordan and Egypt, I was there for about a month.

Benjamin “Bibi” Netanyahu was serving his first term as Prime Minister, but was much less “conservative” than he is now. The only violence deemed front-page worthy by the media was the stabbing murder of two West Bank “settlers.”

Israel is, not surprisingly, a pretty militarized place, and that can be a strange experience. All young people must serve in the military (excepting, curiously, ultra-Orthodox Jews who have been given a pass for religious reasons), and it was not uncommon to find myself sitting next to a beautiful female member of the Israeli Defense Forces on an Egged bus, her rifle resting lightly between her knees as she slept.

And all around Jerusalem and Tel Aviv, I picked up on the pride Israelis feel in their ability to protect their tiny nation, surrounded from its founding by potential enemies. In particular I remember seeing a T-shirt with a photo of an American-made F-16 fighter and the message, “Don’t worry America — Israel is behind you!”

Intended as a winking defiant inversion of a message Israelis must tire of hearing, the shirt conveyed a certain pugnacious grit: After the triumph of the Six Day War in 1967 and the near disaster of the Yom Kippur War in 1973, many citizens of the Jewish state came to believe they could withstand any assault.

Things are more complex now, following more dubious military actions and the continued occupation of territories taken from Jordan, Egypt and Syria. To boot, Israel has taken unilateral, pre-emptive action to forestall what it saw as future threats. That’s what happened in 1981, when IDF planes bombed Saddam Hussein’s Osirak nuclear facility in Iraq and Syria’s incomplete al-Kibar nuclear installation in 2007.

In both cases, the United States government stood firmly behind the nation that receives more American foreign aid each year than any other (about $3 billion annually, or nearly one out of every six U.S. foreign aid dollars; most of it is in military aid).

Now we hear that Israel is prepared to take matters into its own hands and attack several nuclear facilities in Iran, amplified by American politicians eager to seem “tough.” Netanyahu’s government and many Americans are convinced that the big dog of the Persian Gulf (for that we can thank the ill-advised war in Iraq) is pursuing nuclear weapons.

President Obama said Monday that the United States “will always have Israel’s back.” At the same time, he has criticized all the cheap belligerence emanating from GOP presidential candidates and Israeli hawks. On Tuesday, he rightly called out the Republican war hounds for not taking war seriously enough.

“This is not a game,” the president said.

No, it’s not. But it’s all to easy for many Americans to treat it as if it is. The media is generally more than happy to aid and abet that thinking.

After listening to (but in my case, never believing) the lies we were told about the extreme dangers of Hussein’s “weapons of mass destruction,” the recent drumbeats for war against Iran have sounded distressingly familiar.

First, there is not unequivocal evidence that Iran is pursuing nuclear weapons, at least not yet. As Secretary of Defense Leon Panetta told a Senate committee hearing on Feb. 28, “I think they’re developing a nuclear capability (but) our intelligence makes clear that they haven’t made the decision to develop a nuclear weapon.”

And according to many careful military analysts, it’s far from certain that Israel could effectively carry out a mission to destroy or cripple three Iranian facilities, due to limitations in aircraft fueling, among other logistical issues.

And that would mean the U.S. would be forced to enter the fray.

Such a move would almost certainly catalyze further anti-American fury across the Muslim world, set Hezbollah and Hamas aflame on the borders of Israel, kill thousands of Iranian civilians and create chaos on the region — probably the world. What’s more, it could even make it more likely that the Iranians would develop nuclear weapons.

“Should Israel rush to war, Iran might follow Hussein’s example (after the Osirak attack) and rebuild its nuclear program in a way that is harder to detect and more costly to stop,” wrote Colin H. Kahl of the Center for a New American Security in The Washington Post on March 2.

Let’s say Iran does wind up with a nuclear weapon or two. As North Korea has learned, that’s pretty good protection against an attack, which might make it easier to build more nukes.

Netanyahu continually raises the specter of another Jewish holocaust at the hands of a nuclear-armed Iran. And, he suggests, failing to attack preemptively would be the equivalent of appeasing Hitler, Neville Chamberlain-style.

But is Iran truly “insane” enough to attack Israel, the only nuclear-armed nation in the Middle East, with an estimated 200 warheads poised for delivery? To read the Western press, yes, the Persians are all mad, mad I tell you, bent on Israel’s destruction even at the cost of their own annihilation. As someone rather vividly put it to me, if Iran launched prospective nuke(s) at Israel, “It would immediately become the world’s largest ash tray.”

Americans are tired of war, according to most polls. Even so, 48 percent polled by Rasmussen in February said the U.S. should join any effort by Israel to attack Iranian nuclear facilities.

Yet that’s more than the 43 percent of Israeli Jews — compared to 42 percent of all Israelis — who think their nation should attack so long as America joins in. (A solid 32 percent say they don’t think Israel should attack at all.)

Could it be that Israelis, who have tasted the bloody fruits of war, take it more seriously than Americans? We were rightfully aghast at the deaths of some 3,000 people on Sept. 11, 2001. Why is it that so many of us don’t seem to feel that same horror when tens of thousands, or hundreds of thousands, are killed in other nations — sometimes at our hands?

All “those who are … beating the drums of war should explain clearly to the American people what the costs and benefits would be,” Obama said last week.

And if we do take such stock, is it too much to ask that we consider the potential death and suffering of people other than ourselves into those costs?

E-mail: claybonnyman@yahoo.com