At the intersection of healthcare and politics, reason and responsibility are in short supply.  With little or no substitute plan, the House of Representatives voted to repeal Obamacare 67 times.  Medicare Part D (a prescription drug benefit for Medicare enrollees), a necessary but expensive program, was created without budgeting money for it.  And a good policy that promised to enhance end of life planning fell victim to raw politics during the 2008 presidential campaign.  First, some background.

I believe that, as a society, we have learned to take into account the quality  of life much more than even a generation ago.  When I was a resident physician in the late 70’s, we would routinely provide hospital care for patients that, in my mind, except for the provision of comfort measures, should have been left alone.  A typical scenario involved a hopelessly demented, nutritionally compromised patient from a nursing home with a high fever, hypotension (low blood pressure), and an obvious infection, usually originating from the urine or lungs.  More often than not, we were able to “successfully” treat these patients with intravenous fluids and antibiotics, and send the patient back to a nursing home. These were pyrrhic victories, for the same cycle was often repeated a few months later.  

This type of care still occurs, but hospice has provided an excellent alternative to aggressive, and often inappropriate, care.  People are realizing they can make choices in medical matters, and primary care doctors are increasingly urging patients to think about the care they may desire at the end of life.  This type of counseling has not occurred as much as it should—discussions on mortality with a physician take a sensitive approach and a lot of time.  Doctors are frequently scheduled to see a  patient every fifteen minutes (in corporatized medicine, it is often less), and they must deal with a variety of contemporaneous problems like hypertension, diabetes, heart disease.  Taking the time to talk about dying during these routine visits is simply not realistic.  

In the summer of 2008, Medicare tried to create a new billing category so as to explicitly reimburse physicians, who could then set aside the time needed to discuss mortal decisions with patients and their families.  The idea was to give doctors the opportunity to lay out choices that patients face at the end of life.  This was not designed as advocacy for, say, executing a DNR (Do Not Resuscitate) order or even forgoing treatment in a hopeless medical situation.  Rather, it provided time to explain options in treatment and consequences thereof,  This new billing category was a terrific idea, especially as it could be helpful in averting the type of useless and inhumane treatment described above.  It incentivized doctors to do what the best of them were already doing in their routine care of the elderly.

However, the Republican vice-presidential candidate, Sarah Palin, decided that Medicare was creating “death panels” and that Democrats were out to kill the elderly in order to create an electorate better constituted for the Democratic Party.  So Medicare was forced to back off from implementing this rule.  Recently, Medicare did successfully institute the new billing policy, but I often wonder how many painful or otherwise uncomfortable deaths Palin caused with her mindless pandering.