Tuesday, November 17, 2009

Why This Wisconsin City is the Best Place to Die.

A story from NPRs broadcast yesterday looks at La Crosse, Wisconsin, where, because of the local hospital, 96% of elderly community members have advance directives (living wills). The article shows the hospital's efforts have saved thousands of dollars per patient by not pursuing aggressive treatments that patients don't want, only those they desire.

The hospital database records patients' preferences and such information comes up any time the patient is in the hospital. Chaplains, doctors, nurses and others have been trained to update the patient's desires whenever they visit the hospital - which results in an ongoing conversation about the patient's end of life wishes not only at the hospital but among family members. From the story:

But it's expensive to spend time with patients filling out living wills. Medicare doesn't reimburse for the time the hospital's nurses, chaplains and social workers do this. Bud Hammes, the medical ethicist who started the program, called Respecting Choices, says it costs the hospital system millions of dollars a year. "We just build it into the overhead of the organization. We believe it's part of good patient care. We believe that our patients deserve to have an opportunity at least to have these conversations."

And that's how La Crosse unexpectedly got in the middle of the national debate over health care and the so-called "death panels."

A New Standard Of Care

There's a proposal — it's in the health bill passed by the House of Representatives — that would pay for the kind of periodic and continued end-of-life discussions with patients that are routine in La Crosse. Gundersen Lutheran is pushing for it.

Hammes says claims that government-run panels would pressure sick people to die are bizarre exaggerations — and that the experience of this Wisconsin city proves it. "These are conversations that we have with our patients. They're not done in a secret room," Hammes says. "These are open conversations involving family members, pastors, attorneys. It's part of our community fabric now, it's part of how we deliver care."

One result of the way that care is delivered: At Gundersen Lutheran, less is spent on patients in the last two years of life than any other place in the country


Further debunking the claim that end of life discussions lead to coercion of patients to die, the hospital shows that providing patients with choice reduces anxiety, over-treatment, and cost.

The Dartmouth Atlas of Health Care documents the vast difference in health care costs from one place in the country to another. At Gundersen Lutheran, the cost of care for someone in the last two years of life is about $18,000. The national average is close to $26,000. At one hospital in New York City, it's more than $75,000.

"When people see the low cost in La Crosse, there are assumptions about rationing care, about denying care, about limiting — that we limit care for our patients," says Hammes. But it's not that dying people in La Crosse are denied care, he says. It's that they've thought out their wishes in advance, so they get exactly the care they want. And often that means avoiding excessive and unwanted care.


Hammes says the point is to help people make informed choices. Decisions made on the spur of the moment, in crisis, can lead to costly and unwanted care. If a patient's wishes aren't clear, the default choice of doctors and family is often to provide high levels of care — even when it's something unhelpful.

But sometimes, getting a patient to think through choices can mean the patient decides he or she does want the most expensive care.

I have long claimed that rationing could be ameliorated by detailed conversations with elder and terminal patients about their options and choices. In a system that defaults to "every effort" care when most surveyed prefer to die at home or to not undergo excessive treatment, informing patients of their choices and letting them take control of their care choices is just good medicine - and more efficient. Glad to see La Crosse and Gunderson Lutheran taking the lead, standing up for patients' rights, and proving the point that great care does not necessarily equal over-testing, over-treating, and over-medicating.

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Toobin Asks Why the President and Democrats are So Quick to Cede Moral Ground on Abortion.

The President is pro-choice, and he has signalled some misgivings about the Stupak amendment. But, like many modern pro-choice Democrats, he has worked so hard to be respectful of his opponents on this issue that he sometimes seems to cede them the moral high ground. In his book “The Audacity of Hope,” he describes the “undeniably difficult issue of abortion” and ponders “the middle-aged feminist who still mourns her abortion.” Elsewhere, he announces, “Abortion vexes.” The opponents of abortion aren’t vexed—they are mobilized, focussed, and driven to succeed. The Catholic bishops took the lead in pushing for the Stupak amendment, and they squeezed legislators in a way that would do any K Street lobbyist proud. (One never sees that kind of effort on behalf of other aspects of Catholic teaching, like opposition to the death penalty.) Meanwhile, the pro-choice forces temporized. But, as Supreme Court Justice Ruth Bader Ginsburg observed not long ago, abortion rights “center on a woman’s autonomy to determine her life’s course, and thus to enjoy equal citizenship stature.” Every diminishment of that right diminishes women. With stakes of such magnitude, it is wise to weigh carefully the difference between compromise and surrender.

Read more: http://www.newyorker.com/talk/comment/2009/11/23/091123taco_talk_toobin#ixzz0X8KXRgQf

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Pew Surveys Opinion on Faith-Based Programs.

A new poll by Pew looks at public opinion regarding faith-based programs and finds that they are still popular, particularly among Democrats, despite their decline in visibility.

From Religion Press Release Service:

A new report based on a recent national survey by the Pew Research Center's Forum on Religion & Public Life and the Pew Research Center for the People & the Press finds that more than eight years after former President George W. Bush unveiled his faith-based initiative, the policy continues to draw broad public support. At the same time, many Americans express concerns about blurring the lines between church and state, as was the case when Bush first announced the initiative.

The survey, conducted Aug. 11-27 among 4,013 adults, finds that 69% of Americans say they favor allowing churches and other houses of worship, along with other organizations, to apply for government funding to provide social services such as job training or drug treatment counseling, while just 25% oppose this approach.

The report reveals notable shifts among political parties, as Democrats are now more supportive of this program than Republicans. Democratic support has increased from 70% in March 2001 to 77% currently. By contrast, Republicans are less supportive of this program today, with 66% in favor, down from 81% in 2001.

While generally supportive of faith-based social programs, the public also expresses certain reservations. A majority of Americans view the possibility that the government might get too involved in religious organizations as an important concern (69%). A smaller but still sizable majority views the idea that people who receive help from faith-based groups might be forced to take part in religious practices as an important concern (60%).

In addition, about three-quarters (74%) of Americans say religious organizations that receive government funds to provide social services should not be able to hire only people who share their religious beliefs, a long-running point of contention in the debate.

At the same time, when people are asked generally whether religious organizations, non-religious organizations or the government can do the best job providing services for the needy, a plurality (37%) chooses religious organizations. That is up slightly from 2008 (31%) and matches the percentage expressing this view in 2001. And there has been a sharp increase since 2001 in the proportion saying that religious organizations could do the best job of feeding the homeless, with 52% saying religious organizations could do the best job, up from 40% in March 2001.

The report, including an overview, methodology and topline questionnaire, is available online.

This report is a joint effort of the Pew Forum on Religion & Public Life and the Pew Research Center for the People & the Press. Both are projects of the Pew Research Center, a nonpartisan "fact tank" that provides information on the issues, attitudes and trends shaping America and the world.

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RCRC Says HCR Should Reflect All Voices, Faiths.

Good news from other faiths:

The Religious Coalition for Reproductive Choice (RCRC) and Catholic, Protestant, and Jewish agencies today called on the Senate to ensure the finalhealth care reform bill respects diverse religious beliefs on women's health care.

"It is now up to the Senate to keep health care reform free of religious doctrine and restrictions that will prevent women from making their own reproductive health choices," said Reverend Dr. Carlton W. Veazey, President and CEO of the Religious Coalition for Reproductive Choice (RCRC), which convened a news conference in Washington, DC.

RCRC includes more than 40 denominations and religious organizations and thousands of clergy who respect diverse religious beliefs and individual decisions about whether and when to have children.

"We are grateful that the day is approaching when more Americans will have access to health care. Yet we are troubled that the House of Representative has imposed the theological views of the U.S. Conference of Catholic Bishops on the American people," Reverend Veazey said.

"There should be no Stupak-Pitts language in the Senate or conference committee health care bills," he said, referring to a restrictive amendment pushed by the Catholic bishops and passed by the House of Representatives. "RCRC agreed that health care reform must not become tangled in the abortion debate. We supported preserving the status quo. But this was not enough for anti-choice lobbyists who have insisted on using health care reform to expand restrictions on access to abortion services. Women must not lose access to services they may need because of a small but vocal group of activists."

"Health care reform is about expanding access for all, not rolling back women's access to needed health services," he emphasized.

Speakers today included Linda Bales Todd of the General Board of Church and Society of theUnited Methodist Church; Sammie Moshenberg, Director of the Washington Office of the National Council of Jewish Women; Jon O'Brien, President of Catholics for Choice; Sandra Sorensen, Director of the Washington Office of the United Church of Christ Justice and Witness Ministries, and Reverend Barry W. Lynn, Executive Director of Americans United for Separation of Church and State.

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