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Monday
Sep142009

Finding Truth: We Have the Tools

Like many fellow citizens, I'm finding it increasingly difficult to follow a rational and substantial conversation about our nation's healthcare future. Instead of thoughtful arguments, we hear accusations. Instead of taking responsibility, we take sides. It's hard to stay centered on what's real and what we truly stand for.

I don't have a silver bullet -- only two items to share that may make a difference for you too.



Do not believe in anything simply because you have heard it. Do not believe in traditions because they have been handed down for many generations. Do not believe in anything because it is spoken and rumored by many. Do not believe in anything simply because it is found written in your religious books. Do not believe in anything merely on the authority of your teachers or elders. But after observation and analysis, when you find that anything agrees with reason, and is conducive to the good and benefit of one and all, then accept it and live to it."

--The Buddha, in the Kalama Sutta

Number One: Before relying on any talk news station, video, politician, relative or friend, search your own heart and mind in silence. Get away from your usual setting if possible. Don't think about what others have told you or what you are afraid will happen. Focus only on the facts that you know directly, your own experience of what happened -- not an interpretation of history or a prediction of a future.

Decide what you stand for, what you care about right now, that applies in any situation -- not just healthcare. Then remember and rely on your own truth and logic when investigating issues and speaking about them with others.

Number Two: A friend and colleague shared a heartfelt personal story with me this weekend that is her truth. The depth of her message moved me to share it with you...

Death Panels? I don't think so.

My 87-year old, tough-as-nails father passed away this year. Dad -- a World War II vet of General Patton’s army -- was renowned for this toughness, most notably in the end, for the fierce battle he waged to stay alive. His grandchildren called him Grandpa Bull; he deserved the accolade.

He fought for his life harder and more courageously than I thought possible. Racked by multiple illnesses (congestive heart failure, diabetes, crippling arthritis, diverticulitis, prostate problems and more) that progressively took more out of him, he soldiered on.

Up until the year before he died, you could see him out early walking with his four-legged walker before the Tucson sun got too hot. Walking for him meant willing himself to go a little farther, a few more steps. It was painful for him to do; it was painful for me to watch.

If you asked Dad why he did it, he would look incredulous and tell you that he had to, the alternative was worse. The alternative was to give up on life.

His pain was constant, his quality of life marginalized, his parents, siblings and peers all gone. He knew he was on borrowed time. He would come back in from those walks exhausted, sweat dripping off him from exertion and pain. Bill Smith was still fighting for life.

So why am I writing this? What’s so unusual about a willful, proud, 87 year-old WW II vet hanging on to his life? Well, this one was MY willful and proud father, who knew when it was time to stop fighting and to reclaim the dignities and joys still left in his life.

At midnight, roughly 6 months after his passing, I finally understood that he still has a fight in him -- a fight to make sure that the dignity and guidance accorded to him as he closed his life are available to every person living in the great country he fought for so long ago. That’s why I am telling his story.

In the year leading up to his death, he was in and out of the hospital so many times that I lost count. Most of the time he was in Intensive Care; several times we thought he would not make it. He fought on.

Finally, after too many stays in Intensive Care, with tubes coming out of every part of his body, unable to move or do anything himself, utterly miserable and in pain despite all being done for him, he told us he wanted to go home -- and stay there.

For those of you who have walked this path before me, you know that this is often not as easy as it seems. It is not simple. You are bombarded by information (often contradictory), options (too complicated to fathom), uncertainty (in everything you need to know), and decisions (with life and death implications). During all of this, you are pretty much exhausted and numb.

There were so many things going on during Dad’s last visit to Intensive Care. We wanted to know if the trajectory he was on could be changed. We needed to know what his options for care at home were. Inevitably, we needed to know the financial implications of the options presented.

We wanted to get our facts straight and find a way to present them clearly, with care, to our father. It wasn’t even obvious that he would survive our quest for information and support; Dad was in really bad shape.

The point of this? We got help. Doctors confirmed that Dad was very near the end of his life and there was no way around that. Medical Staff and Social Services worked with us to lay out all the possibilities and logistics.

Finally, with sufficient information and Dad improving enough for the most difficult conversation of our lives with him, we asked Dad if he was ready to speak with the doctor.

I will never forget that day as long as I live. My home is in the San Francisco area and I had returned there. My brothers arranged for the doctor to speak to Dad with them and our mother present. I joined by phone.

Far from a Death Panel -- these fine, caring, and informed professionals formed a team of support that represented the healthcare community at its finest. They represented a beacon of dignity and compassion that enabled Dad to control his life with pride.

Dad was discharged to home hospice care (mostly provided by Mom) that day. Completely bed-ridden, Dad lived for four more months. He exercised every day in his bed, fighting for more time.

He passed away while my sister and I were visiting -- without a hint that his death was imminent. His four children were there; I think he finally knew he could stop fighting. He knew we would be there for Mom. His last day was full of laughter and love; he passed quietly in his sleep, in a bed next to the love of his life.

I know my father would want you to know that the simple dignity that he was accorded should be a given for every person in this country. Dad was a retired government employee with great health insurance. He was lucky. Every American should have the same benefit. My father fought for this country. Now it’s our turn to fight.

Celeste Smith Bishop. [Email Celeste]

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Reader Comments (1)

I thank Celeste for sharing a very moving article about how her family supported her father, and how end-of-life discussions can be redeeming and rewarding. I agree. Celeste, I, and all of us probably share the same desires for our loved ones at the end of their lives: having control of the process and having family gathered in support of a loved one going through the process. I bold some items below to emphasize..not shout! :)

I, unfortunately, ran into a different situation with my father, who was a decorated veteran from WWII (who is buried at Arlington) with comprehensive health insurance. When he fell ill with cancer, we advised the doctor NOT to have an end of life discussion with him before we had had the opportunity to do so. Up to this point, our father had battled courageously and was relatively alert. The doctor, however, took it upon himself to tell our father, without our permission, that my father had no chance of survival -- before we ever had a chance to do so. From that point on, our father deteriorated continuously until he had a difficult ending (even with family around him) -- and we always thought that he probably felt betrayed by us because the doctor broke the news before we did.

My point with this is not to indict the medical profession. I think that a doctor's life is a vocation and that this doctor probably did what he thought was somehow right. But the issue is that the patient and related family need to have control of the situation; the FAMILY should decide when these discussions happen. It's not clear in the bill that the control rests with the family.

In fact, the issue is that the health care bill will COMPENSATE/financially incent doctors for conducting these types of discussions. Looking at the Buddha quote above, what do all of us think "in truth" that the end result of these financial incentives and discussions would be? Would the natural result of end-of-life discussions be to extend life and increase costs tremendously when the Quality Adjusted Year value of a terminally ill patient is extremely low? Please ruminate on that for a moment.

I also lost my mother in this past year after a bout of cancer. She had full health care, was a nurse by training, but couldn't find a doctor to have an appointment with in her last weeks of life to ease her pain. The unspoken reason was that her demise was a foregone conclusion -- why would any doctor bother when other, healthier patients are lined up?

Yet wouldn't we agree that she and all elderly deserve to be treated as valuable individuals and not cost streams? If we as a family hadn't advocated continuously on her behalf, we couldn't have gotten her into the emergency facilities/hospice near the end.

In sum, I recommend that everyone place his or her emotions on hold when discussing the health care bill, and instead approach it with a factual/logical investigation of truth.

Read the bill, first of all! I can't emphasize this enough. You'll be surprised what you see. Please read it with neither a conservative nor liberal lens, if you can. Just read it with a common sense lens.

I made it through about 200-300 pages of the bill, and I owe it to myself to review the rest. Various questions arose in my mind and I sent a six-page letter to my Congressional representatives. I won't bore you with all the details, but I can tell you that when you read the document vs what you hear in public, you'll see why there are accusations of lying. E.g., the bill says one thing in plain English (like if you switch employers, you enter the health care exchange...you clearly don't get to keep your current health plan...it's in the bill:Sec 101 and 101c), and then we hear other things from our representatives -- "if you like your current health plan, you keep it."

Short list of questions..I have many more.

1) Why isn't there an overarching focus on cost containment and quality outcomes? If there isn't, then why even have this bill...everyone already is "covered" today when they enter a hospital?
2) Why was a 1200 page bill that is incredibly hard to understand and a hodgepodge of ideas without a unifying framework being rushed through Congress? That's the most mystifying of all.
3) If Medicare has 30 trillion $ of unfunded liabilities (can you believe it?) why would we extend that type of program as a public option?
4) Why isn't competition being fostered among private industry as the best way to lower costs? There's a reason that Lasik eye surgery has dropped in price by more than 50% in the past 10 years...it's not covered by most insurance plans.
5) Why are medical institutions financially incented to hire professionals with diverse backgrounds (Secs. 2213 3d, 748, 749, 765, 2531g2) but not financially incented to increase the quality of outcomes or reduce costs?
6) Why are medical cost increases tied to the CPI (a basket of consumer goods): (sec 122c)? I 'm not arguing that cost containment isn't an objective, but inflation in groceries has nothing to do with health care costs. There are also arbitrary pricing caps (sec 113) set for insurance premiums which will preclude realistic competition.
7) If 90% of people are happy with current plan and, by various estimates, perhaps 10-15 million people are not capable of insuring themselves, why are we overhauling the entire system?
8) Why are we covering non-U.S. citizens when Canada doesn't?
9) Why are covered services not clearly defined (122b)?


Please read the September 09 issue of the Atlantic. The article is "How Health Care Killed My Father" which presents a very balanced view of proposals which might actually work, including a number that I don't support but can certainly understand.

You can find it online at
www.the atlantic.com/doc/200909/health-care

One that struck me is to give everyone coverage for catastrophic illness (e.g., if you spend more than $100K in your lifetime in medical coverage, the rest is covered by insurance -- and that could means-tested for each person based on the person's W-2) but everything else is paid out of pocket. Imagine if you got to take your employer paid health insurance as salary instead...and you used that money to pay out of pocket medical expenses (and set some aside for catastrophic in an IRA). The result would ultimately be that consumers would directly influence medical providers to increase quality and lower costs as happens in every other industry.

I think it's in the best interests of us all to approach this with a balanced view of compassion/empathy with an eye to pragmatic/common sense solutions that leave the consumer and family in control of the most agonizing decisions any of us will ever face.

Sep 15, 2009 at 10:21AM | Unregistered CommenterJohn

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