Originally Posted - May 2, 2006

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Community State Partnership (C-SP) Programs There are 24 state initiatives that are all publications of the National Program Office (Myra's Bioethics Center) for the Community-State Partnerships to Improve End-of-Life Care (C-SP) program, funded and sponsored by the RWJF, and in cooperation with Last Acts, before their demise. Later Initiatives are partnered with Partnership for Caring. Keep in mind assisted suicide in Oregon was already voted into law at the time these initiatives were written and published. www.northcountrygazette.org/articles/042506MyraChristopher2.html

1) State INITIATIVE 1. Focus: Oregon, "Using Qualitative and Quantitative Data to Shape Policy Change." Issue 1, June 1998. (Reform in Oregon) Media reports and simple statistics helped reform policy. Medical curriculum change and hospital policy and practices change aided policy reform. Early research was descriptive. Current research is on research implications for further policy change. Citizen focus groups identified values and helped reform policy. http://www.practicalbioethics.org/FileUploads/SI_1.pdf

2) State INITIATIVE 2. Focus: Oregon, "Oregon Health Decisions: Lighting the Way to Common Ground." Issue 2, October 1998. (Reform in Oregon) This initiative provided more extensive coverage of the Oregon Health Department (OHD). OHD focused on dignity and patient autonomy, advance directives, and comfort care. In attempting change at the state level, Ralph Crawshaw, M.D., states, "every state has to understand its political process. You have to know the 16 people who run the state and are the policy receptor sites, the major obstructionists, and the three geniuses who will spark reform. This means leaders from professions, media organizations, and the grassroots. Then you build a strategy and allocate time and money. In West Virginia, you have to do it the West Virginia way." The Oregon Health Department is responsible for collecting data and providing information on the assisted suicide law. http://www.practicalbioethics.org/FileUploads/SI_2.pdf

3) State INITIATIVE 3. Focus: Oregon, "Implementing End-of-Life Treatment Preferences Across Clinical Settings." Issue 3, April, 1999. (Reform in Oregon) Implementing the POLST Program in Oregon. Physician Orders for Life Sustaining Treatment (POLST) began as a voluntary project. POLST claims to prevent people from unwanted, aggressive life sustaining treatment by Emergency Medical Service personnel. Since EMS responders are required to use aggressive measures to revive patients, unless otherwise directed by valid physician orders, advance directives were generally not followed, unavailable, or misunderstood. POLST was developed at the medical community level, with no legislative inclusion. A 1993 upgrade of the state's advance directive statute enabled the POLST protocol by establishing a liberal surrogacy provision and thus mandating comfort care in explicit terms, along with rescinding presumed consent for tube feeding. In 1995-96, POLST was put into practice. A study asked a group of health care providers and patients to rate the POLST form. Susan Tolle, M.D., director of the Center for Ethics in Health Care stated, "How we emphasize comfort care is different; if you are refusing treatments you may fear abandonment, so we wanted to create opportunities for saying more than 'NO,' opportunities for patients to lay claim to dignity and comfort." Nationwide, POLST has been created either by statute, regulation or guideline, with most by statute. The POLST issue raises serious concerns among healthcare providers and healthcare givers about withholding treatments on the elderly who would improve with aggressive treatments or therapies. http://www.practicalbioethics.org/FileUploads/SI_3.pdf

4) State INITIATIVE 4. Focus: Pain Management, "Advances in State Pain Policy and Medical Practice." Issue 4, April, 1999. (Barriers to pain management and implementing nationwide prescription monitoring programs electronically) Due to cultural misperceptions and ignorance, patients and families are reluctant to accept opioids, and physicians are reluctant to prescribe them early on and aggressively to patients experiencing severe pain. The result is widespread under treatment of pain. Policy makers participated in dialogue to improve pain treatment by removing legislative barriers to pain treatment, relieving physicians' fears of being sanctioned for appropriate prescribing, and creating a policy environment for better pain treatment. Some of the most populous states, California, New York, Illinois, and Texas, are converting from triplicate forms to "electronic data transfer" (EDT) monitoring, whereby pharmacies use telephone lines to transfer prescription information to monitoring agencies, making the monitoring system less invasive, advocates say. JCAHO then became involved and proposed standards for pain assessment and treatment. Still, many patients continue to suffer in pain. In order to control pain, the patient has to accept the medications. The physician must prescribe a dose effective for each patient, even if that means changing to a different class of drugs. Care must also be taken to ensure physicians are not over medicating patients by hastening death or terminally sedating them to death. http://www.practicalbioethics.org/FileUploads/SI_4.pdf

5) State INITIATIVE 5. Focus: Long Term Care - Part 1, "Promising Educational Initiatives for Staff, Regulators, and Families." Issue 5, December, 1999. (Educational training programs for nurses, regulators, and families) The first of four briefs examining different approaches to long term care reform; 1) educational interventions for nursing home staff, regulators, and families of residents; 2) municipal and regional long term care ethics committees and consortia; 3) finance and reimbursement issues; 4) advances in developing quality indicators for palliative care and treatment in long term care settings. Out of educating nursing home staff was the Practice Improvement Clusters (PIC's) component, part of a program funded by C-SP. The PIC model fostered opportunities for nursing homes to share knowledge and practices, and to collaborate on clinical improvements. One of PIC's incentives for staff was to break institutional isolation within the nursing home operation. PICs focused on inter-facility information sharing. "Training the Trainers" program operated on an intra-facility level by educating the staff development nurses who train each facility's CNAs, to provide ongoing orientation for all staff. Training sessions focused on pain assessment and management, charting methods, evaluation methods, and teamwork to develop and enact care plans utilizing pain assessment tools and quality indicators on a pain free and peaceful death. Kentucky addressed the spiritual dimensions of pain in its C-SP-sponsored "Journey's End" program.

At this time, Myra's bioethics center, also serving as the RWJF funded national field office for C-SP, piloted a project funded by Soros's Project on Death in America with eight Kansas facilities. The project was available to entire nursing home staffs that provided an overview of ethical decision making. Additionally, in 1998, Marlys Huez, J.D., DHS Senior Counsel, worked with the California Coalition for Compassionate Care on a pilot project that trained administrators, physicians, and nursing leadership on effective end of life discussions with patients and families, and how to incorporate these discussions into the care planning process. A series of four training programs for facility leaders and ombudsmen was then planned. State surveyors received more formal training at a surveyor conference in 2000, and Ms. Huez provided short training modules on end of life issues to district administrators, managers, and supervisors. She routinely reviewed regulatory actions. The California Coalition for Compassionate Care is currently involved in passing legislation to legalize physician assisted suicide in the state. The coalition is in partnership with scores of organizations, which include Compassion in Dying Federation and Growth House, Inc. They have received funding from RWJF and the C-SP program, and more recently from the Archstone Foundation for improving end of life care by advancing institutional changes. http://www.practicalbioethics.org/FileUploads/SI_5.pdf

6) State INITIATIVE 6. Focus: Long Term Care, Part 2, "How Regional Long-Term Care Ethics Committees Improve End-of-Life Care." Issue 6, January, 2000. (Barriers impede ethical dilemmas) By providing facilities with an ethics consultation and policy development program, trained regional and municipal long term care (LTC) ethics committees and consortiums can infuse ethical perspectives into facility decision making, improve communication with families, and advance the cause of palliative care. They may help prevent or create litigation crises such as the Schiavo and Wendland cases, which plagued court systems in California and Florida. It could be argued they exacerbate litigation crises. Through ethics education, professional networking and support, bedside ethics consultation, institutional policy development and consultation, and policy research, hopefully, expertise would be available from a regional ethics committee to reduce suffering, grief, guilt, and litigation by families. If the ethics committees function like the committee at St Luke's Hospital in Houston, where Andrea Clark is currently under care and at risk of dying, due to an authoritarian decision made to stop her life support by an ethics committee, then there is no decision making, no communication with family, and we see overwhelmed court systems. Myra may have felt she solved one barrier, but actually created another barrier of a different form. http://www.practicalbioethics.org/FileUploads/SI_6.pdf

7) State INITIATIVE 7. Focus: Long Term Care, Part 3, "Facts and Controversies about Nursing Home Reimbursement." Issue 7, February 2000. (Explores reimbursement of end of life care in nursing homes) This initiative addressed three major parts: 1) room and board inclusion, prescription drug benefit, physician reimbursement for end of life consultations, all under Medicare Part A, Medicaid, or private insurance. The research agenda of this C-SP initiative was planned and advanced through Policy makers who "closed the gaps" utilizing selective research, thereby promoting that research and disseminating that information to the public and legislators. http://www.practicalbioethics.org/FileUploads/SI_7.pdf

8) State INITIATIVE 8. Focus: Long Term Care, Part 4, and "Developing Quality Indicators (QI) for End of Life Care in Nursing Homes Issue 8, April 2000. (Barriers impede use of QI in end of life care) This initiative details Quality Indicators, a measurement tool, and the criteria used in assessing patient care outcomes. Researchers involved in this program suggested new QI's specifically for dying residents, and that the MDS be revised to collect data more efficiently and explore other areas in more detail, such as advance care planning, spirituality, and patient satisfaction. Rhode Island legislation now provides their citizens with quality of care information. A coalition of this program sought development of end of life QI's, advocating that use of QI's encourages internal quality improvement. In healthcare, quality indicators and quality assurance has been around for many, many years. http://www.practicalbioethics.org/FileUploads/SI_8.pdf

9) State INITIATIVE 9. Focus: Policy Leaders and End of Life Care, Part 1, "How End of Life Care Can Be a Positive Issue for Policy Leaders." Issue 9, January, 2001. This initiative uses political leaders in creating new policy, revising existing policy, and interpreting laws and regulations for physicians and families. Many states have end of life policy manuals through the C-SP program already. http://www.practicalbioethics.org/FileUploads/SI_9.pdf

10) State INITIATIVE 10. Focus: Education, "Preparing Future Nurses and Doctors to Care for the Dying." Issue 10, February, 2001. (Barriers to educational change) The claim was that end of life issues in health care curriculum was lacking. State legislator's involvement changed the landscape, and considered ways to prepare future nurses and doctors to care for the dying by accreditation and curriculum reform and licensing and certification changes utilizing EPEC and ELNEC curriculum. The cooperation of medical associations and medical regulatory agencies had to be involved at this time and at this level to advance this concept. http://www.practicalbioethics.org/FileUploads/SI_10.pdf

11) State INITIATIVE 11. Focus: Hospice Care, Part 1, "A Policymaker's Primer on Hospice Care." Issue 11, August, 2001. Defines hospice as a philosophy of care. Includes an article on facts and myths by Mary Labyak, Director of the Hospice of the Florida Suncoast. Informational on basic hospice characteristics. http://www.practicalbioethics.org/FileUploads/SI_11.pdf

12) State INITIATIVE 12. Focus: Advance Care Planning, Part 1, "Approaches for Patients from Marginalized Groups." Issue 12, November, 2001. This initiative contains an advance care planning glossary and innovations in assessing and expanding decision making utilizing advance care planning, such as dementia with Alzheimer's or a history of mental illness. The focus is on low income, minorities, and mental health. http://www.practicalbioethics.org/FileUploads/SI_12.pdf

13) State INITIATIVE 13. Focus: Advance Care Planning, Part 2, "Guardianship: A Neglected Piece of the Surrogate Decision Making Picture." Issue 13, March, 2002. Guardianship abuses are unresolved, in spite of more than two decades of changes in statutes. Recommendations for policy reform included due process protections, alternatives to guardianship, and judicial standards, monitoring and accountability. The National Guardianship Association (NGA), founded in 1988, improves the quality of life for people in need of guardian and alternative protective services. The NGA developed a comprehensive set of guardian standards which includes end of life care, a code of ethics, and guardian certification programs at two levels. The NGA also has a judges' advisory panel, an ethics committee, and an ethics hotline. What would make this association functional would be citizens holding the NGA agency accountable. As it currently stands, they are impotent and fail in their duty of protection. http://www.practicalbioethics.org/FileUploads/SI_13.pdf

14) State INITIATIVE 14. Focus: Pain Management-An Update. "The Need for Balance in Controlled Substances Policy." Issue 14, May, 2002. As a follow up to the 1999 brief, this initiative details ineffective pain control, provides examples of appropriate and inappropriate drug policy, and contains pain policy advances and trends. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) released new pain treatment standards for hospitals, nursing homes, home health agencies, and other institutions that provide direct patient care, in 2000. One of the standards requires accredited facilities to assess pain in all patients. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) pain guidelines made institutions accountable for managing patients' pain. http://www.practicalbioethics.org/FileUploads/SI_14.pdf

15) State INITIATIVE 15. Focus: Pediatric Issues, Part 1, "Paying for Care Needed by Children with Life Limiting Conditions." Issue 15, August, 2002. This initiative discusses children's diseases and illnesses that are more complex and different than adults, innovative programs, and inadequate reimbursement policies through private insurance and Medicaid. http://www.practicalbioethics.org/FileUploads/SI_15.pdf

16) State INITIATIVE 16. Focus: Pediatric Issues, Part 2, "Creating a New Policy Framework for Pediatric Palliative Care." Issue 16, September, 2002. This initiative discusses gaps in policy and research, Oregon's POLST form in caring for minors, emerging care practices, and engaging professionals. Innovative policy changes would be adopted through JCAHO, Medicaid policy regulations, and state medical licensing boards. Myra's bioethics center developed guidelines for minors enabling self healthcare treatment decision making. The Footprints program is discussed which offers children with life limiting disabilities to participate in their treatment options via family conference with facilitators. Future care practices are discussed, including neonatal compassionate extubation, a model for standardized care coordination, and palliative care centers for children. Improving professional education by credentialing and certification was another policy goal. Development of pediatric end of life care was another goal. Also under development was reform of pediatric palliative care establishing five key points; 1) respecting goals, preferences, and choices of patients and their families; 2) relieving pain and other symptoms, including emotional distress; 3) using multidisciplinary care teams; 4) addressing caregiver concerns like respite care and babysitting; 5) and building support systems for palliative care through research, innovation, education, and sharing of practices within the field. An initiative to improve professional education and research, and funding research to inform care are also future endeavors. http://www.practicalbioethics.org/FileUploads/SI_16.pdf

17) State INITIATIVE 17. Focus: Hospice Care, Part 2, "Barriers to Hospice Care and Some Proposed Policy Solutions." Issue 17, November, 2002. This initiative discusses Medicare Hospice Benefit's (MHB) creation 20 years ago with an average length of stay in hospice of 36 days in today's market, and hospice viability. Policy promoters and policy barriers are discussed, including Medicare coverage, with the claim that regulations create hardships for hospice centers or completely run them out of business. Proposed policy changes to increase access to hospice and financial viability are examined. The hospice consult is a plan that would reach further back into the illness continuum than hospice is currently allowed, due to legal policy and cultural barriers. If the researchers of this initiative feel regulations bankrupt hospice, would they support eliminating regulation from medical facilities and institutions, and the medical field? Legalized assisted suicide without oversight is unacceptable. http://www.practicalbioethics.org/FileUploads/SI_17.pdf

18) State INITIATIVE 18. Focus: Data Driven Policy Making (An Update), "Using Statistics to Shape Agendas and Measure Progress." Issue 18, February, 2003. End of life care policy has been on the move for 5 years. Leading the way are healthcare professionals, academicians, legislators, administrators, and community activists. Discussed is how using data reforms policy and barriers known as data gaps hinder informed decision making. Resources are provided in this issue. West Virginia is highlighted in this issue with topics such as incorporation of the POST form; pain management; hospice utilization; benchmarking; and professional education requirements. Resources include the National Repository of the Minimum Data Set (MDS) maintained by the Centers for Medicare & Medicaid Services, National Home and Hospice Care Survey administered by the National Center for Health Statistics, Healthcare Cost and Utilization Project, a set of databases managed by the Agency for Healthcare Research and Quality, 1999 Dartmouth Atlas of Health Care, and Means to a Better End: A Report on Dying in America Today, published by Last Acts in 2002, assessing the quality of end of life care in every state using eight measures: 1) effectiveness of state policies in promoting advance care planning; 2) proportion of deaths occurring at home; 3) utilization of hospice care; 4) availability of pain and palliative care services; 5) utilization of intensive care for dying patients; 6) extent to which pain is adequately managed in nursing homes; 7) effectiveness of state policies in encouraging good pain control; and 8) availability of physicians and nurses who are trained and certified in palliative care. Letter grades assigned to each state have raised the attention of legislators and health care leaders in communities across the nation. http://www.practicalbioethics.org/FileUploads/SI_18.pdf

19) State INITIATIVE 19. Focus: Community-State Partnerships, "Championing End of Life Care Policy Change." Issue 19, June, 2003. This initiative explored policy accomplishments and nontraditional activities, and was published by Myra's Bioethics Center, which was partnered with Last Acts, the now defunct right to die organization who claimed partnership with more than 1,000 national and local organizations. Noted accomplishments of this initiative: The North Carolina coalition used an existing coalition structure, which tripled their membership. In Florida, state hospice service areas evolved into local coalitions that carried out much of the work on the Community State Partnerships agenda. The Kansas coalition made "innovative, exemplary" use of the state extension agency. The D.C. coalition included several national associations in its membership, as well as local, grassroots groups that have achieved success on specific issues. Activities of the Policy entailed; neutralize special interests and defuse contentious policy issues, orchestrate reform efforts, leverage resources, including money, time and influence by building private public partnerships, engage (use) the public to create informed, mobilized constituents, build consensus around a societal, public good, provide access to credible sources, produce servant leaders, grounded in the collective good rather than their own personal advancement, collect data on the issues and distribute to the public, engage (use) the news media. Of note, the servant leaders are described as leaders who have the public's best interest at heart, can implement policy in creative ways, and can be called on to function as "SWAT teams" when necessary. http://www.practicalbioethics.org/FileUploads/SI_19.pdf

20) State INITIATIVE 20. Focus: Hospice Care, Part 3, "Maine's Legislative Approach to Expanding Hospice Access." Issue 20, November, 2003. This initiative highlights Maine and hospice issues, such as low utilization, access, institutional and research infrastructure, and Maine's statute on end of life care, including a physician assisted referendum. Legislative provisions are included. http://www.practicalbioethics.org/FileUploads/SI_20.pdf

21) State INITIATIVE 21. Focus: Pain Management, Part 3, "Barriers in Medicaid Reimbursement." Issue 21, November, 2003. This initiative discusses Medicaid's barriers to end of life care. One of the biggest reimbursement barriers is the lack of insurance carriers and Medicaid policies regarding reimbursement for pain management. Researchers outline 5 policy revisions for pain management practice strategies. 1) Relieve patients' limitations and cost burdens, and include medical necessity as a criterion, along with cost effectiveness, in making formulary decisions. 2) Bring Medicaid reimbursements for pain therapies up to par with current practice and costs, and develop systems to keep up with technological changes. 3) Clarify Medicaid policy to specify which pain therapies are covered, to relieve physicians' concerns about prescribing. 4) Ensure Medicaid's timely reimbursement to pharmacies. 5) Simplify reimbursement policies so that patients crossing into different care settings, or with certain illnesses, don't find coverage of medication curtailed. A call for research to study the nature of pain and its management was invited. http://www.practicalbioethics.org/FileUploads/SI_21.pdf

22) State INITIATIVE 22. Focus: Surrogate Decision Making, "Examining New Knowledge and Controversies about Serious Disorders of Consciousness." Issue 22, October, 2004. This initiative was distributed in October 2004, after a meeting of experts convened in May 2004. As NPO, Myra has been Editor of all the initiatives. This particular initiative discusses Terri Schiavo with a focus on surrogate decision making. Five issues are highlighted with three of those involving consciousness disorders; 1) Media Controversies and New Scientific Developments Spotlights Patients with Profound Brain Disorders, 2) Current Legal, Scientific, and Medical Thinking about Vegetative States, 3) Emerging Scientific Knowledge about Minimally Conscious States, 4) Tips for Policymakers, and 5) Thorny Ethical Questions. Through readings of this initiative, recommendations are made to "Increase the Utilization and Scope of Advance Directives for Older Persons and Those Who Are Ill, in Particular." The objective states, "Policymakers and opinion leaders must find ways to make advance directives-particularly durable powers of attorney for health care-a cultural expectation and, in certain circumstances, a requirement (e.g., the State of Maryland's Department of Health makes use of these tools a quality indicator in nursing home regulation)."

Look for Advance Directives to become law enacted by our federal Congress.

Among the "experts" present at the convened meeting were Myra Christopher, President and CEO of the Center for Practical Bioethics, Ron Cranford, MD, physician who pronounced Terri Schiavo with PVS, Joanne Lynn, MD, MA, MS, Director of The Washington Home Center for Palliative Care Studies and Senior Researcher with RAND Health, Karen Orloff Kaplan, MPH, ScD, Former President and CEO of Last Acts Partnership, Myrna Peralta, MSW, JD Coordinator of Rallying Points National Resource Center on Diversity in End of Life Care and President of ALTA Consulting Group, Judy Peres, LCSW-C Former Vice President for Policy and Advocacy, Last Acts Partnership, and True Ryndes, ANP, MPH, President and CEO of the National Hospice Work Group and Vice President for Public Policy and Advocacy at San Diego Hospice and Palliative Care. Legal principles of the right to Self Determination is discussed in this initiative. Disorders of consciousness and consciousness states are defined. http://www.practicalbioethics.org/FileUploads/SI_22.pdf

23) State INITIATIVE 23. Focus: Advance Care Planning, Part 3, "New Directions in Policy and Practice." Issue23, March, 2005. This initiative defines advance directive as "a generic term that describes several different kinds of actions that express preferences about end of life treatments, including living wills, health care treatment directives, and durable powers of attorney for health care." Advance care planning (ACP) involves the process of creating advance directives. This initiative provides a history and ethical issues of advance care planning, such as patient autonomy; the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) standards based on the Patient Self Determination Act (PSDA); strengths and weaknesses of advance directives; examples of tools in use to guide patients and families about end of life care decisions; policy issues on advance care planning; and utilization of the Uniform Health Care Decisions Act (UHCDA). The legislation is provided below.

Right to die advocates want end of life defined as a specific time with specific characteristics and including specific signs and symptoms, but the term is simply impossible to define with specificity. On the other hand, they want advance directive defined generically to include several thoughts, feelings, legal issues, orders, and more. Research will not back the term up as they want it defined. They should have used proper definitions, which are descriptive words, in naming advance directives in the beginning. But then "death documents" or "death decisions" is inflammatory. How could they push their philosophy on anybody with accurate terminology such as the above? People would ask questions and reject the ideas.
http://www.practicalbioethics.org/FileUploads/SI_23.pdf
http://www.abanet.org/rppt/publications/magazine/2001/01mj/01mjenglish.html
http://www.law.upenn.edu/bll/ulc/fnact99/1990s/uhcda93.htm

24) State INITIATIVE 24. Focus: Diversity and Discrimination, "Policies to Address Disparities in End of Life Care." Issue 24, April, 2005. This initiative discusses discriminatory barriers in care and policy comprising access, trust and training. Disparities comprise attitudes, insensitivity, lack of insurance, lack of access, and language barriers. Barriers of poverty and rural isolation are addressed. Barriers for the disabled are addressed. Disability rights advocates' state that dying individuals with disabilities should have pain and other symptoms managed, their families should be supported spiritually and socially, and their preferences and needs should be respected and fulfilled. They should be protected from neglect, abuse and exploitation. Issues 12 and 13 include information on disability and guardianship issues. "Center for Practical Bioethics (CPB) directed the Community-State Partnerships national program office (1998-2003), a program supported by The Robert Wood Johnson Foundation. The CPB continues to provide resources and education about ethical issues in health and health care to advocates, policymakers, professionals, and consumers." Guidance at the Crossroads of Decision is a phrase Myra recently added to her Center's advertising during 2004.. http://www.practicalbioethics.org/FileUploads/SI_24.pdf

25) Describes basic framework of Community-State Partnerships to Improve End of Life Care. http://www.practicalbioethics.org/cpb.aspx?pgID=932

26) Lists accomplishments and collaborations of Myra's Bioethics Center with national Attorneys General, healthcare regulators, programs, donors, and others. http://www.practicalbioethics.org/cpb.aspx?pgID=929

27) A story about Myra's center, the Center for Practical Bioethics. http://www.practicalbioethics.org/FileUploads/KCMag.June%202004.pdf

28) Center Fellows with a short biography on each involved with Myra's Bioethics Center. http://www.practicalbioethics.org/cpb.aspx?pgID=965

29) Senator Danforth, Art Caplan, and others praise Myra's bioethhics center. http://www.practicalbioethics.org/cpb.aspx?pgID=934

30) Speaking for Dying Patients, Health Care Agents Lack a Voice, "From 1999 to 2003, the Washington based Partnership for Caring, (formerly Choice in Dying) (currently Compassion and Choices) explored how healthcare agents and the individuals who appoint them view the role and responsibilities of healthcare agents in making end-of-life treatment decisions."

Myra's initiatives address myriad barriers to healthcare and end of life care. Most are legitimate concerns. If we eradicate the barriers, patients receive quality care. There are also moral barriers, and Myra did not speak of those. Myra was effective in eradicating those moral barriers. Break down the barriers to break down the public's defenses.
http://www.northcountrygazette.org/articles/041606HealthcareConnection.html
http://www.northcountrygazette.org/articles/042506MyraChristopher2.html
5-2-06

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