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In one of the most daring moves to legalize Physician Assisted Suicide
(PAS), a form of euthanasia,
(http://www.cmawashington.org/index.cgi?CONTEXT=art&art=1646&BISKIT=1531536777)
and present it as acceptable mainstream views and medical practice, End
of Life (EOL) and Right to Die (RTD) proponents sponsored by the
defunct Last Acts Coalition, set a plan in motion that not only
identifies and defines specific chronic diseases as terminal, but
rations health care in the process for people with these chronic
diseases.
What are these diseases; cardiac disease, lung
disease, ALS, AIDS, Alzheimer's, diabetes, and even alcohol and drug
addicts, to name a few.
Combine these chronic diseases with "assisted dying for the terminally ill" legislative bills and we are in a heap of trouble.
The project details barriers with "Access to Hospice Care." The main
argument is that "Access," more specifically, current access to hospice
and hospice services and utilization of hospice care is ethically
unacceptable, and that justice and equity demand reform and change.
EOL and RTD proponents collaborated with the Hastings Center, the
National Hospice Workgroup, and the National Hospice and Palliative
Care Organization (NHPCO) to compile their complaints and
recommendations in a report influencing public policy titled, "Access
to Hospice Care: Expanding Boundaries, Overcoming Barriers." Support
for the project was provided by The Arthur Vining Davis Foundation of
Jacksonville, Florida, and the Nathan Cummings Foundation of New York.
EOL and RTD seeks access to patients with certain disease categories;
diseases that people live with for decades before they may succumb to
critical illness or death from the disease itself.
Last Acts summarized the complaints in the Access report:
"Too many Americans approach death without adequate medical, nursing,
social, and spiritual support. In the last stage of a long struggle
with incurable, progressive diseases such as cancer, heart or lung
disease, AIDS, Alzheimer's, Parkinson's, or amyotrophic lateral
sclerosis, their pain is untreated or inadequately controlled. Their
depression or other mental health problems are not addressed.
Debilitating physical symptoms rob them of energy, dignity, and
sometimes the will to carry on."
"In sum, too many Americans die unnecessarily bad deaths- deaths with
inadequate palliative support, inadequate compassion, and inadequate
human presence and witness. Deaths preceded by a dying marked by fear,
anxiety, loneliness, and isolation. Deaths that efface dignity and deny
individual self-control and choice. And too many Americans have their
access to better care and services, through hospice and other forms of
palliative care, blocked by a lack of information, misunderstandings,
and ambivalence about treatment options, unfairly restrictive
governmental policies, financial limitations, and other factors that
can and must be changed."
According to the Access report, EOL and RTD radicals blame "dying
badly" on the health care system we currently have in place. Do we
really die badly? Is dying badly due to society's failure to perceive
and address the ethical and human cost of limited access to, and
inadequate provision of, hospice care, as they claim?
Their goal to propose recommendations for restructuring and reforming
hospice to include more categories of patients they define as dying and
at their end of life is already taking shape in some hospice
facilities. But they also want an earlier introduction to the patient
and their disease process. They want government backing for policy
changes and funding, eliminate regulations that they consider barriers,
and change the cultural attitude to achieve their goals, particularly
with physicians who write the consultations to hospice.
EOL and RTD admit in their report that hospice was not intended to be a
program of chronic or Long Term Care (LTC); it was designed for short
term durations. Hospice now wants LTC patients, and EOL and RTD
advocates are assisting with studies, policy changes, and regulations
to make this a reality.
Hospice will no longer be for the imminently dying. Hospice
introduction in the early stages of a patient's chronic disease process
is what EOL advocates seek.
According to the Access report, the six month rule is a barrier that
was designed to restrict access to hospice for two reasons: to control
the overall costs to the Medicare program, and because the attitude in
the early 1980s was that hospice should be restricted primarily to
those in the terminal stage of an otherwise incurable and lethal form
of cancer that could not be cured. Hospice was not structured to become
another branch of the chronic and long term care health system.
So, the current 6 month to live policy for admission into hospice must
be eliminated. Is this change beneficial to the public, hospice,
government, insurance, or others? They must convince medicine to change
policies, and encourage physicians to refer patients to hospice in
greater numbers. They must have legislation in place that will not
hinder their goals.
Disease states such as chronic and long term conditions will surely be
included. Many of these illnesses will eventually be redefined at the
state levels of government as terminal diseases, just like PVS was
redefined by the Florida State Legislature for the Terri Schiavo case.
For the curious, chronic illness has a gradual onset of symptoms that
occurs over a long period of time; may have multiple and varied causes;
has varied responses to treatments; and the progression cannot be
accurately predicted. Patients may have multiple diagnoses, the
prognosis may be obscure, medical interventions may be ineffective and
require frequent changes, therapies may have adverse side effects or
reactions, and the costs of care may be high. When patients with
chronic obstructive pulmonary disease (COPD) are not experiencing an
exacerbation of their condition, they feel fine. They adapt to their
activity restrictions, use bronchodilators, stop smoking and do not
perceive their limitations as a terminal illness. Death may occur from
pneumonia, lung cancer or airway obstruction. These are the patients
EOL and RTD want to redefine as "terminal" even though they are not
close to death for many years. They argue people with chronic illnesses
never have time to 'wrap up' their lives or plan for death, and so they
do not utilize hospice care. Hospice wants to help.
This new organizational model will be a "community hospice" and a
"comprehensive hospice center." Eligibility will focus on continuity
and appropriate services in patient and family conditions over time.
Hospice will become the focal point in all disease conditions, as
everybody eventually dies.
They envision hospice as a new "model of social health care for an
aging society." They will define, organize, finance, and deliver
hospice care in this expanded role to cope with the staggering numbers
of persons with chronic, degenerative disease, the large numbers of
baby boomers, the fact that people live longer, and utilization of
scarce resources. If baby boomers live into their 90's, they drain the
system, and thus there will be scant resources for the healthy.
Hospice is in the process of transforming itself into a chronic care
socialized system of the future. Some hospices currently work out of
hospital settings. Many admit patients with chronic illnesses. We can
expect these practices to increase.
If EOL and RTD advocates successfully change their Access issues into
public policy, socialized medicine or universal healthcare will be
operational in the U.S., and anybody with a chronic condition, such as
elevated blood pressure, diabetes, and other easily controlled
diseases, will be enrolled in the hospice segment of health services on
initial diagnosis for hospice to follow and evaluate with an objective
to save resources.
Resource utilization is dwelled on in the Access report.
The Access report addresses equitable access. However, the report's
contributors are deceiving the public when they make claim to equitable
access for all, as they only want specific groups and disease
conditions, and these include some of the most vulnerable groups of
people at risk for abuse, neglect, and exploitation; the elderly and
disabled.
Two approaches are listed to reform and restructure financing and delivery systems.
1) Supplement existing hospice services with palliative care
integrated into non-hospice care settings to form a continuum of care,
of which hospice is a part.
2) Expand the scope and mission of hospices to provide palliative care,
beyond their current confines to serve populations of patients who have
longer to live and who are in various health care settings.
These changes will place hospice in hospitals, and Long Term Care (LTC)
and nursing home facilities, and as such, hospice will be consulted on
a routine basis.
The Access report makes claim that Equitable Access is a justifiable increase to access that should take place in three ways.
1) By making more people eligible for hospice admission and insurance coverage;
2) By lengthening the average time spent in hospice, primarily through earlier referral;
3) By maintaining both high-quality care and good stewardship of scarce
resources through a professionally rigorous case management system
within hospice programs.
Typically, hospice does not have patients on their service for long
periods of time; 40 days is the average, and they do admit more than
imminently dying and terminal cases. Hospice would increase their
patient Lengths of Stay (LOS) by implementing the early access ideas.
The report states, "The "chronically dying" or the "chronically
terminally ill" is a perspective consistent with the definition of
palliative care formulated by the World Health Organization, which
makes it virtually identical with hospice: "The active total care of
patients whose disease is not responsive to curative treatment."
(World Health Organization, Cancer Pain Relief and Palliative Care,
Technical Report 804 (Geneva: WHO, 1990).
We detest labeling diseases such as diabetics as terminally ill on the
basis that their disease is not responsive to curative treatments. We
cannot cure diabetes, but we can generally control it.
People with chronic diseases such as Chronic Obstructive Pulmonary
Disease (COPD), Congestive Heart Failure (CHF), Alzheimer's, and
diabetes will fall under hospice care and these patients will be
redefined as "chronically terminally ill." All disease processes that
medicine is unable to "cure" could very likely be lumped into the
hospice category as chronically terminally ill. What does the name,
"chronically terminally ill" mean to insurance providers? What kind of
medical coverage should we expect from this label of "chronically
terminally ill?" EOL and hospice believe withholding life sustaining
treatment is humane.
The hospice idea is to admit patients under palliative care service for
treatment, which includes prevention therapy, then shuffle the patients
to hospice service. Will treatments be denied by such labeling of
patients' diseases? We have no way of knowing what type of treatment
will be provided under hospice to the "chronically terminally ill."
The Access report claims 60 percent of hospice admissions are for a
primary diagnosis of cancer, and recent increases of certain non-cancer
admissions were declining due to what they felt was regulatory scrutiny.
Regulatory scrutiny is part of medicine. If health programs are
implemented within hospice, then hospice must be held to the same
regulatory scrutiny as all medical facilities and professionals,
particularly if they are hospital based and enter the patient's
treatment regimen as case managers where they influence care received
at early onset.
Hospice cannot operate without regulatory oversight and examination.
Accountability and responsibility to the public must be maintained.
According to the Centers for Disease Control (CDC), statistics state
940,000 Americans die each year of heart disease, 113,000 of lung
disease, 158,000 of cerebrovascular diseases, and 23,000 from
Alzheimer's. These people should all be included in hospice referral
and care, according to Access. Hospice and their EOL leaders want all
these patients and more.
www.cdc.gov
The Access report claims Americans' expressed their values in health
policy debates over the years to include "access to an adequate level
of care without excessive burden."
The terms "adequacy" and "excessive burden" are what EOL often define
medical care around. Adequate care is never used in excess; is not a
strain on resources, financial or otherwise; and is not life sustaining
that can drain resources. Their definitions are also fluid and apply
particularly to the elderly, disabled, and infirm. Soon to be added to
the list are all chronic diseases with progressive deterioration.
Excessive burden includes anyone that is a drain on resources; a burden
to their families, even if that familial burden is completely
unfounded; and a specified age. That specific age is uncertain, as it
has not yet been defined by EOL/RTD advocates.
Discussing the benefits versus burden issue in equitable access, the
report says beneficial care ignores the importance of various
treatments and care due to major care being so costly. So, to provide
universal access of all care of any benefit, the ability to spend
resources on other social goods would be compromised.
Their solution is to convince you to limit your own medical care and
refuse some forms of treatment, then you are exercising your self
determination rights, while freeing up resources for others. If you
expect treatment, you are a burden and compromise resources on social
goods.
The report goes on to state that society has no moral obligation to
help you get more than a basic minimum of care. Benefits versus
burdens, resource allocation, and basic minimum care will all be
assessed before you receive care, once this model of socialized
medicine is implemented. You receive minimum care and are entitled to
that, but nothing more. Society owes you no more. However, the report
claims society is responsible in providing EOL care to all people.
Society must provide hospice care to help you die, but not stay alive.
They place responsibility with the whole of society to provide and
enforce hospice care access.
Justice dictates apportionment of health care resources, according to
the Access report. Six material considerations are suggested: (1)
Individual need; (2) Prevalence; (3) Prospect of success; (4)
Alternatives; (5) Cost, and (6) Contribution to the common good.
Apportionment is supposed to promote human flourishing.
If treatment is denied because the prospect of success is uncertain,
that is not standard medical care. That is not even basic minimum care.
If 80% of baby boomers develop a chronic condition, but the cost of
treatment is high, an entire generation could be wiped out of existence.
The report goes on to name Hospice Stakeholders; individuals, families,
organized religion, physicians, organizations that provide and/or pay
for health care (insurance companies and Medicare), and government, and
all these stakeholders are morally responsible to provide and improve
access to hospice.
"The main stakeholder groups-consumers, providers, the hospice
community, public and private policymakers and community leaders, and
the bioethics community-largely agree on what is wrong with the present
system: there is too much emphasis on expensive, burdensome, and futile
life-prolonging care and too little emphasis on palliative care that
relieves suffering and sustains quality of living," according to an
excerpt from the Access report.
They have called for "a new medical ethics" where the focus of ethical
obligations shifts from individuals to populations. If you do not fill
out your Advance Directive to withhold life prolonging treatment or
feeding tubes, maybe the community will do it for you.
In addition to blaming the healthcare system for dying badly, EOL/RTD
blames physicians for not referring patients to hospice. They argue
doctors are committed to curative therapies. Medicine heals; isn't this
what medicine tries to achieve? Many curative therapies result in
symptom management, reversal of the disease, slows progression, and
controls the disease. This is standard medical care. You want curative
treatment. If you cannot be cured, then chronic or terminal condition
applies. So, physicians are committed to curative therapies and that is
proper, adequate and standard medicine. Infectious disease specialists
commit to slow down the progression and defeat AIDS. Cardiologists
commit to defeat heart disease. Endocrinologists commit to controlling
diabetes. Geriatricians commit to managing Alzheimer's. Neurologists
commit to rehabilitation of various forms of brain injury. Are
physicians supposed to halt treatment on these patients because of a
prognostic value that varies, fluctuates, and is unknown, and then
refer these patients to hospice for terminal care? If physicians do
this, they have lost their ability to practice medicine. They have lost
their profession and their attitude directly affects their patients. We
may not qualify for treatment of our diseases if bioethicists and the
EOL/RTD movement have their way.
Once hospice makes inroads into hospitals, nursing homes, and LTC
facilities, information will be provided on EOL care and death, even if
that information does not apply to the patient. Envision feeding tube
pamphlets stuffed in plastic boxes hanging on the corridor walls, along
with other educational information. Envision educational programs on
death and dying on TV in all healthcare facilities. To the elderly and
those with dementia, these tactics compound their confusion. How do
they distinguish reality from fiction when they repeatedly see and hear
what treatments they should forego or refuse? How therapeutic are these
marketing ploys for patients? Many patients who are alert and aware
would find this objectionable and depressing and wonder if they were
dying or had something that their doctor was not telling them. The
physician--patient relationship will dramatically deteriorate. Will you
feel safe in a hospital if this comes to pass?
The Access report says there is a cultural denial of death, resulting in avoidance or delay in hospice care.
Do people deny death? People do not obsess about how they should die,
unlike EOL/RTD advocates. Death is a depressing issue for some. Death
is not a hot topic around the dinner table. People fill out their
Advance Directives, line up their DPOA's, and get on with their life;
kids, family, work, vacations, celebrations.
The Access report also states EOL advocates must disassociate with
their death message. They propose association with burden, support, and
difficulties with health instead. The constant harping about death is
then eliminated. If they propose to disassociate with death, do people
deny death, as the report says, or is EOL and hospice denying death?
Word choice makes a powerful difference in how the public perceives,
accepts, and processes information. EOL will still associate with
death, but that word will not be used as it has in the past.
The EOL and hospice approach still, "forgoes life extending treatment,
which is often futile and inhumane in cases of end-stage Alzheimer's
disease (AD)," the report declares. Their definition of life extending
treatment includes tube feedings and other forms of basic care and they
believe feeding Alzheimer's patients is futile. In the near future,
Alzheimer's is not a disease you want, as your life is at risk.
As EOL declares, they are dealing with dying patients and their
families. To convince the public that their loved ones are in need of
hospice with diseases such as diabetes, heart diseases, COPD and lung
diseases, high blood pressure, dialysis, Alzheimer's, ALS, AIDS, PVS,
severe brain injuries, the elderly demented, coma, or other chronic
disease entities is deceiving and constitutes purposefully misinforming
the public. These disease classes are all EOL targets.
Their list of "terminal diseases" continues to expand as drug and
alcohol addiction has become a "chronically terminal" disease. Will we
close drug rehabilitation centers and admit these addicts to hospice,
instead?
If EOL redefines chronic conditions as terminal illnesses, everybody
who becomes diagnosed with a disease, other than an acute condition
that can be cured, will be considered terminal, chronic, and in need of
hospice.
The Access report claims Alzheimer's families are ready to learn about
the hospice approach to end of life care. They adamantly state, "If the
policymakers, physicians, and other "experts" cannot facilitate this
rapprochement, then they should get out of the way and at least stop
creating barriers to it." The barriers comprise Medicare Hospice
Benefit (MHB) and its six month life expectancy rule; utilization
review and fraud and abuse investigations on Alzheimer patients; and
hospices themselves in admitting Alzheimer patients. EOL/RTD believes
patients with dementia are discriminated against according to the
Access report.
"Prognostication of life expectancy is difficult, if not impossible,
with many chronic diseases that afflict large numbers of people. Life
expectancy for patients with congestive heart failure, chronic
pulmonary lung disease, diabetes, renal failure, and other life
threatening diseases cannot be predicted with the specificity the MHB
regulations require," Access states.
(E. Fox et al., "Evaluation of Prognostic Criteria for Determining
Hospice Eligibility in Patients with Advanced Lung, Heart, or Liver
Disease," JAMA 282 (1999): 1638-45. J. Lynn et al., "Defining the
"Terminally Ill:" Insights from SUPPORT," Duquesne Law Review 35
(1996), 311-36. J. Lynn et al., "Prognoses of Seriously Ill
Hospitalized Patients on the Days before Death: Implications for
Patient Care and Public Policy," New Horizons 5 (1997), 56-61. N.A.
Christakis and E.B. Lamont, "Extent and Determination of Error in
Physicians/Prognoses in Terminally Ill Patients: Prospective Cohort
Study," British Medical Journal 320 (2000), 469-73.)
Hospice admission based on specific prognostication criteria is
medically sound practice to follow in dealing with terminal illness.
However, terminal illness should not be redefined and should not
include chronic diseases. The potential for abuse is astronomical, and
abuse, neglect and exploitation will occur in far greater numbers than
in the Netherlands, as our population is much greater.
Since end stage cannot be determined in these diseases with a degree of
certitude, death cannot be prognosticated accurately. Yet, EOL
advocates want these diseases under their wing. Hospice facilities
could potentially become LTC centers.
The Access report states hospice physicians and those experienced with
Alzheimer's disease (AD) should devise guidelines for the admission and
recertification of AD patients and policy makers ought to accept them.
The report goes on to claim that the current Medical Review Policy on
Alzheimer's is overly restrictive and does not reflect accurate
understanding of end stage AD. Ironically, end stage AD cannot be
accurately defined or prognosticated accurately. Some EOL/RTD advocates
claim end stage AD is when the patient stops speaking. This is simply
false. AD patients have lived 4 years and longer, after they stop
speaking. What will the guidelines reflect that EOL/RTD want in place
that will not jeopardize the life of all patients?
Medical Review Policies are paramount to ensure patients are provided
treatment and care and not prematurely put to death. All regulatory,
oversight and investigative agencies in medicine are restrictive. If
hospice shirks this responsibility, there will be no protections in
place for patients or society, particularly for those with AD and other
"chronic terminal illness."
EOL/RTD firmly believe families of Alzheimer's patients have ethical
and theological concerns about withholding tube feedings, antibiotics,
and other forms of care and treatment. They believe these families, and
the public, should be informed that law, ethics, and theology agree
that hospice care for end stage Alzheimer's patients is ethically
appropriate in almost all cases whereby only palliative and comfort
measures are provided.
Life prolonging treatment in hospice includes nutrition and hydration,
and this does not have to be administered through a feeding tube. A
patient can be starved and dehydrated to death simply by having food
and fluids brought to their bedside and not actively assisting them to
eat. When a patient is placed in hospice, the public and family ought
to know exactly what to expect and what is not going to happen. The
law, bioethicists, and some clergy agree with this lack of basic care.
Myra Christopher's ELNEC and EPEC educational programs have provided
information to medical professionals on the moral acceptance of these
acts that hasten death. The EOL/RTD movement has preached acceptance of
withholding treatments as providing a good death, and that by making
someone eat is forcing care on them, even if they are capable of eating
with their fingers.
The Access report describes barriers within public policy, health
insurance coverage, financing, the attitudes and practices of health
care providers, and the attitudes and preferences of health care
consumers.
3 most powerful barriers according to Access:
(1) Laws, policies, and regulations affecting the organization, financing, and delivery of care,
(2) Attitudes and practices of health care providers, including
referring physicians and hospice professionals themselves, who are the
gatekeepers of the system, and
(3) Consumer misunderstanding, misinformation, and stigma against hospice.
Policy and regulatory changes must occur before EOL can implement
chronic illnesses as terminal. Medical professionals are a barrier to
their goal. The public will be re-educated with the new mission, which
excludes death, permits withholding treatment, and delegate
responsibility onto society for peer pressure.
These proposals presented in the Access report are compiled by EOL/RTD
groups and organizations, some hospice organizations, and the
philanthropists who support euthanasia and assisted suicide under the
pretense of improving health care in this country.
There is fear that certain forms of health care for the aged will
eventually become mandatory which are detrimental to their health and
well being, including the terminally ill, the chronically ill, the
mentally disabled and incapacitated, the frail and elderly, the
demented, and even drug and alcohol abusers, as mentioned in the Access
report.
Many bioethicists publicly surfaced with a philosophy similar to the
euthanasia movement. Unfortunately, the EOL/RTD groups and some hospice
centers share similar views.
They claim dying patients are neglected by medicine. Medicine has not
made a specialty out of death and dying. Dying is a medical issue, a
personal issue, and a societal issue.
We cannot make dying a value judgment and have it compete with medical
care. By doing so, we limit health care to the very people we propose
to serve.
The Access report claims certain people are a drain on resources and so should be placed in a specific care modality.
Portions of the Access project are already implemented in some states.
Medicine has applied some of the protocols proposed in Access. However,
medicine's ability to deliver standard medical care is usurped by
following these protocols which favor PAS and euthanasia. Federal and
state governments are deceived into believing they are passing good law
for the protection and welfare of their citizens. Healthcare regulatory
agencies are used to initiate regulations into practice. The public is
victimized due to their lack of knowledge on healthcare issues and
governmental policies.
There is no way to maintain a balance or achieve a common ground. We either legalize euthanasia or halt it.
EOL can infiltrate government, medicine, policy, and regulation, all of
which influences the care we receive. Can they infiltrate our moral
consciences? 9-26-06
Karen is a registered nurse with a specialty in obstetrics and currently holds licenses in Ohio and Florida
© 2006 North
Country Gazette
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