A physician named Dr. Eliezer Van Allen wrote an opinion column in this morning’s San Francisco Chronicle intending to puncture the fear of “death panels” in the context of our political debate over Obamacare–although he is not discussing the plan’s rationing boards, but rather, the end of life counseling controversy, a different matter altogether. Nobody is against physicians discussing what patients want in specific circumstances. As Dr. Van Allen notes, that is part of the job description for a primary care physician. The fear is that in a cost cutting/quality of life milieu, the counseling could become outcome directed, pushing very ill and expensive patients for which to care in a certain direction–already a problem with some advance directive forms.
Ironically, rather than allaying such fears, Dr.Van Allen’s story of counseling a patient he calls “Grace,” unintentionally illustrates the reason why some are so concerned. From his piece, “Serving On the First ‘Death Panel’” (my emphasis):
After pondering her mortality in silence, Grace made her choice. It turned out that we disagreed on her decision, and I felt compelled to explain my reasoning. She responded with her rationale, I acknowledged her capacity, and we quickly realized we were at an impasse. I did not invoke medical paternalism and demand she change her answer; she did not resort to petty insults and require I agree with her about a choice that she had every right to make for herself.
Grace came to a resolution about her end-of-life plan in the comfort of a quiet clinic room, without the stress and chaos of a true emergency prompting a rushed decision wrought with regret. I was reassured that I was able to provide Grace with the information necessary to make a decision, and Grace’s son was relieved to have talked about a subject that weighed heavily on his mind as Grace’s primary caretaker. Armageddon did not begin, she was not sentenced to death, and our visit ended pleasantly, as they always do with Grace.
Going forward, Grace promised to continue our conversation in the context of her complicated medical conditions, and she did so without the ridiculous fear-mongering and name-calling that infects our political discourse.
I am not castigating Dr. Van Allen in the least. He seems to be a caring physician who was truly concerned with Grace’s welfare. But one can only analyze the situation based on what he wrote, and his own words indicate that he did not finally accept her answer–even though he acknowledged she made her decision in full capacity and assures that he didn’t “demand” she change her answer (which he had no right to do).
No he didn’t brow beat her. But note, he intends to bring the matter up again, that is, to keep the “conversation going,” which one suspects, he would have deemed settled had Grace gone along with his views. And therein lies the potential problem.
This is a nuanced and delicate matter: Patients and doctors should be in continual conversation, particularly as health issues change. But when does “continuing the conversation” amount to refusing to finally accept the patient’s decision? Indeed, I hear often from people who believe they or their aged/ill/disabled loved ones are being pressured into refusing treatment–usually not by being brow beaten or yelled at–but from a constant, drip, drip, drip of conversation after conversation after conversation, which only end when the patient agrees to what the doctor or ethics committee want. In this phenomenon of the never-ending-conversation, people often perceive an attempt to wear them down by sheer exhaustion into acquiescing.
So, was this a “death panel”? No, and frankly, Dr. Van Allen would have better served his readers by not being so snarky. Was it inappropriate. No. But does the story he tells illustrate the rationality of people worrying about pressure by erosion of will? I think it does. And that is precisely why this issue often evokes so much emotion.
April 4th, 2010 | 1:20 pm
[...] This post was mentioned on Twitter by Vince Humphreys. Vince Humphreys said: SHS: Obamacare: Column Illustrates the Potential for “Never Ending Conversation” End of Life Counseling Pressure http://bit.ly/9z7sF8 #tcot [...]
April 4th, 2010 | 2:17 pm
Actually, Wesley, the article says that GRACE “promised to continue the conversation in the context of her complicated medical conditions.”
But so what? Would you have the same objection to a doctor continuing a conversation about quitting smoking over time? How about a conversation about exercise and weight loss? I’m paying a doctor for an educated opinion; otherwise, I could research my own conditions on the internet. I’d be poorly served if that doctor never addressed an issue again after one conversation.
Wesley J. Smith Reply:
April 4th, 2010 at 2:58 pm
Here’s the thing, Rebecca: Read the column and catch the nuance. And then comment.
April 4th, 2010 | 4:57 pm
Based on what he wrote, Dr. Van Allen sounds as if he is developing into a caring and sensitive physician. He and his patient (with her son present, presumably as her advocate) discussed end-of-life eventualities, disagreed and plan to continue the conversation in the future. We should all be so lucky to have such a situation.
There was nothing to suggest he didn’t accept Grace’s decision. If she went into respiratory failure tomorrow do you have any doubt that Dr. Van Allen would abide her wishes? Of course not. Will he try to change her mind at future visits? Probably. That’s his obligation as her physician, but he is honor-bound to put her needs first. But she may change her own mind based on her changing situation anyway.
I assume if you had evidence to support your charges of goverment death panels advocating killing or allowing seniors to die you would present it. Reliance on misinterpreting and overinterpreting the words of economists and physicians is not persuasive.
What do you think Grace decided? Does it matter for the purposes of this discussion?
April 4th, 2010 | 8:24 pm
“I assume if you had evidence to support your charges of goverment death panels advocating killing or allowing seniors to die you would present it.”——Jeffrey, you seem to have completely missed the part where Wesley wrote that the doctor was not actually discussing the “death panels,” also known as comparative effectiveness boards. Your side is constantly conflating Palin’s “death panels” with end of life counseling and I’m not sure why. Comparative effectiveness panels in other countries do, in fact, make rationing decisions which can mean the difference between life and death. I absolutely do not want anyone even remotely associated with the government making a decision about my health care, which is what the disaster called Obamacare, now sadly the law of the land, calls for. I just hope that when Chairman 0bama0 loses in 2012, his successor and the Republican Congress can repeal this health care deform monstrosity that the vast majority of Americans despise.
April 4th, 2010 | 11:01 pm
Chairman obamao? And anyone should take even one word from you seriously?
In any event, Mr. Smith typed this last Friday:
Krugman Admits Rationing (Death Panels) From Obamacare
Friday, April 2, 2010, 11:11 AM
Wesley J. Smith
You see, it’s not just the hapless Ms. Palin touting the non-existent “death panels”.
Wesley J. Smith Reply:
April 4th, 2010 at 11:27 pm
Jeffrey: You really must learn to distinguish between different issues the come under broad umbrellas. The “rationing boards” are the putative “death panels,” the end of life counseling controversy is a different issue. It’s not that hard.
April 5th, 2010 | 9:10 am
“Your side is constantly conflating Palin’s “death panels” with end of life counseling and I’m not sure why.”
I’m afraid you’ve got that backwards. Opponents of healthcare reform allege that government-mandated end-of-life counseling will be used to pressure people to submit to euthanasia. Palin simply uses the same scare tactic from another angle: that government will effectively “euthanize” patients by denying (or “rationing”) health care. Among Obama-haters, death panels and end-of-life counseling are simply opposite sides of the same coin. It’s all part of the blather known as “the culture of death.”
April 5th, 2010 | 11:01 am
I did read the column. But thanks for the suggestion.
However, my point remains the same. So a patient and a doctor will readdress an issue. What’s wrong with that? Nowhere in Dr. Van Allen’s article does he say that he plans to browbeat her. Quite the opposite, in fact.
To what “nuances” do you refer?
Wesley J. Smith Reply:
April 5th, 2010 at 12:34 pm
Rebecca. I meant my post.
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