» Health Care Where the World Finds Bioethics Thu, 18 Dec 2014 19:19:15 +0000 en-US hourly 1 Physician, Torture Thyself Thu, 18 Dec 2014 14:27:45 +0000 ]]> 0 Most Physicians Give ‘Futile’ Life-Sustaining Interventions Thu, 18 Dec 2014 13:42:00 +0000 0 Brain death and uncertainty Wed, 17 Dec 2014 16:29:18 +0000 Read More »]]> 0 How Healthy Food Could Make You Fat Wed, 17 Dec 2014 14:03:56 +0000 Continue reading ]]> 0 Medical Futility Lawsuit in Philadelphia Proceeds Wed, 17 Dec 2014 09:30:00 +0000 0 Follow-Up on My Stoplight Musings Tue, 16 Dec 2014 14:20:10 +0000 Continue reading ]]> 0 Does A Just Society Use the “R” Word? Tue, 16 Dec 2014 14:06:04 +0000 ]]> 0 DRW v. University of Wisconsin – Facilitating Surrogates’ "Illegal" Decisions to Stop Life-Sustaining Treatment Tue, 16 Dec 2014 09:30:00 +0000 0 Notes on the Mill Valley Film Festival, 2014 Tue, 16 Dec 2014 06:23:00 +0000 I saw 19 films at the 2014, 36th Annual Mill Valley Film Festival (MVFF36) this October. After the first five films on my list I realized a pattern which the festival's programmers had not intentionally planned. There were at two major groups that stood out with some that crossed both.

One group of films dealt with people with Enormous Skill, or Promise, Meeting Extraordinary Adversity. They all in some way reflected the relationship between the brain and the mind or how the mind deals with the stress the brain transmits.  The dissolution of the Brain-Mind paradox also reflects ways in which new science, particularly neuroscience, is creating broader social inclusion of individuals with circumstances which previously, historically, would have stigmatized them; autism spectrum traits, physical disabilities, gender differences.

Beneficence - or doing "good" with knowledge, including technology, is Beneficence. I consider these films to illustrate “doing good” with knowledge. I call this set of films 'Promise meets Adversity,' They include: THE IMITATION GAME,  STATES OF GRACE, THE THEORY OF EVERYTHING, IMPERIAL DREAMS and MOMMY.  None of these were comedies but they are all very good.

A second large group of movies at MVFF36 thematically dealt with issues of Proxy Parenting. Who best raises a child? Ethically, we consider that parents represent the best interest of their children, unless proven otherwise.  These films pondered more questions than they answered but Then if not the parent - who? Sometimes the best a parent can do is to select others to act in their stead. Working parents do it all the time, if it can be afforded.  Overwhelmed parents do it also. When parents relinquish parental involvement, temporary or permanently how do we define their right to do so. At what age is a child able to decide on their own about who should parent them?

Medically and legally we have made a value judgment to emancipate children for sexual issues but not for other matters. Should the parameters of emancipation be psychological, cultural, religious or intellectual? Regarding autonomy, do we as bioethicists or clinicians,  “know it when we see it?”  I call this group of films 'Parents and Proxies.'  The MVFF2014 relevant films are: MARIE'S STORY, NATURAL SCIENCES/Ciencias Naturales,  LIKE SUNDAY LIKE RAIN. Li  THE TALE OF PRINCESS KAGUAY/Kaguya-Hime No Monogatari, BLACK AND WHITE and SOLEILS. Many of these films have significant comedic or lighthearted elements though the deal with serious issues.
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Part I: THE IMITATION GAME meets HOW I CAME TO HATE MATH/Comment j’ai détesté les Maths, Moral Relativism vs Beneficence and Justice: Moral Injury, War and Computer Science Tue, 16 Dec 2014 06:19:00 +0000 THE IMITATION GAME 
Alan Turing was a Cambridge trained mathematician, wonderfully portrayed by Benedict Cumberbatch (Sherlock) in the WWII bio-historical thriller, THE IMITATION GAME. The film directed by Morten Tyldum and written by Graham Moore was screened at the 36th annual Mill Valley Film Festival 2014. It is an adaptation of a book by Andrew Hodges, Alan Turing: The Enigma 

While a fellow at the MacLean Center for Clinical Medical Ethics in 1990, it was this writer's profound good luck to meet and spend time with the late Dr. Stephen Toulman, a British born physicist, mathematician, philosopher and communications expert. Also Cambridge educated, Stephen knew Alan Touring and his work. Dr. Toulman shared his 1984 New York Review of Books article 'The Fall of Genius,' a critique of the Hodges book, with a digestible explanation of the way that mathematicians minds work. 

Moral relativism is used in arguments about defense of safety and security in times of war. War being defined as “a state of armed conflict between different nations or states or different groups within a nation or state”. In the loosie-goosie world of the noncombatant, war is often used as a metaphor. Dr. Toulman wanted to be sure of what we spoke. Most importantly he looked at the arguments which drive scientific exploration during war and their consequences. 

The plot of THE IMITATION GAME supplies a protagonist who is focused on the work of his mind, to the exclusion of most social contact nearly on the Asperger's Syndrome spectrum. During this period, that work is construction of a machine ultimately able to decode Nazi strategic plans for attacks on allied forces during WWII. The machine historically is known as the Turing Machine and it’s inventor the father of distributed computing.

At its simplest, distributed computing allows the extraction of any single item from a group, for whatever purposes; defining the human genome or spying on citizens. The popular television show, PERSON OF INTEREST provides many fictional examples. THE IMITATION GAME raises important ethical conflicts which plague each of us in science and medicine and become more tense in the circumstance of war. Applied Science, as was the case of the Turing Machine, can be used for good, but in the process harm can also be done, the traditional “double effect” or duplicity of all things. Navigating such conflicts are the life’s blood of practical Bioethics. 

 In the case of THE IMITATION GAME, members of the British Intelligence Service who were endowed with mathematical sensibility, had to make a moral choices which cost the lives of Allied Soldiers. The choice was necessitated because the technology they built worked so well, they “had to,” let their comrades die. 

“Had to,” is a phrase which always risks moral relativism. All moral frameworks are relative, except the one conveniently determine to be absolute at the moment. There is a plethora of popular television which justifies torture despite article 5 of the Universal Declaration of Human Rights. Immoral actions may be taken, but one shouldn’t fool one’s self with the idea they are the results of absolute moral choices. 

Often in the case in War and triage, “the greater good” doctrine wins as the absolute morality model of the day. In the IMITATION GAME, each mathematician involved believes ending the war sooner, rather than later, is justifiable at the cost of many Allied lives. If they could not choose, they simply could follow the commander’s orders, sounding strikingly like the struck down morality of the Nuremberg defense. Justice, by weighing burdens and benefits is an intellectual as well as an emotional norm. Yet, in the film, though at least considered, the decision is portrayed primarily as emotional. 

Hodges book was written thirty years after Turing died of cyanide poisoning and vicious immoral hormonal castration of his person, his homosexuality being odds with then vile British law and anti-gay bias. One cannot discount the role of “having to “let people die, playing in the psyche of depression and suicide. Those who care for Veterans of active combat dying in hospice, are aware of soldiers' attempts to reconcile moral injury from military obligations with their own humanity. 

Mathematicians generally know the difference between correct and incorrect answers, valid and fallacious arguments. Math and philosophy are intrinsically linked by logic, among other things. It could be argued that the burden of the Turing Decoders inaction to protect Allied soldiers, in THE IMITATION GAME was higher than would be for others, because as mathematicians they could calculate the risks as they were creating them. 

Further watching and reading: 

The Imitation Game (35mm) directed by Morten Tyldum ( 2014) Black Bear Pictures ( UK) 114 mins 

The Imitation Game trailer 

The Universal Declaration of Human Rights accessed December 11, 2014 

Toulman, S. The Fall of a Giant, Andrew Hodges, Alan Touring: The Enigma. October 15, 2010 

National Center for PTSD, Moral Injury in the context of War. accessed November 11, 2014. 

Miles, S.H. Oath Betrayed: Americ's Torture Doctors. University of California Press. 2009. 312p. 

Beneath the Blind Fold (Digital Political Documentary) Directed by Ines Sommer and Kathy Berger Somers ( 2012) Sommer Film Works see 

 Person of Interest (2011-) TV Series. 

H.T. King, Jr., The Legacy of Nuremberg, Case Western Journal of International Law, Vol. 34. (Fall 2002) accessed December 11, 2014.
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Part II: THE IMITATION GAME meets HOW I CAME TO HATE MATH/ Comment J’ai Détesté Les Maths Moral Relativism vs Beneficence and Justice: Maths and Economics Tue, 16 Dec 2014 06:04:00 +0000 HOW I CAME TO HATE MATH/ Comment J'ai Détesté Les Maths is a film Directed by Olivier Peyon and written along with Amandine Escoffier. It  is a documentary whose initial purpose seems hijacked by historical events. Its parallel to the fictional historical biopic thriller, THE IMITATION GAME, screened at the Mill Valley Film Festival 2014, need be made. 
The MATH story, like in THE IMITATION GAME, begins lightly with young people who are awkward. Some of them, like Alan Turing,  grow into the lovely eccentricity that those who both love and understand maths often bear. Peyton’s film tours the world of elite global mathematics prize winners and its retreats. The viewer has the feeling of watching young Einsteins. The film is initially a celebration of Maths. 

After showing the rarefied air which the theoretical mathematicians breathe, MATHS eases viewers into the world of technical applications of maths. Finally, the story leads to the economic crisis of our current millennium and the misleading mathematical modeling which wrought it. 

Mathematicians, on camera, own the horrific results of their science.  It is reminiscent of Einstein after the the theory of relativity was weaponized. A nausea is shared by many clinicians and other applied scientists as they wade through memory of disasters sometimes mediated by applied theory, particularly when ethical parameters were absent. 

 “Is there any definable method for deciding whether any given mathematical assertion is true or not?”  The procedure for seeking this answer required stating a hypothesis, like any other science.  "If it were true," Toulman paraphrased  Alan Turing,  ”Any method of 'routinizing' mathematical proof can be thought of as a mechanical process.” Then the question was one of 'simple' technology “What sort of a “machine” would be needed to carry out such a proof?”   This was how the computer was theorized and developed.  It happened that the resources to build the machine arrived in the form of WWII.  However, the drive, well before the War, was Turing's theory needing proof. It happens that  the military remains one of a few venues where mathematics gets funded. The use of science and medicine in war is a bioethical issue.

“What happened with mathematical modeling?”  the last third of HOW I CAME TO HATE MATHS asks.
When Scientific theory jumps to technology, there is always a risk that those who best know the Science will loose or relinquish control of it. It is the fundamental basis of Bioethics that Scientist and Applied Scientist should resist the temptation to abandon their work to those less knowledgeable of their fields. Bioethics is not only a field for medical doctors, clinical medical ethics is only a subset. 

HOW I CAME TO HATE MATH asserts, mathematicians recognized errors in economic mathematical modeling earlier than has been admitted by financiers. In the blame game, the common person's behavioral finance is often pointed out while financiers and maths models are ignored.  As in other situations of bioethical conflict, the first step is recognizing a conflict and then exploring it. Taking responsibility is  requisite for the minds knowing the field to explore the  conflict, as happens in the film HOW I CAME TO HATE MATH.

Not too far away from the applications of the Turing Machine, or mathematical economic models we have seen similar loss of control of the fields of medicine and public health. Misuse of the technology ( knowledge) related to quarantine, perhaps for political capital, during epidemic scares,  come to mind. The murder of polio vaccine workers by extremist when the vaccine program was used as a shield for covert military activity also is an example. 

The logic of immorality is always flawed and bears consequences. However, detailed moral analysis may also bear negative results. The difference is made,  as in all science and ethics,not only by intention of but attention to details.  The people watching have to be able to recognize what they see. Biological Science receiving federal funding requires those learning to use it  have some training in Bioethics that is, graduate students. Apparently,  maths departments have no ethical educational obligation imposed by financiers. Maths and computer science have major bioethical  context in this and the last century.   Recognizing mathematical modeling’s role in a  devastating economic collapse of the world’s economy does not  excuse the greed of financiers, it only recognizes the bioethical issue.  

Even when those who know the science do their best at moral consideration, monitoring of consequences is paramount, in war and in peace. Having spent the last half of his life on Peace, Einstein would agree.  Hats if to the filmmakers of HOW  I CAME TO HATE MATHS, and the mathematicians they interviewed,  for the jerky C- turn made in the last third of this film. Don’t be fooled by the cute beginning. HOW I CAME TO HATE MATHS chronicles a whiplash in history that threatens to break a century’s neck.


How I Came to Hate Math / Comment j'ai détesté les ma (35mm) Directed by Olivier Peyon.(2013) Documentary. France (103 min)

How I came to  Hate Math  trailer" accessed October 16, 2014

The National Association of Retirement Plan Participants

Enstein, A., Nathan, O., Heinz, N. Einstein on Peace. Simon. 1960 

Punjwani, S. K. (2014). Understanding Underpinnings of
Act of Violence against Polio Workers: A Case Study of Pakistan. In I. Needham,
M. Kingma, K. McKenna, O. Frank, C. Tuttas, S. Kingma, et al., Fourth
International Conference on Violence in Health Sector; Towards Safety, Security
and Wellbeing of all (pp. 80-83). Amesterdam: Kavanah, Dewingeloo & Oud
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GOING THE DISTANCE SCREENING FUNDRAISER Tue, 16 Dec 2014 04:44:00 +0000 0 GOING THE DISTANCE meets SURFING FOR LIFE Tue, 16 Dec 2014 04:22:00 +0000
Bioethical issues in Traumatic Brain Injury 

GOING THE DISTANCE: JOURNEYS OF RECOVERY is a documentary film about the lives of survivors of Traumatic Brain Injury. Directed by multi-Emmy Award winning filmmaker David L. Brown, the project is seeking funding for its finishing phase. This film has had multiple previews in collaboration with brain injury advocates.  It has also been used in therapeutic TBI groups to gauge the communities' take on their depiction. An earlier film by the same director, SURFING FOR LIFE, reinforces that Brown, like any good film auteur, finds different ways of telling stories whose elements are significant to him. 

SURFING FOR LIFE deals with optimizing life from childhood through aging. It explores our relationship with water or what evolutionary biologists J. W. Nichols calls the ‘Blue Mind.’  GOING THE DISTANCE also deals with maximizing people's potential, after the have acquired brain injury. Not surprisingly, some of the films protagonists also have a restorative relationship with water. 

David L. Brown’s films have a solid optimism to them. That’s right, GOING THE DISTANCE is an optimistic film about TBI. The project follows four people through a narrative spanning roughly eight years. The work has the weight of longevity, diversity and the drama of living on the edges between life, death and rebirth. With four main characters, instead of one, the film is racial, gender, and age cohort inclusive. Permutations and combinations leave every viewer identifying with some part of the story. 

Why is Traumatic Brain Injury of particular bioethical concern?  There are tensions between beneficence, autonomy and justice manifest in issues around the epidemic incidence of TBI. The principle of beneficence, doing good with our science, services medical indications.  We now have plenty of neuroscience to support how these injuries occur at the cellular level and the best ways to prevent and deal with the sequelae. Yet, there are organizational and geopolitical barriers to clinicians and survivors accessing, or utilizing that information. Justice is facilitated by equipoise. Equipoise is the equitable distribution of burdens and benefits. Organizational and geopolitical factors often impede equipoise in the prevention and management of TBI. 

Among the important new science is a better understanding of ‘neuroplasticity,’ Dr. Albert Ray considers neuroplasticity the operating system for the nervous system.  It is the mechanism whereby the physical anatomy and physiological workings of our nervous system happen, both in normal and pathological conditions. It is what makes the brain programmable and re-programmable. 

After a period of intense neurological rest, recruitment and retraining of undamaged brain tissue improves functional capacity.  That recruitment process results from neuroplasticity, or reshaping parts of the brain, to assume tasks abandoned in the aftermath of the traumatic injury. Neuroplasticity fuels the work of occupational, physical and speech therapist and those acting in their stead. When forced to prognosticate, professionals do so within the parameters of the resource stressed systems in which they work. For instance they might cautiously say," A person with this initial assessment, receiving therapy weekly, can expect 'X' amount of functionality in one a year." GOING THE DISTANCE is a story about best chances to exceed those expectations.

Other manifestations of conflicts between beneficence and justice affect veterans returning from war zones with undiagnosed TBI as well as Post Traumatic Stress Disorder, car accidents, repetitive concussions from sports, violent assaults and motor vehicle accidents.  All of these disproportionately affect the young, very old,  poor, and people of color.  Adequate activities of known therapeutic benefit and prevention are often unattainable because of cost and lack of trained resources. Though brilliant acute trauma and neurosurgical care occurs in most urban centers in the USA, the follow up care is lacking. TBI, is a health and healthcare disparity issue. 

Traumatic Brain Injury also results in bioethical tensions between beneficence and the principal of autonomy, or the right to do what is in one’s own enlightened self-interest.  Most agree parents are appropriate surrogate decision makers for their children. Substituted judgment in adults, particularly young adults, with brain injury is wrought with uncertainty regarding extent of damage to a person’s decisional capacity. In this way TBI, like dementia, is a moving target. Dementia and TBI are related in other ways as well.

There is compelling data that negative cognitive effects are among the most disabling of post-concussion symptoms following moderate and severe TBI. These effects unfold slowly, sometimes over years and lead to high incidences of dementia. Deficits occur in attention, memory and "executive function," These deficits show up as impulsiveness, mental fatigue, frustration, depression, pain, self-medication, substance abuse and loss of employment. Justice suggest,” those with the most burden should have the most benefit.” In the most developed nations, minds which operate “like steel traps,” are adored. TBI survivors rarely have those kinds of minds and are often not well accommodated by legislative measures, including the application of the American Disability Act. 

The film CRASH REEL gives a good example of autonomy conflicting with beneficence. An extraordinary athlete, champion snow boarder, struggles with his late stage cognitive and physical limits. The recently completed film, STATES OF GRACE (reviewed elsewhere on this blog) like CRASH REEL, is about another person with uncommon capacity facing extraordinary adversity. There is much to learn from these films but it is not the story of GTD. 
GOING THE DISTANCE is about ordinary people riding waves of adversity, while attempting the boring things of daily life. They use “what they’ve got."  What they have is family, friends and advocates.  By example, GTD gently makes the point that those without support have rougher rides and may drown in the surf. GOING THE DISTANCE is a documentary about quiet heroes focused not on what they cannot do in TBI recovery, but what they can.  
GONG THE DISTANCE (Digital) directed by David L. Brown ( 2014) pending release USA.  62 mins
SURFING FOR LIFE  (Video) directed by David L. Brown (1999) USA  68 min. 
THE CRASH REEL (2013) directed by Lucy Walker  HBO Films  USA 108 mins
STATES OF GRACE ( 2014) directed by Helen Cohen and Mark Lipman (USA) distribution pending 71 mins.
Nichols, W. J. Blue Mind. Little, Brown and Company, 2014.
Ray, A. Neuroplasticity, Sensitization, and Pain. in Comprehensive Treatment of Chronic Pain by Medical, Interventional and Behavioral Approaches. ed. Deer, T.R.;Leong,M.S; Ray, A.L. et. al. ; American Acad- emy of Pain Medicine. Springer Inc. 2013.p 759-768,
Shively S1, Scher AI, Perl DP, Diaz-Arrastia R. Arch Neurol. Dementia resulting from traumatic brain injury: what is the pathology? 2012 Oct;69(10):1245-51 accessed December 12, 2014
Carmichael, S. (2010). Translating the frontiers of brain repair to treatments: Starting not to break the rules. Neurobiology of Disease, 37(2), pp. 1-10.

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Tracey v. Cambridge University Hospital – Duty to Consult Mon, 15 Dec 2014 23:00:00 +0000 0 Is Homo Economicus a Psychopath? Mon, 15 Dec 2014 14:48:33 +0000 Continue reading ]]> 0 Ontario Medical Board Seeks Input on Draft End-of-Life Policy Mon, 15 Dec 2014 09:30:00 +0000 The College of Physicians and Surgeons of Ontario has just posted ’s a revised draft policy for external consultation: "Planning for and Providing Quality End-of-Life Care."  

The draft policy sets out professional expectations of physicians and provides guidance on a range of issues relating to quality end-of-life care, including futility and aid in dying.

The CPSO is inviting feedback from all stakeholders, including members of the medical profession, the public, health system organizations and other health professionals on the draft policy. Comments received by February 2015 will assist in developing a final policy which will be considered for final approval by Council.  Several good comments already appear on the online discussion board.

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Patients Abandoned—Who is to blame? Mon, 15 Dec 2014 03:12:43 +0000 0 Mass General – Futility Policy Experience Sun, 14 Dec 2014 10:00:00 +0000 0 Communicating about Prognosis and End-of-Life Care in Patients with Advanced Cancer (video) Sat, 13 Dec 2014 10:00:00 +0000 0 Brain Death – Abandoned in British Labor Case? Fri, 12 Dec 2014 19:21:00 +0000 0 The Ulysses Strategy Fri, 12 Dec 2014 13:09:14 +0000 Continue reading ]]> 0 Carol Taylor – What Constitutes Good Care at the End of Life (video) Fri, 12 Dec 2014 09:30:00 +0000 0 The people who don’t deserve health care Fri, 12 Dec 2014 07:00:08 +0000 Read More »]]> 0 PRIM&R Conference Update: Research Ethics and Incidental and Secondary Findings Thu, 11 Dec 2014 17:28:08 +0000 0 Chicago Brain Death Case Now Federal Lawsuit Thu, 11 Dec 2014 09:00:00 +0000 0 The CIA Torture Report: Health, Medicine & Ethics Thu, 11 Dec 2014 08:02:12 +0000 by Craig Klugman, Ph.D.

On Tuesday, December 9, the U.S. Senate Select Committee on intelligence released its long awaited report on CIA interrogation and torture. This 500-page executive summary details the results of six years of investigations that covered over 6 million pages of records. What was discovered is that torture was more brutal and extensive than reported, that information was kept secret, that the programs were mismanaged and lacked oversight, and that most likely no information came out of it.…

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A different type of virtue Thu, 11 Dec 2014 02:38:00 +0000 Read More »]]> 0 Will A “Red Light” Be An Effective Nudge To Stop People From Drinking Coke? Wed, 10 Dec 2014 14:36:35 +0000 Continue reading ]]> 0 Peter Saul & Michael Ashby – How We Die (video) Wed, 10 Dec 2014 10:00:00 +0000 Dr Peter Saul and Professor Michael Ashby delivered a session on ‘How We Die’ from the perspectives of intensive care and palliative care at the International Conference on End of Life in Brisbane, 2014.

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Medicaid Expansion is Good for Hospitals Tue, 09 Dec 2014 13:53:33 +0000 Continue reading ]]> 0 Rasouli Does Not Require Brain Death Disputes Go to Consent & Capacity Board Tue, 09 Dec 2014 09:00:00 +0000 0 Marketing Extremes That Even Give Big Pharma Supporters Pause Tue, 09 Dec 2014 02:12:55 +0000 0 Short Code Leads to Medical Malpractice Claim Mon, 08 Dec 2014 23:54:00 +0000 0 Text Messaging: A Cure for Common Nonadherence? Mon, 08 Dec 2014 19:34:57 +0000 by Craig Klugman, Ph.D.

According to research studies on medication usage, nearly 22% of all e-prescriptions and 28% of new prescriptions are not filled. For heart medications among people who have experienced a heart attach, one-half to two-thirds (depending on the medication) of patients were nonadherent to a prescription regimen. Patient adherence to medication is related to the disease, side effects, how long they are treated (there is a drop off after 6-months of treatment), complexity of the regimen, severity of disease, and cost of the medication.…

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Debates About the Use of Behavioral Economics in India Mon, 08 Dec 2014 13:49:10 +0000 Continue reading ]]> 0 New Jersey Palliative Care Information Act Mon, 08 Dec 2014 10:00:00 +0000 Rep. PinkinThis week, following California, New York, and several other states, New Jersey introduced a Palliative Care Information Act bill.  

1.  Palliative Care Consumer & Professional Information and Education Program
The bill would first establish a “Palliative Care Consumer and Professional Information and Education Program” in the Department of Health, which would maximize the effectiveness of palliative care initiatives in the State by ensuring that comprehensive and accurate information and education about palliative care is available to the public, to health care providers, and to health care facilities.

2.  Provide Information about Palliative Care Services
The bill would additionally require all licensed health care facilities to establish a system for identifying patients or residents who could benefit from palliative care, and to provide information about and facilitate access to appropriate palliative care services for those patients and residents. A health care facility failing to meet these requirements, could be subject to a civil monetary penalty.

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Duty to Challenge Surrogate with Suspect Authority – Frausto v. Texas Health Harris Methodist Hospital Sun, 07 Dec 2014 09:30:00 +0000 0 Expanding Palliative Care – Saves Billions, Honors Wishes Sat, 06 Dec 2014 11:30:00 +0000 A new report from The Berkeley Forum finds that California hospital spending could be reduced by billions of dollars over the next eight years if patients’ wishes about palliative care were honored. 

The study also found that by expanding access to community-based palliative care to over 100,000 Californians a year through 2022, more than $5.5 billion could be moved from high-cost, unwanted hospital services while honoring patient wishes for care at home and in other community settings.

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Submit Your Comments to CMS on the New Advance Care Planning Codes Sat, 06 Dec 2014 01:06:00 +0000 The Centers for Medicare & Medicaid Services (CMS) is choosing not to pay for new advance care planning codes in this year’s Medicare Physician Fee Schedule.  But CMS is accepting public comment on this decision now through December 30, 2014. 

Submit your comments here and tell them why you support reimbursement for ACP services.

For more background, see excellent posts over at GeriPal and PalliMed.

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Trapper’s Care in the Animal ER and Frank Talk about Costs Fri, 05 Dec 2014 14:54:00 +0000 Chelsea A. Jack]]> 0 Putting the Sin in Sin Tax Fri, 05 Dec 2014 14:27:41 +0000 Continue reading ]]> 0 Michael Fratkin’s End-of-Life Care Program – ResolutionCare Fri, 05 Dec 2014 12:06:00 +0000 Michael Fratkin is the medical director of the Palliative Care Service at a community hospital in rural Northern California.  

He recently founded ResolutionCare as a response to the exploding need for capable and soulful care for everyone, everywhere as they face the completion of life.  (NPR)

ResolutionCare will do three things. First, it "will provide outpatient palliative care to people in their own homes, either via house calls or through virtual house calls using telemedicine technology."  (Lost Coast Outpost)

Second, Resolution Care will provide "telemedicine consultations to patients anywhere in California, particularly in rural areas where palliative care is lacking."

Third, Resolution Care will "reproduce this palliative care model elsewhere in the state." 

The ReSolutionCare website has lots of additional materials and videos.  The basic description is as "a social enterprise responding to exploding demand for severely limited Palliative Care services as people face mortality within a fragmented and transforming health care system."

"The quality of care for individuals facing the end of their lives—and their loved ones—is often characterized by unmet needs for even basic symptom control, confusion in the navigation of labyrinthine healthcare delivery systems, and the loss of empowerment and self-determination."

"The field of Palliative Care has gotten enormous traction with policy makers and professional organizations over the last 10-15 years by delivering high quality person-centered support for well being, in parallel with disease-targeted medical care."

"In the face of shifting incentives, evolving sensibilities, and shear demographic weight of the aging ‘Baby Boom’ generation, the demand for Palliative Care is growing exponentially while the supply of skilled and inspired professionals lags far behind. The result is unnecessary suffering, and costs, and an enormous opportunity to make a meaningful difference for everyone at the most vulnerable moment imaginable."

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Disparaging Remarks about the IPAB Fri, 05 Dec 2014 05:36:58 +0000 Read More »]]> 0 Obamacare 2.0—Better than Version 1.0? Thu, 04 Dec 2014 18:23:48 +0000 Continue reading ]]> 0 The Age Of Electronic Medical Records Is Upon Us Thu, 04 Dec 2014 18:01:59 +0000 Continue reading ]]> 0 Simon’s Law in Missouri Would Require "Written Permission" to Stop Life-Sustaining Treatment Thu, 04 Dec 2014 14:22:00 +0000 Ordained Christian minister and Missouri state representative Bill Kidd has introduced H.B. 113.  It contains two main provisions.

The first provision is uncontroversial.  It is a futility policy disclosure rule that mirrors recent laws in Michigan and obligations already binding on all U.S. hospitals under the PSDA.

"Upon the request of a patient or resident or a prospective patient or resident, a health care facility, nursing home, or physician shall disclose in writing any policies relating to a patient or resident or the services a patient or resident may receive involving life-sustaining or non-beneficial treatment within the health care facility or agency."

"Upon admission and upon request, if the patient or resident or prospective patient or resident is a minor child or minor ward, the health care facility, nursing home or physician in charge shall provide in writing the policies described in subsection of this section to at least one parent or legal guardian of the patient or resident or prospective patient or resident."

More controversially, the bill also follows Idaho and Oklahoma in always requiring consent to stop life-sustaining treatment.  But in contrast to those other states, the Missouri bill is focused on only treatment of children.

"No health care facility, nursing home, physician, nurse, or medical staff shall withhold life-sustaining procedures, food, medication, or nutrition, nor place any restrictions on life-sustaining procedures including, but not limited to, food, medication, or nutrition for any minor patient, resident, or ward without the written permission of at least one parent or legal guardian of the minor patient or ward."

"No do-not-resuscitate order or similar physician’s order shall be instituted either orally or in writing without the written permission of at least one parent or legal guardian of the minor patient or resident or prospective minor patient or resident."

"Nothing in this section shall require a health care facility, nursing home, or physician to have a written policy relating to or involving life-sustaining or non-beneficial treatment for minor or adult patients, residents, or wards."

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Protecting Transgender Students Thu, 04 Dec 2014 13:09:02 +0000 ]]> 0 James and Lamar’s Excellent Adventure Thu, 04 Dec 2014 02:12:11 +0000 0 Diagnosing Death in the 21st Century (video) Wed, 03 Dec 2014 10:00:00 +0000 Dale Gardiner delivered an outstanding (and entertaining) keynote at the International Conference on End of Life in Brisbane, 2014. The conference was co-hosted by QUT’s Australian Centre for Health Law Research, Dalhousie Health Law Institute and Tsinghua Health Law Research Centre.

At the same conference, I more briefly discuss brain death as part of a panel on "Comparative flash points in end of life law, ethics and policy."

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Medical Futility: A New Look at an Old Problem Tue, 02 Dec 2014 22:45:00 +0000 0