» Health Care Where the World Finds Bioethics Fri, 24 Jul 2015 20:26:18 +0000 en-US hourly 1 Hospice Concurrent with Curative Treatment – Medicare Care Choices Model Fri, 24 Jul 2015 20:26:00 +0000 0 Dead Mother [EOL in Art 74] Fri, 24 Jul 2015 08:30:00 +0000 0 Nevada Brain Death Dispute – Aden Hailu UPDATE Fri, 24 Jul 2015 01:10:00 +0000 0 A Step Toward a Cultural Transformation in the Way Pain is Perceived, Judged and Treated Thu, 23 Jul 2015 19:13:00 +0000 The following blog post is the executive summary of the June 29-30, 2015, PAINS Collaborators Meeting in Washington, DC, held in response to Department of Health and Human Services’ publication of the National Pain Strategy Report. 


In anticipation of publication of the National Pain Strategy (NPS) Report, in June 2015 the Pain Action Alliance to Implement a National Strategy (PAINS), a coalition of national leaders and organizations committed to advancing the sixteen recommendations made in the Institutes of Medicine’s report, Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research, convened a Collaborators Conference in Washington, DC. The purpose of the meeting was to discern opportunities and challenges to implementation of the report, to build enthusiasm for it and promote collaboration among attendees in order to move the NPS Report from a vision to a reality. More than 100 prominent leaders from professional societies, academic institutions, federal agencies, patient advocacy groups, and policy organizations met to review the NPS Report and discuss each of its six sections.

In April 2015, the NPS Report underwent preliminary review by multiple federal agencies and was then posted in the Federal Register for public commentary. In opening remarks, Walter Koroshetz, Director of the National Institute of Neurological Disorders and Stroke (NINDS), told attendees that more than 770 responses were received and the plan is expected to be released in the late summer/early fall. Expectations for it are high. The report’s vision states, “If the objectives of the National Pain Strategy are achieved, the nation would see a decrease in prevalence across the continuum of pain, from acute, to chronic, to high-impact chronic pain, and across the life span from pediatric through geriatric populations, to end of life, which would reduce the burden of pain for individuals, families, and society as a whole. Americans experiencing pain — across this broad continuum — would have timely access to a care system that meets their bio-psychosocial needs and takes into account individual preferences, risks, and social contexts. In other words, they would receive patient-centered care.”

PAINS surveyed participants prior to the meeting and found that overall, the NPS Report was well received by respondents, and stakeholders expressed appreciation and support for it. One respondent said about the report, “It presents a rare opportunity for cultural change with across-the-board goals and strategies.” The three foci in which attendees were most interested were:  professional education and training (72.7%), public education and communication (69.7%) and prevention and care (57.6%).

However, concerns were also expressed about the lack of specificity and accountability, the absence of a timeline, and the fact that there has been no appropriation of funding designated for implementation of the plan.  


In the opening keynote address of the two-day conference, Dr. Sean Mackey, co-chair of the NPS Report Oversight committee, said, “Eighty incredibly dedicated national experts covering a wide range of the bio-psychosocial aspects of pain – including expertise from clinical and public health, legal, ethical and payment, including both traditional and complementary medicine – volunteered their time to develop the plan.” He introduced the concept of “high-impact chronic pain,” which the NPS Report defines as “pain associated with substantial restriction of participation in work, social, and self-care activities for six months or more.” Mackey said that doing so was meant to address challenges there have been to the IOM report’s claim that “at least 100 million Americans live with chronic pain…. and that there is a clear need to better understand the numbers of people with high-impact chronic pain, how to provide them with the best care to avoid both under- and over-treatment, and to identify those at risk for developing high-impact chronic pain after injury or surgery.” He said, “The NPS is a great document. It is not a perfect document.” He urged those present and others committed to transforming pain care in America not to pick the document apart, but to support it in its entirety. He also argued for the development of clear messaging explaining what the NPS Report is and what it is not.  Compellingly, he asked all those present to speak with one voice and not let the perfect be the enemy of the good.


In brief reports, members of the six NPS Workgroups presented highlights of the section of the report they worked on, shared personal observations and then engaged with all those present in robust conversation. Key elements of those included:

• The need for research, including population, basic science, clinical translational, comparative effectiveness, and quality improvement were all discussed. Greg Terman, member of the NPS Oversight Committee, said that with the help of others at CDC and NIH, a set of pain questions are being developed to be included in the National Health Interview Survey.

• The importance of addressing historic disparities in health and healthcare was recognized as critical to successful implementation of the report in that they permeate the entire report. Nadine Gracia, Deputy Assistant secretary for Minority Health, cautioned that “culturally and linguistically appropriate language” must be incorporated in education and communication efforts called for in the report.

• Learning from efforts of the Department of Defense to improve pain care for veterans that have preceded the NPS Report was promoted by Dr. Chester “Trip” Buckenmaier in his report on Care and Prevention. In particular, he encouraged consideration of the Pain Assessment Screening Tool and Outcomes Registry (PASTOR), the Patient Reported Outcome Measurement Improvement Survey (PROMIS) and Computer Adaptive Testing (CAT).

• On behalf of the Service Delivery and Reimbursement Workgroup, Marianne Udow-Phillips cautioned attendees not “to think that we are going to abandon fee-for-service” because she said large self-insured employers like it. Everyone recognized improved reimbursement as a keystone issue. Udow-Phillips encouraged the audience by saying that there is interest among payers in programs that improve quality and save money.  She called for small pilot programs to demonstrate the feasibility and efficacy of comprehensive pain care, including exploration of “fee-for-service with incentives.” 

• Although professional education and training is recognized as critically important, 
Dr. Mac Gallagher, reporting on behalf of the Professional Education and Training Section, said, “We can’t wait for the medical schools and licensure groups to change.” Attendees were enthusiastic about and supportive of the NIH Pain Consortium’s program to develop Centers of Excellence in Pain Education. However, Dr. Dave Davis, Senior Director of Continuing Education and Improvement at the Association of American Medical Colleges, agreed with Gallagher and encouraged more focus on continuing medical education for practicing clinicians, including biomedical, behavioral and complementary therapies. He also pointed to the importance of IEPs (inter-professional education programs).

• Penney Cowan, co-chair of the Public Education and Communication Workgroup, reported that two public education campaigns were recommended by the group. The priority campaign being an extensive public awareness campaign about chronic pain and the secondary campaign being on safe medication use by patients. Four “core messages” developed by the Chronic Pain Advocacy Task Force (CPATF), a coalition of 17 consumer advocacy organizations, were presented. The messages clearly resonated with meeting attendees and became a major focus of actions following the conference.


Outside experts provided input and perspective for consideration from public health, politics, and addiction advocacy. Dr. Georges Benjamin, Executive Director of the American Public Health Association, encouraged the use of patient narratives about those living with extreme chronic pain. He also encouraged gaining more clarity about the problem and reframing discussion using more of a public health framework. Dr. Keith Wailoo, historian and author of Pain: A Political History, shared how concerns about disability, physician assisted suicide, the “War on Drugs,” and dramatic increases in addiction to prescription pain medications have shaped pain policy over the last seven decades and impacted the lives of those living with chronic pain. He also discussed how the so-called “red state vs. blue state” worldview negatively impacts those who live with chronic pain and other diseases, including addiction. Dr. Jeff Levi, CEO of Trust for America’s Health, began his presentation by saying, “All politics, perhaps especially health politics, is personal.” He said that “the pain community starts with the individual in pain and wants to find the best solutions for that individual…. The substance abuse prevention world starts with preventing addiction and looks in particular to find structural interventions that make it harder for someone to become addicted.” Dr. Levi, as had others throughout the day, called for finding common ground and suggested specific strategies for doing so, with one of those strategies being to focus on harm reduction.


One the second day of the conference, participants broke out into groups focused on each section of the report and then shared thoughts and ideas about how to advance the strategies and objectives in the NPS Report. Those reports are incorporated in the full report in their entirety.

Key to the success of the meeting was the involvement of people living with chronic pain – a highly successful environmental lawyer injured in a bicycling accident fifteen years ago, a professor of bioethics and public health born with sickle cell disease, and Cindy Steinberg, a person who experienced a “crushing accident” more than a decade ago who has become a self-educated policy wonk and now dedicates her life advocating for better care for the 100 million Americans who live with chronic pain. 

Ms. Steinberg was the closing keynote speaker for PAINS Collaborators Meeting. In an impassioned appeal, she called for PAINS and all those present to do four things:
1) Endorse the four core messages developed by CPATF.
2) Develop op-eds in support of the NPS Report at the time of its release.
3) Advocate for peer reviewed articles about the Report.
4) Work together to develop a national communication strategy in time for Pain Awareness Month in September. 

Based on a robust evaluation plan, PAINS believes the Collaborators Meeting achieved the goals that had been set for it. (Perceptions and opinions of attendees regarding the meeting are included entirely as received.) One reason PAINS invested significant resources into evaluation was to assess attendees’ views about the role of PAINS in implementation of the National Pain Strategy Report. Based on responses to a meeting with key national leaders immediately following the conference, responses to a post-meeting survey, emails received from attendees, and a report from the meeting facilitator, PAINS believes that its greatest contribution is to continue to serve in the role of neutral convener and facilitator of collaboration among the many groups committed to advancing the NPS Report.

The conclusion of the report states the obvious, “A cultural transformation in the way pain is perceived, judged and treated” will require almost unimaginable resources, numbers of organizations and committed individuals, political will, and changes in attitudes. However, the dialogue, discourse and enthusiasm at the PAINS Collaborators Meeting encouraged those who convened and planned it and gave hope to all those present that the U.S. is at the precipice of a cultural shift in the way chronic pain is managed. The report’s vision can become reality, but there is much to be done. There is no time to rest on one’s laurels. As Henry Ford once said, “Coming together is a beginning, staying together is progress and working together is success.”

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Responding to the “Dogma” charge Thu, 23 Jul 2015 18:52:31 +0000 Read More »]]> 0 Bioethics Deliberation and Education in New Directions Thu, 23 Jul 2015 15:42:59 +0000 0 City Hospital [EOL in Art 73] Thu, 23 Jul 2015 09:00:00 +0000 0 Planned Parenthood and fetal tissue donation Thu, 23 Jul 2015 07:07:30 +0000 0 Planned Parenthood and the moral standing of the medical profession Wed, 22 Jul 2015 15:15:08 +0000 Read More »]]> 0 Island of Death [EOL in Art 72] Wed, 22 Jul 2015 09:00:00 +0000 Bocklin's Island of the Dead invites contemplation on the mystery of what lies beyond death.

The stones and trees make for an interesting comparison – both are symbols of the natural world, the former dead and cold, the latter alive yet silent. The apparent lack of human life on the island is made poignant by the knowledge that once upon a time, the stone ruins must have housed living men. Now, however, like death, the island is an isolated, isolating, and lonesome place. (Project Gutenberg)

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Jahi McMath – Now Alive and on Medicaid Tue, 21 Jul 2015 20:58:00 +0000 0 Beyond the “Silver Tsunami”: Toward an Ethic for Aging Societies Tue, 21 Jul 2015 14:54:00 +0000 0 Intensive Care Room [EOL in Art 71] Tue, 21 Jul 2015 09:30:00 +0000 0 Title: OA Journals Are More For Biomedical Scientists And Not for (All) Bioethicists Tue, 21 Jul 2015 07:07:42 +0000 0 Paying for Medicare Advance Care Planning Puts “Duty to Share” Squarely on the Patient Mon, 20 Jul 2015 20:00:00 +0000 Why is it that Americans seem to be the only people on the planet who live their lives as though death were an optional event? For many of us who have worked for years helping families and clinicians grapple with difficult choices in “shared decision making,” we’ve been challenged by that convention despite the evidence that 75% of us claim that preparing a living will and appointing a healthcare proxy are critically important. Yet fewer than one third of us do anything to make it happen.

Perhaps it’s our willing adherence to myths; most notably our believing that when the time comes, we’ll know, and we’ll have time to get our affairs in order, making our wishes known. This “just-in-time” approach may be comforting but, in reality, it’s magical thinking. For most of us, the “right time” never comes, but the crisis does. Believing in a scenario that we’ll luck into a peaceful passing without ever having so much as an uncomfortable conversation with anyone doesn’t support the reality that 80% of us will eventually rely on a proxy to make decisions for us.

Beyond “Just in Time”

So, how do we prepare for the realities of dying? First, name someone to speak for you when you cannot speak for yourself. But don’t stop there. Talk with that person about what matters most to you. Proxies need to be ready to respond to uncertainties, in a way that you would. Commit to ongoing conversations with loved ones and health providers, so your values and preferences are truly “shared.”

On July 8, the Centers for Medicare and Medicaid proposed new rules to pay for these conversations beginning January 2016.  If all goes as planned, Medicare will begin reimbursing providers for engaging in these discussions. That’s good news, because evidence shows that when patients’ expressed wishes are honored, survivors and clinicians report higher satisfaction because treatments align with goals. Anxiety and crises abate.

The Most Important Decisions

Before beginning this overdue conversation about values and preferences in end of life decision making, let’s examine a caution. Our tendency in healthcare is to “medicalize” everything. Getting older is not a disease. The most important decisions you and your proxy will have to make aren’t medical ones. They are emotional, social and spiritual. Death is not a medical event so much as it is a human, community experience.

So, before you take advantage of Medicare’s “advance care planning,” know what you want to say. You don’t have to be ready to answer questions about what kinds of treatments you do or don’t want, because research also shows that we’re not very good at predicting how we will feel about them in the future anyway. Instead, share values, what it means to be fulfilled, how important it is to know the details of your illness, what gives life meaning, and what a “complete life” looks like to you. Those are the kinds of things that will help your decision makers stand in and up for you when the time comes. 

Take advantage of the Center for Practical Bioethics’ resource, Caring Conversations®, available online for free (or in print for a nominal fee). There are no right and wrong answers, but there can be peace of mind. We know – and now Medicare agrees – that talking before the crisis can work. It leads to more favorable outcomes and higher likelihood that preferences get honored. Satisfaction improves. Patient-centered outcomes matter to everyone. Helping providers find that path is a duty we all bear. End of life is inevitable. Death may be a sad outcome, but it doesn’t have to be a bad one. 

John G. Carney is the president and CEO of the Center for Practical Bioethics. In 2008 he served as one of the co-authors in a Report to Congress on Advance Care Planning.
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EMTs Misinterpret POLST Forms Mon, 20 Jul 2015 17:53:00 +0000 A new study in ED Management, finds that emergency providers lack consensus on what action to take when they have Physicians Orders for Life Sustaining Treatment (POLST) forms.  

In a continuing line of research by Ferdinando Mirarchi (medical director of the Department of Emergency Medicine at the University of Pittsburgh Medical Center Hamot in Erie, PA). 

In a survey of emergency physicians and pre-hospital providers, responders were given scenarios in which the patient had a POLST. The providers were then asked to decide what to do. Unfortunately, providers often know that the form exists but fail to read it, making assumptions about what it says.  For example, DNR orders are equated with "do not treat" orders. 

The outcomes of the study prompted the team to suggest that clinicians use a checklist built on the letters A, B, C, D, and E: 

  • A = Ask patients and surrogates to clarify their intentions about DNRs, POLST and other end-of-life planning documents.
  • B = Be clear about the status of the patient, including terminal or critical illness “that can be treated.”
  • C = Communicate with the patient about prognosis and expected outcomes.
  • D = Design plans for care and review the steps in the plan.
  • E = Explain about hospice and palliative care, and let patients know that treatment choices are up to them, and that their wishes will be honored.

The researches suggest that hospitals establish quality control procedures to ensure that end-of-life-care documents are prepared and interpreted accurately. 

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On a Radioactive Pig and Pope Francis Mon, 20 Jul 2015 14:54:00 +0000 Stephen F. Eisenman]]> 0 Tender Loving Care [EOL in Art 70] Mon, 20 Jul 2015 09:00:00 +0000 Elizabeth Layton - TENDER LOVING CARE

“Not everyone is caught up in technology. Legal, financial, ethical puzzles engulf us. We have the answers - the procedures, the tubes, the machines, the know-how. When do we stop to open the envelopes and address the questions? What can we handle? How much technology can we live with? Is another Challenger exploding in our faces? Can we change so drastically in these few decades? For ages, man has struggled to accept death. In the traditional way of dying, we spoon-fed a little ice, not enough to sustain life but sufficient to comfort the body and nourish the soul. Sheets, clean and straightened, shelter a cherished privacy.”

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Margot Bentley, Advance VSED, and Ulysses Contracts Mon, 20 Jul 2015 00:05:00 +0000 0 Pulling the Plug [EOL in Art 69] Sun, 19 Jul 2015 09:00:00 +0000 Elizabeth Layton - PULLING THE PLUG - 1987

“Symbolic of the many means of keeping a body functioning. Restraint is a necessity. She has wasted minutes, hours, months. Would she want to add all that wasted time to this very end?”

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The Courtroom [EOL in Art 68] Sat, 18 Jul 2015 09:00:00 +0000 Elizabeth Layton - THE COURTROOM - 1990

“The sign on the door to the courtroom says, KEEP OUT. The doctors, nurses, and family are not allowed in. The comatose patient on the consultation table has a funnel leading directly into her stomach. Black-robed Justices pour in nutritious foods - artificial grapes, fish, oats, peanut butter, pure H2O, 7-Up. The 25-watt light bulb symbolizes the dim illumination perfect strangers might have on the case.”

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Jahi McMath Family Still Denies She Is Dead Sat, 18 Jul 2015 07:30:00 +0000 0 Revolutionary Change for Life’s Final Choices Would Reduce Unwanted Care Fri, 17 Jul 2015 12:40:00 +0000 0 Who Was All Becomes Nobody [EOL in Art 67] Fri, 17 Jul 2015 09:30:00 +0000 0 Art about Death Makes People Think [EOL in Art 66] Thu, 16 Jul 2015 09:00:00 +0000 0 Ned Cassem and the MGH Optimum Care Committee Thu, 16 Jul 2015 08:30:00 +0000 0 Medicare Considers the Value of Advance Care Planning Thu, 16 Jul 2015 02:07:55 +0000 0 New Educational Module from the Bioethics Commission on Vulnerable Populations in Neuroscience Research Now Available Wed, 15 Jul 2015 16:39:33 +0000 0 Physicians, the morality of euthanasia, and the Hippocratic Oath Wed, 15 Jul 2015 12:12:33 +0000 Read More »]]> 0 Awareness & Preparedness for Death [EOL in Art 65] Wed, 15 Jul 2015 09:00:00 +0000 0 Way More Patients Now Getting "All Care Possible" Wed, 15 Jul 2015 08:30:00 +0000 0 Wherever You Go: Self-Representation and Williams Syndrome Tue, 14 Jul 2015 21:04:13 +0000 0 From Jackie and Me: A Plea for Opt-Out Organ Donation Tue, 14 Jul 2015 14:54:00 +0000 Hilde Lindemann]]> 0 New York State Surrogate Decision Making Committee – Protecting Unrepresented Patients Tue, 14 Jul 2015 09:00:00 +0000 0 Dr. Byrne Examining Jahi Mcmath [EOL in Art 64] Tue, 14 Jul 2015 09:00:00 +0000 0 The Physician’s Imprimatur Tue, 14 Jul 2015 01:01:34 +0000 Read More »]]> 0 California’s Strides in Providing Health Care for Undocumented Immigrants Mon, 13 Jul 2015 14:54:00 +0000 0 A Dis Eased Life Mon, 13 Jul 2015 08:30:00 +0000

The following is a guest post by MPR News host Cathy Wurzer.

If you are young and vital, it will seem odd to suggest that you are actually living with some kind of dis ease but trust me, you are. If you are a bit older or have elderly parents, then it is quite likely that there is some kind of physical disease that has been served up alongside a heaping helping of dis ease.

Disease. Dis-ease. Confused yet?

You'll note I separated the "dis" from the "ease." The concept of dis ease came to Dr. Bruce Kramer, my late friend and co-author of We Know How This Ends: Living while Dying shortly after he was diagnosed with the deadly disease known as amyotrophic lateral sclerosis, ALS, or Lou Gehrig's disease. He was given the news that was to change his life on December 6, 2010. Bruce dryly joked that the diagnosis should have been delivered the next day, December 7th, to coincide with the anniversary of the bombing of Pearl Harbor in 1941, because both events carried the weight of massive upheaval, destruction, and death. My friend had a quirky sense of humor.

ALS is no joke. It remains a medical mystery. Researchers haven’t been able to figure out why neurons in the brain and spinal cord that communicate with the body's muscles become disconnected. The muscles required to move arms and legs, to talk, swallow, and breathe become completely paralyzed. Death usually occurs in two to five years after diagnosis. There is no cure for ALS and, unlike other diseases, there's not even a decent treatment for it.

In the weeks after his diagnosis, Bruce, an intelligent and thoughtful man, a college dean and educator, found journaling to be a safe haven to explore his raw feelings. He expanded his writing to blogging in order to share his experiences with a wider audience and that's when his blog, the Dis Ease Diary was born. When I started interviewing Bruce for a series of recorded conversations for Minnesota Public Radio News on what it was like to live in the shadow of terminal illness, one of our first conversations included mention of his blog. I thought it was the Disease Diary but Bruce gently corrected me. "It is the DIS ease Diary. DIS ease.” I gave a mental shrug, thinking it was just a little clever word play on his part and tried to plow on, but Bruce wanted to talk about dis-ease.

Bruce Kramer correctly observed that most of us want to lead lives that are as free of pain and suffering as possible. We have an internal blueprint of what our lives are supposed to be. We harbor hopes of health and happiness, sunshine and rainbows that will last until we die at a ripe old age, preferably in our sleep.  A disease diagnosis, especially a terminal diagnosis, erases that dream and ruptures the ease of our lives. ALS was the bomb that blew up what Bruce always thought would be an easy ride into his later years.

When talking with friends, family, and colleagues about his ALS, Bruce quickly discovered that dis ease is the tie that binds, and it often has nothing to do with the physical illness. In our book, We Know How This Ends: Living while Dying, Bruce writes that his friends and colleagues "had their own variations on my ALS theme: ‘I have cancer.’ ‘I am sick with depression.’ ‘My husband doesn't love me anymore.’ ‘The pain in my legs is unbearable.’ I realized their story lines were awakenings, profound connections in the moment of shared revelation that each of us carries uneasiness, often unacknowledged but always present."

Cathy Wurzer (MPR News)
Bruce Kramer (M. Ekern UST)

I recall asking Bruce one day, as I dealt with an especially difficult personal problem, if he felt that all of life was an exercise in dis ease management. He smiled a wry smile.

Bruce recognized that dis ease is a state of being. It is part of the human condition. Instead of working so hard to avoid or deny it, acknowledging and embracing dis ease may allow a little grace into our lives; solace in the knowledge that our burdens are shared by many. We are not alone in our dis ease, although it often feels that way. 

Maybe what we need to do is to find that holy balance between the fixable and the inevitable, and in that space find the peace so many of us spend our lives searching for.

Here is a link to the new MPR News podcast on Bruce Kramer’s life with ALS.

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Death and the Apothecary [EOL in Art 63] Mon, 13 Jul 2015 08:30:00 +0000 0 Do Physicians Follow the Golden Rule? Some Thoughts on End of Life Care Mon, 13 Jul 2015 04:07:51 +0000 0 Futility in Chronic Anorexia Nervosa Sun, 12 Jul 2015 09:00:00 +0000 Medical futility is usually discussed in the context of life-sustaining treatment in the ICU.  But the new June 2015 issue 15(7) of American Journal of Bioethics addresses futility in another context.

There is one 10-page target article and six 2-page commentaries.

Futility in Chronic Anorexia Nervosa: A Concept Whose Time Has Not Yet Come

Cynthia M. A. Geppert

Anorexia Nervosa, “Futility,” and Category Errors

Ronald W. Pies

The Futility of Arguing About Medical Futility in Anorexia Nervosa: The Question Is How Would You Handle Highly Specific Circumstances?

Joel Yager

“Futility” Is a Failed Concept in Medical Decision Making: Its Use Should Be Abandoned

John J. Paris & Andrew Hawkins

Is Resistance (N)ever Futile? 

Cushla McKinney

Compulsory Treatment in Chronic Anorexia Nervosa by All Means? Searching for a Middle Ground Between a Curative and a Palliative Approach

Manuel Trachsel, Verina Wild, Nikola Biller-Andorno & Tanja Krones

Ms X: A Promising New View of Anorexia Nervosa, Futility, and End-of-Life Decisions in a Very Recent English Case

Robin Mackenzie

A Misunderstanding Concerning Futility

Tommaso Bruni & Charles Weijer

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Garden of Death [EOL in Art 62] Sun, 12 Jul 2015 08:30:00 +0000 0 Opposition to Medicare Paying for Advance Care Planning Sun, 12 Jul 2015 01:01:00 +0000 Flash back to 2009.  Opponents of Medicare coverage for advance care planning have reemerged in response to Medicare's new plans to pay for advance care planning.

Sarah Palin writes:  "Certainly, all patients and families should be advised of options, but we engage in that today and we don't need government bribing any party to do so. . . .  Government needs to stay the hell out of our "end-of-life" discussions. . . ."

"[A]nswering a government questionnaire that will be judged by faceless bureaucrats just doesn’t cut it. . . .  Be aware that most of these questions are for the benefit of a far-away, bankrupt government, they're not for the benefit of the patient."

Betsey McCaughey similarly called the rule a "disguise" for what's "actually intended" — the government deciding when people die. 

"It's none of the government's business how we die. . . .  Patients and their families should be very well informed about the agenda here, because it is not just ensuring their doctor is adequately paid, it's about ensuring they're pressured into a shorter end of life."

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All Is Vanity [EOL in Art 61] Sat, 11 Jul 2015 09:00:00 +0000 0 Doctors Ignore Advance Directives Sat, 11 Jul 2015 08:30:00 +0000 0 Gentle Death [EOL in Art 60] Fri, 10 Jul 2015 09:00:00 +0000 0 British Courts Adjudicate Medical Futility Cases Fri, 10 Jul 2015 08:30:00 +0000 0 PAS Shelved (For the Moment) in California Fri, 10 Jul 2015 03:36:52 +0000 Read More »]]> 0 Causes of Death [EOL in Art 59] Thu, 09 Jul 2015 09:30:00 +0000 0 Medicare Coverage for Advance Care Planning Thu, 09 Jul 2015 09:00:00 +0000 CMS has just published a major proposed rule addressing changes to the physician fee schedule, and other Medicare Part B payment policies. 

Significant among these changes, the proposed rule makes the two advance care planning codes established in 2015 "active" and begins the process of allowing physicians to code and be paid for advance care planning discussions.

I have written about the history of CMS and advance care planning here and here.  Comments on the proposed rule are due by September 8, 2015.  Here is the relevant text: 

c. Advance Care Planning Services

For CY 2015, the CPT Editorial Panel created two new codes describing advance care planning (ACP) services: CPT code 99497 (Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health professional; first 30 minutes, face-to-face with the patient, family member(s) and/or surrogate); and an add-on CPT code 99498 (Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health professional; each additional 30 minutes (List separately in addition to code for primary procedure)). 

In the CY 2015 PFS final rule with comment period (79 FR 67670-71), we
assigned a PFS interim final status indicator of ‘‘I’’ (Not valid for Medicare purposes. Medicare uses another code for the reporting and payment of these services) to CPT codes 99497 and 99498 for CY 2015. We said that we would consider whether to pay for CPT codes 99497 and 99498 after we had the opportunity to go through notice and comment rulemaking.

We received many public comments to the final rule recommending that we recognize these two CPT codes and make separate payment for ACP services, in view of the time required to furnish the services and their importance for the quality of care and treatment of the patient.

For CY 2016, we are proposing to assign CPT codes 99497 and 99498 PFS status indicator “A,” which is defined as: “Active code. These codes are separately payable under the PFS. There will be RVUs for codes with this status.” The presence of an “A” indicator does not mean that Medicare has made a national coverage determination regarding the service. Contractors remain responsible for local coverage decisions in the absence of a national Medicare policy. We are proposing to adopt the RUC-recommended values (work RVUs, time, and direct PE inputs) for CPT codes 99497 and 99498 beginning in CY 2016 and will consider all public comments that we receive on this proposal.

Physicians’ services are covered and paid by Medicare in accordance with section 1862(a)(1)(A) of the Act. Therefore, CPT code 99497 (and CPT code 99498 when applicable) should be reported when the described service is reasonable and necessary for the diagnosis or treatment of illness or injury. For example, this could occur in conjunction with the management or treatment of a patient’s current condition, such as a 68 year old male with heart failure and diabetes on multiple medications seen by his physician for the evaluation and management of these two diseases, including adjusting medications as appropriate. 

In addition to discussing the patient’s short-term treatment options, the patient expresses interest in discussing long-term treatment options and planning, such as the possibility of a heart transplant if his congestive heart failure worsens and advance care planning including the patient’s desire for care and treatment if he suffers a health event that adversely affects his decision-making capacity. In this case the physician would report a standard E/M code for the E/M service and one or both of the ACP codes depending upon the duration of the ACP service. However, the ACP service as described in this example would not necessarily have to occur on the same day as the E/M service. 

We seek comment on this proposal, including whether payment is needed and what type of incentives this proposal creates. In addition, we seek comment on whether payment for advance care planning is appropriate in other circumstances such as an optional element, at the beneficiary’s discretion, of the annual wellness visit (AWV) under section 1861(hhh)(2)(G) of the Act.

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