President Obama's flip-flop this week over whether the government should prescribe end-of-life counseling for seniors showed the "death panel" debate hasn't lost its political power.
But the reversal didn't change much for patients and doctors struggling with the tough issue of who decides what happens in the event of a devastating accident or terminal illness.
Experts say planning for the end of life remains largely a private responsibility for all patients, not just seniors. Some doctors are more comfortable than others bringing the topic up, especially given their time constraints. So patients should take the initiative in making their wishes known.
Democrats initially sought to include end-of-life counseling in the health care reform law, but dropped it after Sarah Palin and other Republicans drummed up the specter of bureaucrats deciding who would live and die.
Those "death panel" charges were, many thought, thoroughly debunked. Then the Obama administration decided to quietly insert a voluntary counseling provision in a Medicare rule concerning new annual wellness visits in the government insurance plan for seniors.
As attention came to the rule taking effect on Jan. 1, the old death panel talk resurfaced, just as Republicans geared up efforts to derail the entire health care reform act. In a matter of days, the administration backpedaled.
The change in course isn't expected to have much impact on patients and their doctors, since the counseling wasn't mandatory, and doctors would not have received a specific payment for doing it.
But to leading physician groups and other supporters of helping patients consider how they want their own lives to end, the reversal sent a disappointing message.
"This is a very sensitive issue, one where the doctor cannot just walk into the room, put a stethoscope on the chest and give antibiotics and walk out," said geriatrician Inna Sheyner, chief of long-term care services at the James A. Haley VA Hospital in Tampa and an associate professor at the University of South Florida.
"This is not a physical problem which can be touched, assessed and where we have a clear answer," she added. "This is where the art of medicine comes in vs. the science of medicine."
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Doctors have vastly different approaches to bringing up the end of life discussions with patients. Sheyner, for example, won't ask healthy patients about their end-of-life wishes unless they initiate the conversation, but raises the issue in the face of a terminal illness or a prognosis like dementia.
Even then, she finds the discussion can last anywhere from 10 minutes to an hour, depending on how much the patient already knows about the complex issues involved.
The chief medical adviser for Consumer Reports, Dr. Marvin M. Lipman, believes that everyone — young or old, sick or healthy — should have an advance directive. He asks his patients if they have one as a part of their regular checkups. "This is not an end-of-life decision. This is a decision that should be made in middle age. It's a living will," he said. "The best time to make a living will is when you're healthy. Like life insurance, it's there in case you need it."
An internist who sees mostly Medicare patients at his private practice in Scarsdale, N.Y., Lipman finds the discussion rarely is difficult. His most challenging conversations involve patients in their 20s and 30s. He reminds them that accidents involving head injuries are a leading cause of death at their age. Their preferences should be known if they become unable to communicate.
Such was the case with one of the nation's most prominent end-of-life cases, involving Pinellas County's Terri Schiavo, who collapsed at her home at the age of 26. She was left in what many doctors considered a permanent vegetative state, and her husband and parents argued in court about whether to keep her on life support for years before her feeding tube finally was removed.
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For many doctors and their patients, the counseling issue comes down to time and priorities. Bottom line: If patients want their wishes followed, they need to make them known.
Dr. David Lubin, a South Tampa family physician, rarely asks patients about their end-of-life wishes during routine visits. It's not that the topic is too touchy; he simply doesn't have time to address it along with everything else he needs to do in a 10-minute visit. Most of the Medicare patients he sees are on managed-care plans.
"It's one of those things — out of sight, out of mind," Lubin said. "I just don't think about it when I am trying to handle someone's diabetes, and I'm trying to get them to lose weight because their cholesterol is high."
Earlier this week, a patient asked Lubin if he wanted a copy of her living will. He told her it wouldn't be a bad idea, but both quipped it might be more valuable to post her directive on her fridge, where paramedics could see it in an emergency.
Vicki Gottlich, senior policy attorney for the nonpartisan Center for Medicare Advocacy, said patients should make sure that caretakers and every doctor they see is aware of their end-of-life wishes — and post it somewhere visible in the house, such as the fridge.
Gottlich was disappointed to see the end-of-life counseling provision removed from the new Medicare rules. "The people who claim 'death panels' and scream about it the most don't understand what it entails," she said. "It's really important for people to discuss with their doctor whatever care they want." And that includes, she noted, making sure a doctor knows if you are a patient who wants to have every effort made to resuscitate you and keep you on life support.
Letitia Stein can be reached at firstname.lastname@example.org or (813) 226-3322. For more health news, visit www.tampabay.com/health.