Doctor On End-Of-Life Care

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Dr. David Casarett, associate professor of medicine at the University of Pennsylvania, talks about the rhetoric around the end-of-life issues addressed in some of the proposed health care legislation.

MELISSA BLOCK, host:

Some of the most twisted bits of rhetoric used by opponents of the health- care overhaul are these: death panels, forced euthanasia.

The actual provision in the House bill has to do with end-of-life care. It would pay for doctors to offer Medicare patients counseling about end-of-life issues. The counseling would be voluntary, not mandatory.

We're going to hear now from a doctor who engages in end-of-life discussions with patients. Dr. David Casarett started the palliative care service at the VA hospital in Philadelphia.

Dr. Casarett, welcome to the program.

Dr. DAVID CASARETT (Medical Director, VA Hospital, Philadelphia): It's a pleasure to be here.

BLOCK: If you're talking to a patient for the first time about these end-of-life issues, what would that conversation include?

Dr. CASARETT: Usually, I try to begin these conversations by talking about patients' hopes and fears, their goals more broadly. I think, often, these discussions come down eventually to treatment preferences, the sorts of treatments that people want and don't want, things like whether patients would want to be hospitalized and under what conditions they would want to be hospitalized, whether they would want to spend time in an intensive care unit.

But they really start out - at least the effective conversations start out by talking in more general terms about what's important to people, what they would like their future to look like, and what they're afraid of, what they want to avoid.

BLOCK: Well, when you hear talk about death panels pulling the plug on grandma, things like that, how do you react?

Dr. CASARETT: I'm still mystified. I really can't begin to figure out where this language is coming from. It bears really no resemblance to what's in the provision of the health-care reform bill. What's in the health-care reform bill is in general, text that I think most Americans and certainly all of my patients would support.

The text of the bill really talks about giving patients and families the information they need to make the right choices. It's about giving patients an idea of what their options are. And it's giving patients and families a chance to talk about these things. So patients, families and physicians are all on the same page.

Really, these sorts of discussions are about autonomy. They're about freedom. They're about independence. They're about having a say in your own health care. They're about values that are about as American as anything else I can think of.

And so, to see this debate framing it in terms of some of the terms you mentioned before - death panels and euthanasia - is really both odd and frankly, startling to me that it's gone that far.

BLOCK: Would your fear be that as this rhetoric continues and escalates, that it will damage your practice in some way, that people will have the wrong idea about what you're trying to do?

Dr. CASARETT: That's interesting. The one person who seems to be more concerned about this than anybody else is my grandmother. Many of her friends in her retirement community she lives in are worried by all of this discussion. They're worried and confused about what this will mean for them. And my grandmother is also worried about what all this hullabaloo, as she calls it, was going to mean for me as a palliative care doctor.

I think, in general, patients trust their health-care providers, they trust their physicians, they trust their nurses. And I think, at least on a local level, this probably won't have any large effect. I do think on a national level in terms of legislation, this may have a huge effect.

End-of-life care discussions, advanced care planning has now, in the space of about a week, become a political third rail that I think politicians in Washington will want to avoid. And I think that's going to be a real shame.

BLOCK: What do you make of this argument that doctors, because they'd be reimbursed for these discussions, would have a financial incentive to pressure patients to have end-of-life conversations, maybe to sign an end-of-life directive, if part of the idea behind health-care overhaul is to save the government money? Is there an implicit agenda here, in other words?

Dr. CASARETT: I don't think that's true at all. Frankly, I can't even see how people would think that's true. This is a mechanism by which physicians and others are paid to talk to patients about their options, to give patients a chance to tell physicians the treatment that they want and don't want. This could be, and arguably should be, a chance for some patients to tell physicians that they want everything possible to be done. That's an entirely legitimate outcome of these conversations, and that certainly wouldn't save money at all.

So this really is all about a chance for patients to have their say in the care that they get. And those patients may choose to back off on some treatment. They may choose to refuse some treatments or others, or they may choose to get more treatment. And that really is up to each individual patient and family member.

BLOCK: Well, Dr. Casarett, thank you very much for talking with us.

Dr. CASARETT: You're most welcome.

David Casarett teaches palliative care at the University of Pennsylvania School of Medicine. He's also author of the upcoming book, "Last Acts: Discovering Possibility and Opportunity Near the End of Life."

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