Friday, August 19, 2016
I'm always just a bit suspicious of books that promise to make me laugh. I think it is because I like to be surprised by humorous moments, rather than feel duty-bound to chuckle, guffaw or giggle.
Nonetheless, I succumbed to the promise in the blurb for Michael Kinsley's 2016 book, Old Age: A Beginner's Guide, that it was a "surprisingly cheerful book ... and a frequently funny account of one man's journey to the finish line."
And I'm glad I did. I did indeed laugh, and at the most surprising of moments, as when he described the need to avoid the doors of his refrigerator because of the magnets that might interfere with the technology in his brain used to keep symptom of Parkinson's Disease at bay. He has the knack of making wry observations about his own mortal state to think broadly about what it is for all of us to age. I can see the short essays that make up this book being useful in a class on elder law or estate planning.
His words are perhaps most poignantly relevant to boomers. For example, on a goal of living longer, he writes:
Even before you're dead, you may want to ask yourself whether this is what you really want. Is being alive all that desirable if you're alive only in the technical sense? Millions of boomers are watching their parents fade until they are no longer there. As they approach their seventies, they start observing their own peer group losing their collective marbles, one at a time. And they reasonably conclude that the real competition should not be about longevity. It should be about cognition.
But he doesn't stop there, exploring other, potentially more important goals for the competitive boomer generation to consider.
This is a short, deep book. And I recommend it, not least of all because it gives readers welcome opportunities to smile.
Monday, August 1, 2016
As some readers may recall, last year we reported on the emotionally fraught criminal trial in Iowa for a former state legislator, who was ultimately acquitted of sexual assault of his wife. The allegations arose in the context of alleged sexual relations with his wife after she was admitted to a nursing home.
Assistant Professor of Law Alexander A. Boni-Saenz, from Chicago Kent College of Law, has drawn upon this case and others to further explore his proposals for "advance directives" whereby adults could specify their decisions in advance of incapacity. Alex's latest article, Sexual Advance Directives, forthcoming in the Alabama Law Review, is available on SSRN here. From the abstract:
Can one consent to sex in advance? Scholars have neglected the temporal dimension of sexual consent, and this theoretical gap has significant practical implications. With the aging of the population, more and more people will be living for extended periods of time with cognitive impairments that deprive them of the legal capacity to consent to sex. However, they may still manifest sexual desire, so consenting prospectively to sex in this context serves several purposes. These include protecting long-term sexual partners from prosecution by the state, ensuring sexually fulfilled lives for their future disabled selves, or preserving important sexual identities or relationships. The law currently provides a device for prospective decision-making in the face of incapacity: the advance directive.
The central claim of this article is that the law should recognize sexual advance directives. In other words, people facing both chronic conditions that threaten their legal capacity to make decisions and institutional care that threatens sexual self-determination should be able to consent prospectively to sex or empower an agent to make decisions about sex on their behalf. To justify this claim, the Article introduces a novel theory of sexual consent—the consensus of consents—that diffuses the longstanding philosophical debates over whether advance directives should be legally enforceable. With this normative foundation, the Article then draws on insights from criminal law, fiduciary law, and the law of wills to fashion a workable regime of sexual advance directives that adequately protects individuals from the risk of sexual abuse.
Alex is a thoughtful writer on challenging topics, often looking at the intersection of health care, estate law and elder law planning.
Monday, July 25, 2016
The answer might surprise you. It turns out that the older the person, the less the person spends Kaiser Family Foundation reports in a recently released Medicare data note. Medicare Spending at the End of Life: A Snapshot of Beneficiaries Who Died in 2014 and the Cost of Their Care was published July 14, 2016.
Of the 2.6 million people who died in the U.S. in 2014, 2.1 million, or eight out of 10, were people on Medicare, making Medicare the largest insurer of medical care provided at the end of life. Spending on Medicare beneficiaries in their last year of life accounts for about 25% of total Medicare spending on beneficiaries age 65 or older. The fact that a disproportionate share of Medicare spending goes to beneficiaries at the end of life is not surprising given that many have serious illnesses or multiple chronic conditions and often use costly services, including inpatient hospitalizations, post-acute care, and hospice, in the year leading up to their death. (footnotes omitted)
The authors examine the data on a number of points, with explanations and corresponding charts. Among their findings
Our analysis shows that Medicare per capita spending for beneficiaries in traditional Medicare who died at some point in 2014 was substantially higher than for those who lived the entire year, as might be expected. It also shows that Medicare per capita spending among beneficiaries over age 65 who die in a given year declines steadily with age. Per capita spending for inpatient services is lower among decedents in their eighties, nineties, and older than for decedents in their late sixties and seventies, while spending is higher for hospice care among older decedents. These results suggest that providers, patients, and their families may be inclined to be more aggressive in treating younger seniors compared to older seniors, perhaps because there is a greater expectation for positive outcomes among those with a longer life expectancy, even those who are seriously ill.
In addition, we find that total spending on people who die in a given year accounts for a relatively small and declining share of traditional Medicare spending. This reduction is likely due to a combination of factors, including: growth in the number of traditional Medicare beneficiaries overall as the baby boom generation ages on to Medicare, which means a younger, healthier beneficiary population, on average; gains in life expectancy, which means beneficiaries are living longer and dying at older ages; lower average per capita spending on older decedents compared to younger decedents; slower growth in the rate of annual per capita spending for decedents than survivors, and a slight decline between 2000 and 2014 in the share of beneficiaries in traditional Medicare who died at some point in each year.
The report is also available as a pdf here.
Thursday, July 21, 2016
The National Academy of Medicine (NAM) held a meeting in late May, 2016 to update progress since the release of the major report on Dying in America. NAM "hosted “Assessing Progress in End-of-Life and Serious Illness Care,” a private working meeting for stakeholders to assess progress since the September 2014 release of Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life." The meeting recap is available here. The recap includes transcripts of remarks and discussions as well as slides if used by presenters. The focus of the day was on 5 topics that included "(1) delivery of person-centered, family-oriented care; (2) clinician-patient communication and advance care planning; (3) professional education and engagement; (4) policies and payment systems; and (5) public education and engagement." After breakout sessions,"participants generated 3-5 top priority action items in each area .... [which] will inform the strategic planning of a new Roundtable on Quality Care for People with Serious Illness at the National Academies of Sciences, Engineering, and Medicine (the Academies)."
Wednesday, July 20, 2016
I wanted to make sure you didn't miss these developments.
First, Colorado voters in November may see a ballot initiative on physician-aided dying. Proponents are collecting signatures according to an article in the Denver Post, Right-to-die initiative headed for Colorado’s November ballot. It's not a slam-dunk however. The article notes that there is opposition to the proponents efforts to place the initiative on the ballot. Proposed legislation failed previously. Stay tuned.
Second, in case you missed it, on June 30, 2016, the New Mexico Supreme Court issued its ruling in Morris v. Brandenburg, a physician-aided dying case that has been making its way through the appeals process. The court held "we decline to hold that there is an absolute and fundamental constitutional right to a physician’s aid in dying and conclude that Section 30-2-4 is not unconstitutional on its face or as applied to Petitioners in this case." The court relied heavily on the U.S. Supreme Court opinion in Washington v. Glucksberg and found no specific reasons under the NM Constitution to depart from that precedent since physician-aided dying is not a fundamental right. Here's an excerpt from the opinion:
New Mexico, like the rest of the nation, has historically sought to deter suicides and to punish those who assist with suicide, with limited exceptions in the HCDA and the Pain Relief Act. However, these exceptions occurred as a result of debates in the legislative and executive branches of government, and only because of carefully drafted definitions and safeguards, which incidentally are consistent with the safeguards urged by Petitioners. Numerous examples of such definitions and safeguards exist in the UHCDA. In addition to those previously identified in paragraph 35 of this opinion, the following reflect other safeguards relevant to our analysis... These and other provisions of the UHCDA further many of the government interests recognized by the Glucksberg Court as unquestionably legitimate, and which made Washington’s ban on physician aid in dying reasonably related to their promotion and protection…Indeed, if such exceptions and carve-outs to the historical national public policy of deterring suicide properly exist, they are certainly borne of the legislature and not the judiciary.
A summary of the opinion appeared in the July 13, 2016 eBulletin (full disclosure-I'm one of the editors).
Monday, July 11, 2016
JAMA Internal Medicine ran an article about a study concerning quality of care in end of life, looking specifically at the illnesses. Quality of End-of-Life Care Provided to Patients With Different Serious Illnesses was published on June 26, 2016. According to the abstract, "[e]fforts to improve end-of-life care have focused primarily on patients with cancer. High-quality end-of-life care is also critical for patients with other illnesses." The authors wanted "[t]o compare patterns of end-of-life care and family-rated quality of care for patients dying with different serious illnesses." The study offers several findings, including:
In a large national cohort of nearly all patients dying in VA inpatient facilities, we observed important differences in the end-of-life care received by individuals with different illnesses. Overall, we found that diagnosis was significantly associated with the quality of end-of-life care as measured both by family surveys and by several established measures of quality of end-of-life care. Patients with end-organ failure and frailty generally received lower-quality end-of-life care than did patients with cancer or dementia. (citations omitted).
After discussing their findings, the authors conclude
While there is room for improvement in end-of-life care across all diagnoses, family-reported quality of end-of-life care was significantly better for patients with cancer and those with dementia than for patients with ESRD, cardiopulmonary failure, or frailty. This quality advantage was mediated by palliative care consultation, do-not-resuscitate orders, and setting of death. Increasing access to palliative care and increasing the rates of goals of care discussions that address code status and preferred setting of death, particularly for patients with end-organ failure and frailty, may improve the quality of end-of-life care for Americans dying with these conditions.
The article is free and is available here.
Thursday, June 23, 2016
I don't think we should be surprised to learn that a lawsuit has been filed, challenging California's aid-in-dying law that became effective earlier this month. The LA Times reported on June 9, 2016 that a suit had been filed. Opponents Sue to Overturn California's New Aid-in-Dying Law explains that two organizations and some individual doctors filed the suit and claim that the law is unconstitutional,"argu[ing] that California’s law is a civil rights violation, stripping terminally ill patients of protections afforded to other Californians." The article notes that the judge assigned to the case denied a TRO but a hearing on the plaintiffs' motion for a preliminary injunction will be held in late June.
Friday, June 17, 2016
The ABA's Bifocal publication includes a new resource guide designed to help lawyers identify and help to implement decision-making options for persons with disabilities that are less restrictive than guardianships.
The "PRACTICAL Tool," with the first word intended to serve as an acronym for nine steps that a lawyer can use to identify legal and practical approaches, includes:
- Presume guardianship is not needed
- clearly identify the Reasons for concern;
- Ask if a triggering concern may be temporary;
- determining whether the concerns can be addressed by Community resources;
- ask if the person already has a Team to help make decisions;
- Identify the person's abilities;
- screen for potential Challenges;
- Appoint a legal support consistent with the person's values; and
- Limit any necessary guardianship petition.
For more, read Resource for Lawyers Targets Options Less Restrictive than Guardianship, Bifocal, the Journal of the ABA Commission on Law and Aging, Volume 37, Issue 5.
Tuesday, June 14, 2016
We often write here about end-of-life decisions. But, recently a friend shared with me one of the more remarkable accounts of decision-making I have seen, by a couple in their 80s.
I'm not even going to attempt to summarize this story, but I do recommend reading all the way to the end of the Gainesville Sun's report on "After nearly 59 years of marriage, Joe and Jean Subers die together."
Tuesday, May 31, 2016
The annual American Society on Aging (ASA) conference is scheduled for March 20-24, 2017 in Chicago. The planning committee is now accepting proposals to present at the conference. For more information or to submit a proposal, click here. The deadline for submitting a proposal is June 30, 2017.
May 31, 2016 in Advance Directives/End-of-Life, Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Health Care/Long Term Care, Programs/CLEs | Permalink | Comments (0)
Thursday, May 26, 2016
We all know folks who are the glass half-full type (optimist), as well as the glass half-empty type (pessimist). When one talks to those folks, how those folks interpret what they hear depends on what "glass type" they are. The Journal of the American Medical Association (JAMA) ran a story about a study, Prevalence of and Factors Related to Discordance About Prognosis Between Physicians and Surrogate Decision Makers of Critically Ill Patients. According to the abstract, "[m]isperceptions about prognosis by individuals making decisions for incapacitated critically ill patients (surrogates) are common and often attributed to poor comprehension of medical information."
The authors noted how important it is for the health care surrogate to have information in order to make a health care decision for the patient. But, according to the study,
Numerous studies over the last 3 decades indicate that surrogates of patients with advanced illness often have optimistic expectations about prognosis. This is problematic because optimistic expectations are associated with more use of invasive treatments in dying patients and delayed integration of palliative care. Clinicians cite unrealistic expectations by surrogates as one of the most important barriers to high-quality end-of-life care in seriously ill patients.(citations omitted).
The authors look at some of the reasons for this disparity in viewpoint (including the lack of medical knowledge by surrogates). Here is one example of their findings regarding the disparity of views:
Physician-surrogate discordance about prognosis occurred in 122 of 229 instances (53%; 95% CI, 46.8%-59.7%). Among the 229 surrogates participating in the study, 98 (43%) were more optimistic than physicians and 24 (10%) were more pessimistic. Sixty-five instances (28%) were related to a combination of misunderstandings by surrogates and differences in belief between the physician and surrogate about the patient’s prognosis; 38 (17%) were related to misunderstanding only; 7 (3%) were related to different beliefs; and data were missing for 12.
The authors explore the reasons for the surrogates' glass half-full view and learned that the surrogates felt that a positive attitude: "would improve the patient’s outcomes or protect themselves from emotional distress"; was justified because they knew the patient better than the doctor, including knowing if the patient were a strong person; and/or was based on their religious beliefs.
The study also explored the glass half-empty views of surrogates. The study authors concluded that "[a]mong critically ill patients receiving care in ICUs, discordant expectations about prognosis were common betwTeen patients’ physicians and surrogate decision makers and were related to both misunderstandings by surrogates about physicians’ assessments of patients’ prognoses and differences in beliefs about patients’ prognoses."
The article is available here for free
Tuesday, May 3, 2016
The New York Times ran an article by a doctor, When the Patient Won’t Ever Get Better, which illustrates a difficult scenario for patients and families. A patient, doing well, is hospitalized for some condition, surgery may occur and although successful, subsequently the patient develops one health problem after another, and will never recover to her condition prior to the hospitalization. Detailing the ups and downs of one patient, the doctor describes the patient "[a]nd then, things stopped getting better. Time slowed. There she was – neither dead nor truly alive – stuck, it seemed, in limbo." The patient declined again, more infections, use of a ventilator, etc. and then "[w]ith ... [the] constellation of ventilation dependence, infections and delirium, she had what doctors call 'chronic critical illness.'”
According to the author, this isn't that unusual a story.
[T]here are about 100,000 chronically critically ill patients in the United States at any one time, and with an aging population and improving medical technologies, this number is only expected to grow. The outcomes of these patients are staggeringly poor. Half of the chronically critically ill will die within a year, and only around 10 percent will ever return to independent life at home.
We can all imagine the scenario where our parent has a health crisis and all we want to know is whether she survived and is she "stable." After time passes, we learn that she is stable, but is chronically critically ill and won't improve. Here's how the author describes the situation
In the early moments of critical illness, the choices seem relatively simple, the stakes high – you live or you die. But the chronically critically ill inhabit a kind of in-between purgatory state, all uncertainty and lingering. How do we explain this to families just as they breathe a sigh of relief that their loved one hasn’t died? Should we use the words “chronic critical illness”? Would it change any decisions if we were to do so? ....
Perhaps this reality would be a good situation to use to discuss with our students whether they can draft language in an advance directive to deal with these situations.
Wednesday, April 27, 2016
JAMA's Journal of Internal Medicine ran an article in the April issue, The Challenge of New Legislation on Physician-Assisted Death . From the legal profession, we know how these laws work. But from the medical profession, according to the article, doctors need to think about how to incorporate this into their practices. Here is a sample of the article:
By the end of 2016, more than 80 million people in the United States and Canada will live in a jurisdiction allowing physician-assisted death. As such, this practice can no longer be considered a quirky experiment in a few states. The North American experience with physician-assisted death began in 1994, when voters in Oregon approved a ballot measure, the Death With Dignity Act, allowing a physician to prescribe a lethal dose of a medication that a patient voluntarily self-administers. Oregon stood alone for 14 years until Washington (2008), Vermont (2013), and now California (2015) approved similar laws. As of January 2016, the effective date of the California law, known as the End of Life Option Act, is uncertain. These laws are in general very similar, with safeguards that include requirements for a waiting period and that eligible patients be mentally competent, not mentally ill, and have a life expectancy of less than 6 months. In 2009, the Montana Supreme Court removed prohibitions against physician-assisted death for competent patients. There are no reporting requirements in Montana, so little is known about the actual practice of physician-assisted death in that state. In 2015, the Canadian Supreme Court unanimously reversed a federal law that prohibited physician-assisted death and gave the government until June 2016 to establish mechanisms for access to such assistance. (citations omitted)
A subscription is required to read the entire article.
Friday, April 22, 2016
This semester, I took a poll with my students in Elder Law, asking their views about right to die issues. This year, perhaps more than in past years, the poll came out strongly in favor of honoring clear, adequately informed decisions of individuals to end their lives. Of course, we discussed the many grey areas, and the impact of high profile cases, such as Brittany Maynard, on current thought. We debated both the question of affirmative actions to die, particularly in states that permit physician assistance, and the potential to assume -- and or even over-assume -- that a completed "living will" is a choice to reject so-called extraordinary life-saving measures. Just because we are now more likely to support personal choices to die, does not mean we should assume that all accept a nearer end.
Relevant to this discussion is a Washington Post essay by Boston-based internal medicine and primary care resident Ravi Parikh on When a Doctor and Patient Disagree About Care at the End of Life. He describes his own experiences as he begins his career:
Not long ago, a frail-looking elderly patient appeared at my cardiac health clinic with a file full of hospitalizations stemming from a heart attack years before. He’d had three coronary stents put in, had had heart bypass surgery and was unable to walk for more than a block due to chest pain. I saw that a previous doctor had written “DNR” — do not resuscitate — in his chart, so I asked him to confirm his wishes.
No, he said, to my surprise. He actually wanted to be a “full code” — meaning that chest compressions, shocks and intubation were to be used if necessary to keep him alive.
I was taken aback....
This experience pushed him to rethink his approach to the topic, which in turn led him to The Conversation Project website. His exploration concludes with the thought that "Once we listen enough to learn, maybe those 'goals of care' discussions will start focusing on the goals of the patient, not the doctor."
Our thanks to George Washington Law's Naomi Cahn for sending this piece; she and frequent writing colleague Amy Ziettlow have a thematically related piece for a recent University of Illinois symposium on "Law, Religion and the Family Unit After Hobby Lobby: A Tribute to Professor Harry Krause."
Wednesday, April 20, 2016
Prime Minister Justin Trudeau was the focus of an article in the New York Times last week on physician-aided dying in Canada. Justin Trudeau Seeks to Legalize Assisted Suicide in Canada reports that a proposed law was introduced that would allow physician-aided dying "for Canadian residents and citizens who have "a “serious and incurable illness,” which has brought them 'enduring physical or psychological suffering.'"
Under Canada’s proposed law, people who have a serious medical condition and want to die will be able to commit suicide with medication provided by their doctors or have a doctor or nurse practitioner administer the dose for them. Family members and friends will be allowed to assist patients with their death, and social workers and pharmacists will be permitted to participate in the process.
One striking difference in the proposed legislation in Canada compared to those states in the U.S. where physician-aided dying is legal is that "a doctor or nurse practitioner [may] administer the dose for them. Family members and friends will be allowed to assist patients with their death, and social workers and pharmacists will be permitted to participate in the process."
Not all in Canada are in favor of the legislation. CBC Canada ran a story, Religious groups react to physician-assisted dying bill LIVE where a number of groups stated concerns about the legislation. The video is available here.
If any of our readers are from Canada, we would be very interested in hearing more about the discussion in Canada on this proposal.
Friday, April 15, 2016
Lately, I've been hearing and seeing the phrase "living wills" in mainstream news sources such as the New York Times, but at first the context was confusing to me because the media were speaking and writing about Big Banks, not humans. So, how did it come about that following the 2008 financial crisis, regulators started requiring large financial institutions to have "living wills?"
The Wall Street Journal explains in What You Need to Know About Living Wills [in the context of Big Banks]:
A living will is a document from a financial firm that describes how it would go through bankruptcy without causing a broader economic panic or needing a bailout from taxpayers. The largest U.S. banks have filed several versions of them since the 2010 Dodd-Frank law, which required living wills from financial firms that were judged to pose a potential risk to the broader economy. The documents are also known as resolution plans. “Resolution” is regulatory parlance for dealing with a failing financial firm. Living wills are separate from other regulatory requirements, such as annual “stress tests” that measure whether could banks survive a severe recession.
I've not yet determined who first came up with "living wills" to describe what Dodd-Frank, at 12 U.S.C. Section 5361(d), refers to as "resolution plans." Without accurate, full disclosure, addressing all aspects of the financial institution's operations, such plans -- by any name -- seem unlikely to achieve the goal of greater market stability. As another WSJ writer points out, the utility of Big Banks' living wills comes if not just regulators, but the Bank executives, are paying attention:
The point of the living wills, like the stress tests, is to sit banks down and make them comb through their businesses in excruciating detail, with a focus on grim aspects like liquidity crunches and operational risks in bankruptcy. A useful result of the living wills is that, if they're done correctly, they give regulators a good overall picture of how a bank works, how money flows between its parts, what its pressure points are, and how it responds to crisis. But a much more important result is that, if they're done correctly, they give bankers themselves that same overall picture: They force a bank's executives and directors to understand the workings of the bank in a detailed and comprehensive way. And if they're done incorrectly, that's useful too: They let the regulators and bankers know what they don't know.
The full article on this point is titled, with nice irony, Living Wills Make Banks Think About Death. There, a least, is one similarity in living wills for humans and banks.
Thursday, March 31, 2016
A friend sent me several recent resources about elders with dementia. The Hospice and Nursing Home Blog published a video on Doctors’ End-of-Life Language, Impact on Patient-Caregiver Decisions. The Agency on Healthcare Research and Quality published Nonpharmacologic Interventions for Agitation and Aggression in Dementia. The pdf of the article is available here. Finally, in February, 2016, this article, Palliative care of patients with advanced dementia was published in UpToDate (which is "an evidence-based, physician-authored clinical decision support resource....")
Thanks to my friend Pamela Burdett for sending me the links to these 3 publications.
Tuesday, March 29, 2016
Roz Chast's memoir of life with her parents as they aged, Can't We Talk About Something More Pleasant?, uses humor to explore the complicated issues that can arise when aging parents and their adult children try to address physical frailty and financial complexities in the "third age" of life. Another look, equally realistic and also ruefully humorous, comes from William Power, writing for the Wall Street Journal in "The Difficult, Delicate Untangling of Our Parents' Financial Lives." Thanks to the WSJ for making this an unlocked article for digital access!
Power begins with that ever-humbling attempt to use "help lines" to solve problems by phone:
“No, no, no, don’t transfer me to her again,” pleads my wife. It is a typically frustrating moment in our family crisis, one that many grown children will have to face, ready or not: We are people in our 50s who are unraveling the finances of parents who can no longer do it themselves.
My wife, Julie, is on the phone with the company where her 82-year-old dad had once worked, trying to change the direct deposit of his pension checks to a bank closer to the assisted-living home where he and his wife now live, which is near us in Pennsylvania. Again and again, she is transferred to the person in charge, “Rose.” And every time, the same recording: “This number has been disconnected.”
Power's account is punctuated by practical advice for others, including the importance of teamwork, involving both family members and others, in tackling the issues, as well as the use of key document-based tools, including Powers of Attorney, or as he stresses, "Repeat after Me: POA, POA, POA."
My thanks to Amy Bartylla, a long-time friend, for this article referral.
March 29, 2016 in Advance Directives/End-of-Life, Consumer Information, Dementia/Alzheimer’s, Estates and Trusts, Ethical Issues, Health Care/Long Term Care, Property Management | Permalink | Comments (0)
Tuesday, February 23, 2016
Here are three recent articles of note on Physician-Aided Dying (PAD) that might be useful in your classes.
First, the Journal of the American Medical Association (JAMA) Psychiatry ran at article on February 10, 2016, Physician-Assisted Death for Patients With Mental Disorders—Reasons for Concern. As the article opens:
Physician assistance to help people end their lives—by prescribing or directly administering medication—is now legal in some form in 4 American states, Canada, and 4 European countries. In the United States, laws permitting physicians to write prescriptions for medications intended to end patients’ lives are limited to patients with terminal conditions and preclude physician administration of the medication. However, other countries, including the Netherlands, allow direct physician involvement and have expanded the criteria to include patients with irremediable suffering, whatever the cause. Therefore, the door has been opened for people whose suffering is primarily due to mental disorders to seek assistance in dying. (citations omitted)
Next in the same volume is the article about the study referenced in the first article: Euthanasia and Assisted Suicide of Patients With Psychiatric Disorders in the Netherlands 2011 to 2014. The full article is free, and the tables and references are also available in the online version. The authors conclude
Despite some limitations, an important strength of our study is that we examined reports of actual psychiatric EAS cases across an entire jurisdiction, rather than asking physicians to recollect their experiences or opinions. The results show that the patients receiving EAS are mostly women and of diverse ages, with various chronic psychiatric conditions, accompanied by personality disorders, significant physical problems, and social isolation or loneliness. Refusals of treatment were common, requiring challenging physician judgments of futility. Perhaps reflecting the complexity of such situations, the physicians performing EAS generally sought multiple consultations (but not always), and disagreement among physicians—especially regarding competence and futility—was not unusual. Despite these complexities, a significant number of physicians performing EAS were new to the patients. We conclude that the practice of EAS for psychiatric disorders involves complicated, suffering patients whose requests for EAS often require considerable physician judgment. The retrospective oversight system in the Netherlands generally defers to the judgments of the physicians who perform and report EAS. Whether the system provides sufficient regulatory oversight remains an open question that will require further study.
The New York Times ran an article about the study on February 10, 2016. Assisted Suicide Study Questions Its Use for Mentally Ill notes that
A new study of doctor-assisted death for people with mental disorders raises questions about the practice, finding that in more than half of approved cases, people declined treatment that could have helped, and that many cited loneliness as an important reason for wanting to die. The study, of cases in the Netherlands, should raise concerns for other countries debating where to draw the line when it comes to people’s right to die,
Discussing the findings from the study, the NY Times article notes that that it
finds that cases of doctor-assisted death for psychiatric reasons were not at all clear-cut, even in the Netherlands, the country with the longest tradition of carefully evaluating such end-of-life choices. People who got assistance to die often sought help from doctors they had not seen before, and many used what the study called a “mobile end-of-life clinic” — a nurse and a doctor, funded by a local euthanasia advocacy organization.
Good sources for your classes and for students writing papers on the topic!
Monday, February 22, 2016
A John A. Hartford Foundation-sponsored study released this month uses Medicare data to examine health care for older Americans, with a self-described "emphasis on the patient's perspective." Both the methodology and the conclusions are intriguing. The researchers report:
For the first time, we measure the intensity of care in terms of how many days per year the average Medicare beneficiary is in contact with the health care system. We can see that beneficiaries in some regions see twice as many unique clinicians for ambulatory care than in others. We also can see in which regions beneficiaries are more likely than not to have a primary care physician as their predominant provider of care.
We also examine the adoption of new evidence-based practices to show that, while some regions showed substantial progress, others still fall short. For example, in some regions, fewer seniors are being prescribed inappropriate high-risk medications, and in others, thirty-day readmission rates are falling. Yet screening tests for prostate cancer and breast cancer among beneficiaries 75 and older remain unnecessarily high, and the data in this report suggest that we are still waiting too long to refer patients to hospice care.
On the one hand, the report demonstrates wide regional variation in the percentage of patients enrolled in "hospice" during the last three days of an individual's life. The researchers conclude: "Referrals to hospice care that are done too late ... adversely affect the quality of care, the reported experiences of patients and families, and their satisfaction with the health care system."
On the other hand, the report cites "clinical evidence" that shows that "feeding tube placement" in patients with advanced dementia "does not prolong life or improve outcomes, and in fact leads to further complications and adverse effects such as the increased use of restraints." Nonetheless, the report shows that in some regions of the country, 12% to 14% of patients with dementia may be on feeding tubes, pointing to locations such as southern California, Lake Charles, Louisiana, and Dearborn, Michigan.
For the full report, see the Dartmouth Atlas project report, "Our Patients, Ourselves: Health Care for an Aging Population."
Further, for an region-specific analysis of the report findings, see iNewsource's "Care for San Diego's Dying Patients Needs to Improve, Study Finds."