Aug. 12, 2009— -- The debate about euthanasia has gone too far.
Someone's intent to do a good and necessary deed has now been transformed into a hideous misrepresentation that not only affects our humanity and dignity as a nation, but goes to the heart of the physician-patient relationship and the responsibility that physicians have to provide healing and comfort as well as treatment.
That's our oath, and that's what we are supposed to do. Recognizing that imperative is not something that should be punished as an evil act.
Perhaps some background would be helpful in framing the issue:
Medicare is supposed to only pay for medically necessary and effective care. It is not allowed to provide other services such as screening or prevention unless specifically authorized by Congress.
End-of-life counseling falls under the category of non-covered services, but probably gets into the payment mix as part of other billing codes doctors use to get paid for more routine "evaluation and management" services.
Providing explicit payment for this service will encourage appropriate and needed discussions between physicians and patients on this very important, difficult and humanitarian topic.
For years, many of us have been concerned about end-of-life issues, such as living wills, pain management and hospice care. Counseling our patients as they age about their options -- and equally important, understanding what our patients' wishes may be -- is an honored part of the physician-patient relationship, especially for primary care internists, family physicians and oncologists. The reality is that we have not been as successful as we need to be in encouraging these discussions.
We have tried for years to get people to sign living wills and provide durable powers of attorney for health care. Medical professionals need guidance -- preferably in advance of the moment -- on what patients want done, either at the time when their lives are coming to an end or when they may not be able to speak for themselves.
There is nothing inhumane or inappropriate about that discussion. It is a discussion that no one wants to have, and one that is never easy. But it is the right thing to do, and there are plenty of medical and patient organizations who have devoted considerable effort to encourage these discussions.
There is nothing about the discussion that is preordained to limit care. In fact, some patients and families want "everything done" even when medical professionals find that directive to be against their own ethical instincts.
I learned these lessons early in my career as a medical oncologist. Having discussions about end-of-life is an unfortunate reality in cancer care.
What surprised me at the time -- when there was less I could do for many patients than is the case today -- was the number of patients and families who told me they were more interested in comfort than they were in treatment. They wanted to be certain someone would be there to care for them through their last days or months and ease their pain and suffering more than they were concerned about getting the next drug, which more likely than not would have given them more discomfort than hope and relief from their suffering.
Those discussions had an incredible impact on me as a person and a physician, and the experiences remain with me today.
I didn't euthanize anyone, and never, never would such a thought enter my mind. My patients taught me that having a heart beat and being alive to see the sun rise another day was not living and was not life. That was their decision, not mine. I would do what they wanted, but almost always what they wanted was care, compassion and relief from pain. That is what we tried to offer.
When I recently heard the gross misrepresentation surrounding the portion of the health care bill that referred to paying health care professionals for these end-of-life discussions, I couldn't help but be concerned and confused. When I heard the rhetoric stormed up to a level of "death panels" and "Nazis" I knew we had gone too far.
I have stayed out of the politics of health care reform in these blogs, and will continue to do so. But as I mentioned in my comments the other day, someone has to be an honest broker of what is going on out there, dealing with some of the rhetoric that is coming from both sides and that is designed to inflame rather than inform.
If you are a physician who has cared for a patient for years or even decades, you know that person as a friend as well as a patient. Your goal is to provide the best care you can, but also to provide comfort when cure is no longer the goal. You counsel your patient and their family on what you think the best path may be at that moment and in the future, whether it be treatment or comfort. You act as protector for their wishes, the guardian of their health, and at the appropriate time the minister for their comfort.
You are not a Nazi. You are not triaging who will live and who will die. You are not some thoughtless bureaucrat who is concerned about how much it will cost to keep someone alive.
I have stood in the places of remembrance for people who were killed without cause. I have cried my tears over those who were lost by senseless murders. I have read the writings of those who survived. And I will never forget.
So please do not dehumanize the memories of those who suffered from terminal illnesses or the ravages of age by suggesting that somehow our great country, our great people, and our great physicians and health professionals are somehow going to become agents of the state and in turn agents of death.
Please understand that dignity in our lives must always be paramount in our thoughts. Discussing end-of-life wishes is humane and appropriate. Providing counseling, care, hospice and pain control is in the noblest traditions of our profession and our country. Listening to our patients and their families is what we do, and what we pledge to do.
Continue with the debate and the discussion, make your case and make your points, but do not dishonor those of us who have tried to do the right thing for our patients, families and friends and the memories of those who have died in peace, honor and dignity by making the choices that were best for them.
Len Lichtenfeld is deputy chief medical officer of the American Cancer Society. You can view the full blog by clicking here.