The Unwitting Birthplace of the 'Death Panel' Myth

LA CROSSE, Wis. -- This city often shows up on "best places to live" lists, but residents say it is also a good place to die -- which is how it landed in the center of a controversy that almost derailed health-care reform this summer.

The town's biggest hospital, Gundersen Lutheran, has long been a pioneer in ensuring that the care provided to patients in their final months complies with their wishes. More recently, it has taken the lead in seeking to have Medicare compensate physicians for advising patients on end-of-life planning.

The hospital got its wish this spring when that provision was inserted into the health-care reform bill -- only to see former Alaska governor Sarah Palin seize on it as she warned about "death panels" that would deny care to the elderly and the disabled. Despite widespread debunking, those warnings have led lawmakers to say they will drop the provision.

"It's really distressing," hospital official Bud Hammes said. "These things need to be addressed."

President Obama's health-care initiative was nearly consumed by the furor over that provision, and Republicans continue to argue that the legislation would ration care for the elderly. The debate has underscored how fraught the discussion is on end-of-life care in a country where an optimistic ethos places great faith in technology and often precludes frank contemplations of mortality. That tendency has a price tag: A quarter of Medicare costs -- totaling $100 billion a year -- are incurred in the final year of patients' lives, and 40 percent of that in the last month.

But the controversy has had most resonance where it arguably took root, in this town of 52,000 where nearly everyone of a certain age has an advance-care directive.

La Crosse became a pioneer in addressing end-of-life questions in the mid-1980s, after Hammes, a native of the city who has a doctorate in philosophy from Notre Dame, arrived at Gundersen as the director of medical humanities, charged with educating resident physicians about ethics. He noticed a "troubling pattern," he said, in which family members struggled to make medical decisions, such as whether to continue dialysis after a stroke.

"We'd turn to the family and say, 'We need your input. If your mother or father could speak now, what would they tell you?' And the family would say, 'If we only knew,' " said Hammes, 59. "I could see the distress. They were going to have to live with themselves, with the worry about making a mistake. This was unacceptable."

The hospital began urging families to plan while people are healthy. For those who want help writing a directive, a physician will discuss the powers and limits of medicine and explain to family members what it means if they agree to serve as the "health-care agent." They will also help people define the conditions under which they would no longer want treatment. Hammes said people often define this as "when I've reached a point where I don't know who I am or who I'm with, and don't have any hope of recovery."

The directives are power-of-attorney forms that protect physicians and family members against liability, and the hospital makes clear to its doctors that they are expected to follow them. Today, more than 90 percent of people in town have directives when they die, double the national average.

The reliance on directives has an impact on the type of care people receive: Gundersen patients spend 13.5 days on average in the hospital in their final two years of life, at an average cost of $18,000. That is in contrast with big-city hospitals such as the University of California at Los Angeles medical centers (31 days and $59,000), the University of Miami Hospital (39 days, $64,000) and New York University's Langone Medical Center (54 days, $66,000).

Those disparities are not explained just by the hospital's end-of-life philosophy. Under Medicare formulas, Gundersen and other Upper Midwest hospitals receive lower reimbursements. The high-spending hospitals argue that they are also dealing with a more diverse and costly patient base.

Gundersen and other Upper Midwest providers are also less costly in general, partly because they follow a model of integrated care where doctors work closely together to minimize waste. At Gundersen, doctors receive a salary instead of being paid for each procedure they perform.

But locals say the city uses less health care in large part because of how people view the end of life. Some of this may be rooted in the down-to-earth sensibility of their German and Scandinavian forebears. (Hammes said his late mother, who had dementia, was a "pragmatic German" who thought that paying to keep herself alive was a "waste of her money.")

Mostly, though, locals say it is because Gundersen and the town's other hospital, Franciscan Skemp, have urged planning. "People here have their feet planted in the ground," said Barbara Frank, a retired teacher. "They're no-nonsense sorts of people, without a lot of illusion. That was the fertile soil upon which it was planted. But there's no question it was helped by the two medical centers taking the lead and saying, 'This is a good thing for you to do.' "

She and her husband, Donald, a retired train engineer, signed a directive 10 years ago, when they were in their 60s. "You increasingly realize that they're not going to make an exception in your case. We all die, and we want to do so with the most dignity and most control," she said. "It seemed a no-brainer. And it spares our children from making those decisions."

Over time, the practice caught on. "People talk to people who talk to people. They say, 'Do you have one?' 'Yeah,' or 'I have to get that done,' " said Ann Kotnour, a nurse whose 89-year-old mother is receiving care at home for her advanced Parkinson's after signing a directive in 2001 saying she did not want aggressive measures taken.

Financial planner Jeff Lokken's parents had met with their children and doctors in the mid-1990s to draw up directives, a step that was helpful a few years later, when he and his siblings needed to decide whether to keep their 77-year-old father on a ventilator after heart surgery. The living will also helped when his mother's health failed when she was 82. "There needs to be a conversation. In our case we had good conversations," he said.

But Gundersen staff members say those conversations take a lot of time -- a good hour, plus follow-up talks to alter directives as medical situations evolve. And Medicare does not reimburse doctors for the time spent on such discussions.

Backed up by a few other hospitals, Gundersen set out to change the federal rules to reward end-of-life planning. A Gundersen administrator testified on Capitol Hill last fall, and, with the help of a lobbyist, reached out to lawmakers such as Sen. Herb Kohl (D-Wis.), Sen. John D. Rockefeller IV (D-W.Va.) and Rep. Ron Kind (D-Wis.).

After sporadic bipartisan attempts in recent years to add consultation payments to Medicare, Rep. Earl Blumenauer (D-Ore.) submitted legislation this spring, with several Republican co-sponsors, that included a provision to reimburse doctors for consultations. A few months later, House Democrats tucked similar language into their health-care reform bill -- a legislative triumph for the small hospital in La Crosse.

Then the uproar began, capped by Palin's "death panel" remark. Gundersen officials and town residents were aghast. "It's totally absurd," Frank said. "It's just the opposite -- it's giving you a choice of how you want to be treated."

Gundersen officials were particularly upset when Sen. Charles E. Grassley (R-Iowa), whom they had considered an ally, said that the government should not "pull the plug on Grandma" and that the provision would be dropped. They were also dismayed when the provision was criticized by former House speaker Newt Gingrich (R-Ga.), who had been open about how much he appreciated the end-of-life care his father-in-law received at Gundersen.

Rep. Paul D. Ryan (R-Wis.) admires Gunderson generally but said it erred in pushing for Medicare to cover consultations. "It's right and proper for Gundersen to innovate in these directions, but it's a wholly different thing for the federal government" to endorse end-of-life planning, he said.

Gundersen officials are still fighting to keep consultation payments in the bill, with support from Sen. Mark Warner (D-Va.), who has become a leading advocate for such planning. But this week, word came that the White House is willing to drop the provision. The hospital officials are even less hopeful about more ambitious terms they sought to add -- changing Medicare payments for end-of-life care so that they are based not on the procedures a patient receives in the final months but on whether care complied with the person's wishes.

No matter what, they will keep trying to get payment for consultations into future legislation. "The [directive] itself doesn't really matter very much -- it's the clearly expressed belief and shared understanding that it represents," Hammes said. "The family members have to believe that what they do is not only legally right, but personally right. If Mom said, 'Don't do this or do do this,' it's much easier for them to say, 'I'm doing a loving thing,' and it's a decision you can live with."

The discussions do not promote less aggressive care, he said: "We're not trying to talk them into anything. We're trying to understand their values and goals, and tell them what medical science can and can't do." But many people do settle on less care. "In our community," he said, "people don't want to die hooked up to machines."

By Alec MacGillis
Washington Post Staff Writer
Friday, September 4, 2009

Dumb, Dumber, and Just Plain Assholes

This is one more piece of proof that Republicans are scum-sucking pieces of lying trash and that the people who believe talking points without doing their own research are moronic sheep.

Preying on Fear and Predicting the Final Solution
by Lou Dubose | September 1, 2009
The Dalles, Oregon

WHEN DEMOCRAT JEFF MERKLEY WAS THE UNDERDOG challenging Republican incumbent Gordon Smith in 2008, he promised that if elected he would hold one town hall meeting a year in every county in Oregon. Because they usually begin with a 3,000-mile flight from Washington, D.C., congressional town hall meetings in Oregon are a heavy lift. And there are thirty-six counties in the state. So Senator Merkley was meeting with constituents months before claques of red-faced white men kicked off their summer of hate.
The senator had scheduled four town hall meetings (across 610 highway miles) for August 2 and 3—on the weekend after the House Energy and Commerce Committee completed a 1,000-page health care reform bill. Merkley's August meetings occurred just as right-wing fanatics were preparing to hijack the national health care reform discussion.

I caught up with the senator at his first meeting on Saturday morning in Tillamook and proceeded up the coast for an afternoon meeting in Astoria. On the following day Merkley held meetings in The Dalles and Madras, two smaller towns east of the coastal range.

Ten minutes into the meeting at the Tillamook library, a man asked the question that would be asked at least twice, in one form or another, at each of the four meetings: "I hear if you're a certain age, you're going to have to go before a committee where they're going to try to convince you that it's not in the interest of the country for you to get the medical care that you need."

The senator explained that a provision in the House bill would require the government to pay private physicians for one voluntary counseling session regarding end-of-life decisions every five years. The questioner didn't buy it. It reminded him of Jack Kevorkian, the Michigan physician who served seven years in prison for assisting terminal patients to end their lives.

End-of-life counseling was the topic of the moment. That afternoon in Astoria a woman asked, "Why do we have to have mandatory end-of-life counseling?" The senator again explained the provision in the House bill: an optional consultation with your private physician paid for by the government. His explanation was followed by a variation on the same theme from yet another woman. "Would you be willing to let me counsel your parents without knowing what my belief system was and I encourage them to end their life?" she asked. "I think the government has no business making end-of-life decisions." She angrily refused to accept the senator's explanation that counseling would be provided by private physicians.

It was evident that these questions had little to do with the actual content of any health care bill. It was also evident that the most vocal opponents of reform were literally reading from the same script. In this case, a script that revealed the influence of Christian extremists, whose sloppiness in dealing with facts and programmatic deceit has been largely ignored by the media.

I spoke with one of the women who had asked about mandatory end-of-life counseling. She said she knew the counseling was mandatory because "it's in the bill." Yet she hadn't read the bill. She was reading from a memo posted on the website of the Liberty Counsel, a Christian law firm and advocacy group related to Jerry Falwell's Liberty University in Virginia.

Among the 112 talking points in the Liberty Counsel's ten-page electronic samizdat were the following:
Sec. 2511, Pg. 992 - Government will establish school-based "health" clinics. Your children will be indoctrinated and your grandchildren may be aborted!

Sec. 1233, Pg. 429, Lines 10-12 - "Advanced Care Consultation" may include an ORDER for end-of-life plans - from the government.

Sec. 1713, Pg. 768, Lines 3-5 - Nurse Home Visit Services – Service #1: "Improving maternal or child health and pregnancy outcomes or increasing birth intervals between pregnancies." Compulsory ABORTIONS?

Sec.1751, Pg. 800 - The government will decide which Health Care conditions will be paid. Say "RATION!"
None of these claims are true. Nor were they compiled by the Liberty Counsel's staff. They were provided by right-wing blogger Peter Fleckenstein and posted under the imprimatur of the Liberty Counsel.

HITLER, OBAMA, AND MALTHUS—Sunday meetings in The Dalles and Madras were more angry and volatile.There was a lot of concern about a nonexistent provision in the House bill that would provide free health care for illegal aliens. And the end-of-life questions continued.

In The Dalles, a seventy-four-year-old woman wearing a nasal oxygen tube held in place by a retaining headband asked about "this new House measure in the bill which says the government will determine when I stay and when I go." When I asked her about her sources, she handed me a printout of the Liberty Counsel talking points, which she said she "got from a pastor on the Internet." She also said that "getting rid of the old people was how Hitler got started."

In Madras, where the crowd was extremely vocal and angry, an elderly woman linked the House's proposed solution to the nation's health care crisis to the final solution. "In Germany when Hitler came in, he started out with the insane and mentally retarded," she said. "And nobody ever saw them again. Then he came for the senior citizens. Later word got out that they were all euthanized. Hitler said we'll have more food for the healthy people." (She neglected to mention six million Jews.)

The woman said she is Christian and believes in "the End Times," in which she fears Obama is playing a role. When I spoke to her, I found that she, too, was reading from the Liberty Counsel talking points, printed out from Rick Joyner's Web site.

Rick Joyner is "the pastor on the Internet" who somehow managed to inform much of the debate in Oregon. He is a South Carolina evangelical with a large church and an even larger Web-based ministry. He derives his spiritual authority from a claim to have been transported to Heaven for an extended conversation with Jesus. Joyner has done eight "National Health Scare Bulletin" Webcasts that are also available in transcript format. They all provide links to the Liberty Counsel memo, which he continues to promote.

Joyner insists that it is a Christian duty to speak out about Obama's health care reform plan. In his health care homilies, the pastor links reformers to Nazis in Hitler's Germany:

"They started with abortion. Then they started with all the retardeds; they gathered up all the retarded and said the state can do a better job taking care of the retarded than families: No one ever saw them again. Then they went on, to the elderly to the infirm…. Nobody knew what happened to them.

"You may have heard the one German who said when they came for the Jews I didn't complain, because I wasn't Jewish. When they came for the Catholics, I didn't complain because I wasn't Catholic. When they came for the union leaders I didn't complain because I wasn't in a union. When they came for the Protestants, I didn't care because I wasn't a Protestant. When they came for me, nobody complained because there was nobody left."

Joyner admits that there are errors in the Liberty Counsel memo and said that its executive director, Mat Staver, and Staver's staff are working on a revised copy. Two weeks after the Oregon hearings, I called to ask about the inaccuracies. Joyner's administrative assistant told me they would get back to me. I called the Liberty Counsel, where a woman in the press office told me she knew nothing about any revisions and that Mathew Staver would call me with a further explanation. As this issue went to press, neither Joyner nor Staver had returened calls. These are organizations that enjoy non-profit status under the IRS Code, are fully engaged in the health care debate, yet answer to no one.

In his Webcasts (http://www.morningstarministries.org) Joyner persists with his claims about Nazi Germany, a historical moment he claims to have studied extensively.

I found it odd that a pastor who is an authority on Nazi Germany would have missed Pastor Martin Niemöller, the "one German" quoted by Joyner. Joyner might be surprised to learn that Niemöller was in fact a Protestant, a Lutheran pastor and theologian.

Niemöller actually said:

"First they came for the communists, but I was not a communist so I did not speak out. Then they came for the socialists and the trade unionists, but I was neither, so I did not speak out. Then they came for the Jews, but I was not a Jew so I did not speak out. Then they came for me, and there was no one left to speak out for me."

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If you would like to read the Health Care Bill for yourself (instead of letting liars tell you what is in the bill, when it really isn't) go here to read the Bill.

BTW, the kicker about the Death Panels--- you're going to love this--the End of Life Counseling language was put in the Bill by Republican Olympia Snowe, and, and similar End of Life Counseling language in the 2003 law which created the Medicare prescription drug benefit was supported by and voted for by Republicans Senators Grassley, Lugar, and Collins, and Republican Reps. Patrick Tiberi of Ohio, Geoff Davis of Kentucky, and Charles Boustany, R-La.

In fact Rep. Charles Boustany, a heart surgeon and a co-sponsor of the counseling bill, says the legislation is aimed at promoting important discussions between doctors and their patients about critical end-of-life issues, such as having a living will. He says those discussions are a "good medical practice," and doctors who spend time counseling their patients about their wishes should be reimbursed through the Medicare system, as the legislation allows.

Dumb, Dumber, and Just Plain Assholes.