"Death Panels" Born in Heartland Hospital

Washington Post: Wis. Hospital Long Recognized as Pioneer in End-of-Life Care

(Washingtonpost.com)  This story was written by Alec MacGillis.

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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 House Democrats inserted that provision into their 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."

[deather2009]

Keep up with the latest Deather and Death Panel information at www.whatisadeather.com!

[HGOODGUY]

The republican agenda can be summed up very simply
1. Invent a word ("death panel").
2. Make you afraid of it

[burneb]

Rather than have the terminally ill patient (and/or family) and doctor discuss the options, and the doctor get paid for this counseling time, wouldn't we all rather have our insurance companies making these decisions about what will be covered?

After all, if it is an insurance company deciding what is covered, and therefore for most people determining what they can do, then we don't call them bureaucrats or "death panels".

[daisyjingles]

The big health care insurance companies are the OPEC of America.

They do not want the competition that would be there if we have a public option.

Their goal is to get richer any way they can.

This is a capitalistic society in which there should be competition. The biggies also make it harder for smaller insurance companies to get a foothold because changing insurance companies can mean that pre-existing condiitions are not covered. When that happens, it is too costly to change companies. Health care insurance should be as competitive as car insurance.

[rmonroe401]

hockeymom441,

Forget about talking sense to the people in this country. All they know is to follow what Fox News and Rush Limbaugh tell them to do. They don't have minds of their own to look into the misleading dangerous rhetoric being sent out by these irresponsible fools who are paid off by special interests and the insurance industry. Either that or they have such a deep seeded hatrid for people who are different then them they will stop at nothing to discredit anything a minority President will do. Sad

[tafhdyd]

BeckieBest said it best in the first post!

[Hosheen]

Albert Einstein was right. "The two most common elements in the universe are hydrogen and human stupidity." Isn't it amazing how much of the latter is concentrated in neo-cons?

Ignorance and fear-mongering seem to be he party platform now. I guess if you have no facts or logic, that's all that's left and it's what they have to do.

[lovegetpeace]

Folks,

Please do not share the following secrets about our Private health Insurance industry........

In 2008, the cost of our Private Health Care Insurance increased by 7%.

In 2008, the Out-Of-Pocket Deductible of our Private Health Care Insurance doubled.

In 2008, the Benefits of our Private Health Care Insurance decreased by 11%.

In the last 3 years, Private Insurance Companies have refused 12 million procedures suggested by doctors. Please do not call this rationing or death panel.

In the last 3 years, Private Insurance Companies have dropped 921,300 policies right when the customer got sick. Please do not call this rationing or death panel.

In 2008, the Health Care Industry made a little over $13,000,000,000.00 in Profit.

Now, facts......

All Seniors are very happy with Socialized Health Care (Medicare and Medicaid). Sooner or later you will be a Senior. All low-income Children are happy with Socialized Health Care (S-CHIP). All Federal workers are happy with their Socialised Health Care. All Military Veterans are very happy with Socialized Health Care. All congressmen and congresswomen are very happy with Socialized Health Care.

Who said the Government does nothing right!

[lovegetpeace]

Amigo Republicans,

Please do not look at your weekly Paycheck Stubs. You will get a heart attack just from knowing how much your Private Insurance is costing you and your employer with Increasing Out-of-Pocket Deductibles and Lower Benefits each year.

You are already paying these expensive 'Taxes' (Premiums) even for the Un-Insured. How much more poorer and poorer (take home check) do you wish to get each year?

[lovegetpeace]

Hey jackp32,
The only way government can control cost is as follows:

Medicare versus Private Health Insurance:
The Cost of Administration
http://www.cahi.org/cahi_contents/resources/pdf/CAHIMedicareTechnicalPaper.pdf


Private Insurance is 5 times more expensive to administer than MediCare. Most of the extra cost is for taxes, commissions, dividends and profit. The government never pay taxes, commission, dividend and profit to itself.

But, more powerful reason than these is the fact that the government got a 320 millions pool to distribute the risk when determining cost per policy.

[lovegetpeace]

Folks,

Let me share a personal story related to this 'death panels' nonsense.

In January 2005, the doctor told us my father-in-law had lung cancer and had about 9 months to live. He was a big smoker. Within 1 week, the entire family of my wife privately decided to not treat him and give him the very best life in his final months. Important to this story was the fact that my father-in-law was never told or suspected that he had lung cancer. He passed away exactly 11 months later. Except for his last 2 weeks, he was the happiest man on this planet.

Why?

In 2002, a neighbor of one of my brother-in-laws had lung cancer and was told he had 11 months go live. The family of that neighbor decided to treat him until the end. The doctor removed the cancer in a surgery and started chemotherapy and Radiation Therapy Treatments using very toxic and powerful cancer drugs. This old man died 4 months later and during these 4 months, he was under a lot of pain.

My point is that sometimes treatment is NOT worth the cost and pain to the family and to society.

[lovegetpeace]

Folks,

Let me share a personal story related to this 'death panels' nonsense.

In January 2005, the doctor told us my father-in-law had lung cancer and had about 9 months to live. He was a big smoker. Within 1 week, the entire family of my wife privately decided to not treat him and give him the very best life in his final months. Important to this story was that my father-in-law was never told or suspected that he had lung cancer. Except for his last 2 weeks, he was the happest man on this planet.

Why?

In 2002, a neighbor of one of my brother-in-laws had lung cancer and was told he had 11 months go live. The family of that neighbor decided to treat him until the end. The doctor removed the cancer in a surgery and started chemotherapy and Radiation Therapy Treatments using very toxic and powerful cancer drugs. This old man died 4 months later and during these 4 months, he was under a lot of pain.

My point is that sometimes treatment is NOT worth the cost and pain to the family.

[lovegetpeace]

Folks,

Let me share a personal story related to this 'death panels' nonsense.

In January 2005, the doctor told us my father-in-law had lung cancer and had about 9 months to live. He was a big smoker. Within 1 week, the entire family of my wife privately decided to not treat him and give him the very best life in his final months. Important to this story was that my father-in-law was never told or suspected that he had lung cancer. Except for his last 2 weeks, he was the happest man on this planet.

Why?

In 2002, a neighbor of one of my brother-in-laws had lung cancer and was told he had 11 months go live. The family of that neighbor decided to treat him until the end. The doctor removed the cancer in a surgery and started chemotherapy and Radiation Therapy Treatments using very toxic and powerful cancer drugs. This old man died 4 months later and during these 4 months, he was under a lot of pain.

My point is that sometimes treatment is worth the cost and pain to the family.

[jackp32]

The only way gov't can control health care costs is to cut services to those who are dying which includes mostly seniors. The decision on end of life matters belong with the patient, their doctor, and family members. Keep the gov't bureaucrats out of the loop. I lost my mother recently but she had prepared an end of life request rejecting any last minute revival efforts. Her request was honored as she slipped into an eternal sleep because of congestive heart failure. No gov't counselor was involved. Let's keep it that way.

[lovegetpeace]

Hey jackp32,
The only way government can control cost is as follows:

Medicare versus Private Health Insurance:
The Cost of Administration
http://www.cahi.org/cahi_contents/resources/pdf/CAHIMedicareTechnicalPaper.pdf


Private Insurance is 5 times more expensive to administer than MediCare. Most of the extra cost is for taxes, commissions, dividends and profit. The government never pay taxes, commission, dividend and profit to itself.

[jackp32]

If Medicare, a gov't program, is so great, why is it near bankruptcy and has unfunded liabilities of trillions of $?

[lovegetpeace]

Hey stryker54,

If you hate Medicare and Medicaid, then uou must not be old yet.

This is what American's get for $3.6 Trillions a year from our current Private Health Care system:

America ranks #42 worst in Infant Mortality Rate in the modern world:
https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html

America ranks #47 in Life Expectancy Rate in the modern world:
https://www.cia.gov/library/publications/the-world-factbook/rankorder/2102rank.html

America got the #1 Highest Healthcare Cost (over twice (2X) 2nd place Sweden) in the modern world:
http://dll.umaine.ed/ble/U.S.%20HCweb.pdf

When you are ill or injured and especially in an emergency, nobody shops around for the clinic or hospital with the best value care. Hence, there cannot be Competition in Health Care.

Over Half of all personal bankruptcies filed in the U.S. every day are because of medical cost issues.

All Foreign Capitalists have a Huge Competition Advantage against all American's Capitalists because they never pay Private Health Insurance.

All Seniors are very happy with their Socialized HealthCare (Medicare). Sooner or later you will be a Senior. All low-income Children are happy with their Socialized HealthCare (CHIP). All Military Veterans are very happy with their Socialized Health Care. All Federal workers are very happy with their Socialized Health Care. All congressmen and congresswomen are very happy with their Socialized Health Care. Republicans say they want the same deal that our congressmen/women have!

American are paying $6,000.00 more per year (2x) per person than the next most costly nation Sweden with worst ranking results. Sweden is a very Socialistic nation.

What good is it to have the most advanced/high-tech Health Care in the world if nobody can afford it?

[lovegetpeace]

CORRECTION to my previous entry: ...or... >>> ...of...

[Sloughfoot]

Your assumtive BS is full of more holes then Swiss Cheese.

[bantamei]

There seems to be an epidemic of stupidity sweeping over conservatives in this country.

[lovegetpeace]

Folks,

I think I finally got it, Americans want a Health Care reform that:

-is Free!
-is 1 page long!
-is written at the 1st grade level.
-works immediately for our 'Instant Gratification'.
-lower costs (forget who will be sacrificed).
-got no 'Death Panel'.
-got no rationing.
-works perfect the 1st time.
-is not close to the Canadian's Universal Health Care system.
-is exactly what Senior citizens (Medicare and Medicaid) get today.
-is exactly what our Military and veterans get today.
-is exactly what our poor children (S-CHIP) get today.
-is exactly what our Congress and President get today.
-is exactly what our U.S. Federal employees get today.
-is not administered by the U.S. Government.
-is not Socialism!

.....did I get it right this time? Please correct me if I am still do not get it!

[stryker54]

ever hear of a living will? been around a long time and gives the person the right to express their wishes. this whole thing is stupid. shouldn't even be there. as far as govt. health care, fix medicare and medicaid. we already have medical care for people who can't aford it. the govt. can't even run these 2 and now the public wants more ineffective govt. crapola.

[lovegetpeace]

Hey stryker54,

Do you hate Medicare and Medicaid? You must not be old yet.

This is what American's get for $3.6 Trillions a year from our current Private Health Care system:

America ranks #42 worst in Infant Mortality Rate in the modern world:
https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html

America ranks #47 in Life Expectancy Rate in the modern world:
https://www.cia.gov/library/publications/the-world-factbook/rankorder/2102rank.html

America got the #1 Highest Healthcare Cost (over twice (2X) 2nd place Sweden) in the modern world:
http://dll.umaine.ed/ble/U.S.%20HCweb.pdf

Americans have the only Private Health Care system in the world. When you are ill or injured and especially in an

emergency, nobody shops around for the clinic or hospital with the best value care. Hence, there cannot be Competition

in Health Care. Therefore, Capitalism should go elsewhere.

Over Half of all personal bankruptcies filed in the U.S. every day are because of medical issues.

All Foreign Capitalists have a Huge Competition Advantage against all American's Capitalists because they never pay

Private Health Insurance.

All Seniors are very happy with their Socialized HealthCare (Medicare). Sooner or later you will be a Senior. All

low-income Children are happy with their Socialized HealthCare (CHIP). All Military Veterans are very happy with their

Socialized Health Care. All Federal workers are very happy with their Socialized Health Care. All congressmen and

congresswomen are very happy with their Socialized Health Care. Republicans say they want the same deal that our

congressmen/women have!

American are paying $6,000.00 more per year (2x) per person than the next most costly nation Sweden with worst

results. Sweden is a very Socialistic nation.

What good is it to have the most advanced/high-tech Health Care in the world if nobody can afford it?

[lovegetpeace]

Folks,

I did not know Private hospitals such as Gundersen Lutheran were already r advising patients on end-of-life planning.

Why are the Republicans not mad at these Private Enterprise Hospitals?