Sunday, September 13, 2009

Isn't this what Christians are for?: The Case for Killing Granny


The Case for Killing Granny
Rethinking end-of-life care.

Dana Neely / Getty Images
By Evan Thomas | NEWSWEEK


My mother wanted to die, but the doctors wouldn't let her. At least that's the way it seemed to me as I stood by her bed in an intensive-care unit at a hospital in Hilton Head, S.C., five years ago. My mother was 79, a longtime smoker who was dying of emphysema. She knew that her quality of life was increasingly tethered to an oxygen tank, that she was losing her ability to get about, and that she was slowly drowning. The doctors at her bedside were recommending various tests and procedures to keep her alive, but my mother, with a certain firmness I recognized, said no. She seemed puzzled and a bit frustrated that she had to be so insistent on her own demise.
The hospital at my mother's assisted-living facility was sustained by Medicare, which pays by the procedure. I don't think the doctors were trying to be greedy by pushing more treatments on my mother. That's just the way the system works. The doctors were responding to the expectations of almost all patients. As a doctor friend of mine puts it, "Americans want the best, they want the latest, and they want it now." We expect doctors to make heroic efforts—especially to save our lives and the lives of our loved ones.
The idea that we might ration health care to seniors (or anyone else) is political anathema. Politicians do not dare breathe the R word, lest they be accused—however wrongly—of trying to pull the plug on Grandma. But the need to spend less money on the elderly at the end of life is the elephant in the room in the health-reform debate. Everyone sees it but no one wants to talk about it. At a more basic level, Americans are afraid not just of dying, but of talking and thinking about death. Until Americans learn to contemplate death as more than a scientific challenge to be overcome, our health-care system will remain unfixable.
Compared with other Western countries, the United States has more health care—but, generally speaking, not better health care. There is no way we can get control of costs, which have grown by nearly 50 percent in the past decade, without finding a way to stop overtreating patients. In his address to Congress, President Obama spoke airily about reducing inefficiency, but he slid past the hard choices that will have to be made to stop health care from devouring ever-larger slices of the economy and tax dollar. A significant portion of the savings will have to come from the money we spend on seniors at the end of life because, as Willie Sutton explained about why he robbed banks, that's where the money is.



As President Obama said, most of the uncontrolled growth in federal spending and the deficit comes from Medicare; nothing else comes close. Almost a third of the money spent by Medicare—about $66.8 billion a year—goes to chronically ill patients in the last two years of life. This might seem obvious—of course the costs come at the end, when patients are the sickest. But that can't explain what researchers at Dartmouth have discovered: Medicare spends twice as much on similar patients in some parts of the country as in others. The average cost of a Medicare patient in Miami is $16,351; the average in Honolulu is $5,311. In the Bronx, N.Y., it's $12,543. In Fargo, N.D., $5,738. The average Medicare patient undergoing end-of-life treatment spends 21.9 days in a Manhattan hospital. In Mason City, Iowa, he or she spends only 6.1 days.
Maybe it's unsurprising that treatment in rural towns costs less than in big cities, with all their high prices, varied populations, and urban woes. But there are also significant disparities in towns that are otherwise very similar. How do you explain the fact, for instance, that in Boulder, Colo., the average cost of Medicare treatment is $9,103, whereas an hour away in Fort Collins, Colo., the cost is $6,448?
The answer, the Dartmouth researchers found, is that in some places doctors are just more likely to order more tests and procedures. More specialists are involved. There is very little reason for them not to order more tests and treatments. By training and inclination, doctors want to do all they can to cure ailments. And since Medicare pays by procedure, test, and hospital stay—though less and less each year as the cost squeeze tightens—there is an incentive to do more and more. To make a good living, doctors must see more patients, and order more tests.
All this treatment does not necessarily buy better care. In fact, the Dartmouth studies have found worse outcomes in many states and cities where there is more health care. Why? Because just going into the hospital has risks—of infection, or error, or other unforeseen complications. Some studies estimate that Americans are overtreated by roughly 30 percent. "It's not about rationing care—that's always the bogeyman people use to block reform," says Dr. Elliott Fisher, a professor at Dartmouth Medical School. "The real problem is unnecessary and unwanted care."
But how do you decide which treatments to cut out? How do you choose between the necessary and the unnecessary? There has been talk among experts and lawmakers of giving more power to a panel of government experts to decide—Britain has one, called the National Institute for Health and Clinical Excellence (known by the somewhat ironic acronym NICE). But no one wants the horror stories of denied care and long waits that are said to plague state-run national health-care systems. (The criticism is unfair: patients wait longer to see primary-care physicians in the United States than in Britain.) After the summer of angry town halls, no politician is going to get anywhere near something that could be called a "death panel."
There's no question that reining in the lawyers would help cut costs. Fearing medical-malpractice suits, doctors engage in defensive medicine, ordering procedures that may not be strictly necessary—but why take the risk? According to various studies, defensive medicine adds perhaps 2 percent to the overall bill—a not-insignificant number when more than $2 trillion is at stake. A number of states have managed to institute some kind of so-called tort reform, limiting the size of damage awards by juries in medical-malpractice cases. But the trial lawyers—big donors to the Democratic Party—have stopped Congress from even considering reforms. That's why it was significant that President Obama even raised the subject in his speech last week, even if he was vague about just what he'd do. (Best idea: create medical courts run by experts to rule on malpractice claims, with no punitive damages.)
But the biggest cost booster is the way doctors are paid under most insurance systems, including Medicare. It's called fee-for-service, and it means just that. So why not just put doctors on salary? Some medical groups that do, like the Mayo Clinic, have reduced costs while producing better results. Unfortunately, putting doctors on salary requires that they work for someone, and most American physicians are self-employed or work in small group practices. The alternative—paying them a flat rate for each patient they care for—turned out to be at least a partial bust. HMOs that paid doctors a flat fee in the 1990s faced a backlash as patients bridled at long waits and denied service.
Ever-rising health-care spending now consumes about 17 percent of the economy (versus about 10 percent in Europe). At the current rate of increase, it will devour a fifth of GDP by 2018. We cannot afford to sustain a productive economy with so much money going to health care. Over time, economic reality may force us to adopt a national health-care system like Britain's or Canada's. But before that day arrives, there are steps we can take to reduce costs without totally turning the system inside out.
One place to start is to consider the psychological aspect of health care. Most people are at least minor hypochondriacs (I know I am). They use doctors to make themselves feel better, even if the doctor is not doing much to physically heal what ails them. (In ancient times, doctors often made people sicker with quack cures like bleeding.) The desire to see a physician is often pronounced in assisted-living facilities. Old people, far from their families in our mobile, atomized society, depend on their doctors for care and reassurance. I noticed that in my mother's retirement home, the talk in the dining room was often about illness; people built their day around doctor's visits, partly, it seemed to me, to combat loneliness.
Physicians at Massachusetts General Hospital are experimenting with innovative approaches to care for their most ill patients without necessarily sending them to the doctor. Three years ago, Massachusetts enacted universal care—just as Congress and the Obama administration are attempting to do now. The state quickly found it could not afford to meet everyone's health-care demands, so it's scrambling for solutions. The Mass General program assigned nurses to the hospital's 2,600 sickest—and costliest—Medicare patients. These nurses provide basic care, making sure the patients take their medications and so forth, and act as gatekeepers—they decide if a visit to the doctor is really necessary. It's not a perfect system—people will still demand to see their doctors when it's unnecessary—but the Mass General program cut costs by 5 percent while providing the elderly what they want and need most: caring human contact.
Other initiatives ensure that the elderly get counseling about end-of-life issues. Although demagogued as a "death panel," a program in Wisconsin to get patients to talk to their doctors about how they want to deal with death was actually a resounding success. A study by the Archives of Internal Medicineshows that such conversations between doctors and patients can decrease costs by about 35 percent—while improving the quality of life at the end. Patients should be encouraged to draft living wills to make their end-of-life desires known. Unfortunately, such paper can be useless if there is a family member at the bedside demanding heroic measures. "A lot of the time guilt is playing a role," says Dr. David Torchiana, a surgeon and CEO of the Massachusetts General Physicians Organization. Doctors can feel guilty, too—about overtreating patients. Torchiana recalls his unease over operating to treat a severe heart infection in a woman with two forms of metastatic cancer who was already comatose. The family insisted.
Studies show that about 70 percent of people want to die at home—but that about half die in hospitals. There has been an important increase in hospice or palliative care—keeping patients with incurable diseases as comfortable as possible while they live out the remainder of their lives. Hospice services are generally intended for the terminally ill in the last six months of life, but as a practical matter, many people receive hospice care for only a few weeks.
Our medical system does everything it can to encourage hope. And American health care has been near miraculous—the envy of the world—in its capacity to develop new lifesaving and life-enhancing treatments. But death can be delayed only so long, and sometimes the wait is grim and degrading. The hospice ideal recognized that for many people, quiet and dignity—and loving care and good painkillers—are really what's called for.
That's what my mother wanted. After convincing the doctors that she meant it—that she really was ready to die—she was transferred from the ICU to a hospice, where, five days later, she passed away. In the ICU, as they removed all the monitors and pulled out all the tubes and wires, she made a fluttery motion with her hands. She seemed to be signaling goodbye to all that—I'm free to go in peace.

The "State" of our State Department

Hitting Bottom in Foggy Bottom

The State Department suffers from low morale, bottlenecks, and bureaucratic inepititude. Do we need to kill it to save it?

BY MATTHEW ARMSTRONG | SEPTEMBER 11, 2009

Discussion over the fate of Foggy Bottom usually focuses on the tenure of Secretary of State Hillary Clinton, the troubles of public diplomacy, and the rise of special envoys on everything from European pipelines to Afghanistan and Pakistan. But Americans would benefit more from a reassessment of the core functionality of the U.S. State Department.

Years of neglect and marginalization, as well as a dearth of long-term vision and strategic planning, have left the 19th-century institution hamstrung with fiefdoms and bureaucratic bottlenecks. The Pentagon now funds and controls a wide range of foreign-policy and diplomatic priorities -- from development to public diplomacy and beyond. The world has changed, with everyone from politicians to talking heads to terrorists directly influencing global audiences.

The most pressing issues are stateless: pandemics, recession, terrorism, poverty, proliferation, and conflict. But as report after report, investigation after investigation, has highlighted, the State Department is broken and paralyzed, unable to respond to the new 21st-century paradigm.

But how did it get so bad? Is it possible to fix? Or should we just push it over the wall like a great Humpty Dumpty and reassign the pieces?

There is growing evidence that the internal machinations of the State Department have corrupted its "core missions" of traditional diplomacy and public diplomacy.

This year, for example, the Government Accountability Office (gao) found that the department completely failed in its now four-year-old attempt to reorganize its nonproliferation bureau (a bureau that remains leaderless).

Besides failing to address mission overlap, low morale, and lack of career opportunities, the failed reorganization caused a significant drop in expertise in offices focused on proliferation issues -- including "today's threats posted by Iran, North Korea, and Syria," the gao's report said -- and coordination with bodies like the International Atomic Energy Agency.

Another report by the State Department's inspector general this year described severe and broad dysfunction within the Africa bureau, while ignoring -- perhaps considering it a given -- the lack of departmentwide integration and leadership in operations. Examples of the dysfunction range from not providing public diplomacy personnel with computers capable of reading interoffice memos to a failure to effectively work with the new Africa Command.

By necessity, the Defense Department has stepped in where State Department has tuned out: Foggy Bottom relies on Pentagon funding and even personnel for basic operations central to its mission. For example, the Defense Department now performs much strategic communications work traditionally the purview of the State Department. In Somalia, for example, the State Department's budget for public diplomacy is $30,000. The Pentagon's is $600,000. And, in the State Department's bureaucratic wisdom, the $30,000 does not even belong to its undersecretary for public diplomacy and public affairs.

Further, rivalries between the different "cones" -- or career tracks, referred to by one insider as the "conal caste system" -- at the State Department severely impact morale, career growth, and even operations. The report on the Africa bureau noted that in 2002, public affairs and public diplomacy was a "failed office" -- and that the situation is worse in 2009. Public outreach workers said the bureau's leadership "does not understand public diplomacy." The sentiment is widespread. A 2008 report by a congressional ombudsman, the U.S. Advisory Commission on Public Diplomacy, described a systemic failure to support and train public diplomacy officers in the field, as well as professional discrimination against those in the career track.
Attempts to fix the State Department have focused on short-term issues, such as ameliorating its shortages in human and financial resources. The last eight secretaries of state have attempted to bolster the department by bolstering its bottom line.

 No less than Defense Secretary Robert Gates and the chairman of the Joint Chiefs of Staff, Adm. Mike Mullen, have long suggested transferring funds from the Defense Department to State Department. But the situation is so dire that the State Department, at this point, could not even absorb and spend that much-needed infusion of cash. If there were a wholesale transfer of funds tomorrow, the lack of capacity and skills at the State department would mean it would have to give it back to the Defense Department or dole it out to contractors.


The creeping militarization of U.S. foreign policy is itself deeply worrying, not just to Gates and Mullen, but also to such luminaries as Secretary Clinton and Vice President Joe Biden. In 2008, then-Senator Biden questioned the "expanding role of the military in U.S. foreign policy." He said he was concerned by the "migration of functions and authorities from U.S. civilian agencies to the Department of Defense."

Some commentators have even wondered aloud whether the best way to fix the State Department might be to destroy it. Foggy Bottom could retain a small core staff for its embassies and ambassadors. All other functions -- such as public diplomacy, countering misinformation and propaganda, and development, including provincial reconstruction staffing -- could migrate to the Pentagon or become wholly independent agencies.
But atomizing the State Department would ultimately prove dangerous and further the militarization of foreign policy. The Pentagon needs a counterbalance, a vertically integrated State Department that the president, Congress, and the U.S. public can count on. Change, rather than creative destruction, is what Foggy Bottom needs.

Envision a State Department capable of leading whole-of-government initiatives with a strategic focus instead of one hidebound department geared by structure and tradition to execute state-to-state diplomacy. This "Department of State and Non-State" would be as deft at tackling stateless terrorist networks and hurricanes as it would be at fostering and upholding alliances with foreign ministers. To transform Foggy Bottom in this way will require breaking the rigid hierarchy, stovepipes, and bottlenecks which make the Pentagon look lean and dynamic in comparison.

Modern global affairs are not compartmentalized by political borders. Besides expanding the overly shallow and narrow authorities of the public diplomacy bureau, Clinton must restructure the State Department to focus less on countries and more on regions. Currently, each of Foggy Bottom's regional bureaus, such as Near East Affairs, is configured to oversee its patch of embassies. Country desk officers, and most ambassadors, report to an assistant secretary, the regional head. The assistant secretary in turn reports to an undersecretary, who reports to Clinton.

Clinton should name the regional bureau heads, currently assistant secretaries, to undersecretary status. This would help eliminate an unnecessary bureaucratic layer and would also align the State Department with the Defense Department (which has powerful regional commands, such as Centcom and Africom). The State Department's regional leaders would hold an equivalent civilian rank to four-star combatant commanders like Gen. David Petraeus. These changes would promise to improve communications, synchronize missions, and put the department on the right path for today's requirements.

But Clinton should beware reforming the State Department too quickly from within -- her efforts could be paralyzed by a bureaucracy in mutiny that would simply wait her out. U.S. national security would suffer and the Pentagon's growing power would become more entrenched. Clinton will need the clear and unequivocal support of the president and more importantly Congress, which authorizes State Department spending bills, to have a chance at success.

In a burst of activity after Barack Obama's election, Congress authorized more money and people for the State Department and pushed for greater public diplomacy. Still more is required. The question asked over the last eight years as the State Department abrogated its various responsibilities -- if not Defense, then who? -- will not, indeed cannot, be answered until the department steps up to the plate and becomes effective and visible in leading and implementing U.S. foreign policy. This will take time. But, as the saying goes, there is no time like the present.

The United States now has a Congress that supports change, secretaries of state and defense who want change, a president whose entire election platform was built around the word "change," and an American public that would be outraged at the dysfunction if it only knew the details.

Grace: God's Perfect Expression of Love ~ John Dillard

Grace: God's Perfect Expression of Love


In my youth and in my lack of understanding of truth and without wisdom, I used to want what was "fair" and what was "coming to me." However as Jesus continues His work in me I have learned that nothing could be further from the truth. I want grace: God's unmerited favor.

        
Salvation is a free gift of the highest order that all we have to do accept. Grace is God giving of himself and offering forgiveness rather than condemnation for those who seek it. For those who think they want what they deserve, I would ask them to evaluate the truth. If you have ever spoken too quickly or harshly, do you desire to be scolded or chastised. If you are driving too fast and are pulled over by the police, would you prefer a warning or a ticket. If you are student and fail to either remember or turn in your homework, do you want a "F" as a grade or would you prefer the chance of a "do over" or as golfers prefer to call a mulligan.
Grace is the highest form of love for it is love in action. It is not words or mere deeds but it is the act of being like Jesus Christ.

Imagine if our faith was "works based" and that we had to work our way into Heaven. We would never be able to do enough or be good enough to earn our way into eternity as there would always be more to do and a higher standard yet to aspire to.

It was by Jesus coming to earth that He paid the ultimate price, death on a cross and in so doing was a perfect example of His sacrifice, His love, His commitment to us, that was indeed His unblemished expression of love offering us eternal favor and grace.