# Are the Deathers (gulp) kinda right? **URL:** \ **Category:** Great Debates\ **Created:** [August 14, 2009, 9:47pm UTC](https://boards.straightdope.com/t/are-the-deathers-gulp-kinda-right/506452 "2009-08-14T21:47:41Z")\ **Posts on this page:** 20\ **Page:** 1
**Author:** ![intention](https://avatars.discourse-cdn.com/v4/letter/i/e95f7d/32.png) [@intention](https://boards.straightdope.com/u/intention)\ **Post date:** [August 14, 2009, 9:47pm UTC](https://boards.straightdope.com/t/are-the-deathers-gulp-kinda-right/506452/1 "2009-08-14T21:47:41Z")
Let me preface this by saying that I’m a liberal Democrat who voted for Obama, so keep the flames turned down. Here’s the thing. The part of the Health Care bill in question (Section One Thousand Two Hundred and Thirty Three, I kid you not) ADVANCE CARE PLANNING CONSULTATION is available [here.](http://www.agingoptions.com/ContentPage.aspx?WebPageId=23449&GroupId=-1) My problem is in this part: > [@](#): > > `(4) A consultation under this subsection may include the formulation of an order regarding life sustaining treatment or a similar order. > > `(5)(A) For purposes of this section, the term `order regarding life sustaining treatment’ means, with respect to an individual, an actionable medical order relating to the treatment of that individual that– > > `(i) is signed and dated by a physician (as defined in subsection (r)(1)) or another health care professional (as specified by the Secretary and who is acting within the scope of the professional’s authority under State law in signing such an order, including a nurse practitioner or physician assistant) and is in a form that permits it to stay with the individual and be followed by health care professionals and providers across the continuum of care; > > `(ii) effectively communicates the individual’s preferences regarding life sustaining treatment, including an indication of the treatment and care desired by the individual; > > `(iii) is uniquely identifiable and standardized within a given locality, region, or State (as identified by the Secretary); and > > `(iv) may incorporate any advance directive (as defined in section 1866(f)(3)) if executed by the individual. > > `(B) The level of treatment indicated under subparagraph (A)(ii) may range from an indication for full treatment to an indication to limit some or all or specified interventions. Such indicated levels of treatment may include indications respecting, among other items– > > `(i) the intensity of medical intervention if the patient is pulse less, apneic, or has serious cardiac or pulmonary problems; > > `(ii) the individual’s desire regarding transfer to a hospital or remaining at the current care setting; > > `(iii) the use of antibiotics; and > > `(iv) the use of artificially administered nutrition and hydration.'. Now, call me crazy, but to me that part says that an “Order” can be (reasonably) issued by an MD, an NP, or a PA … but there is absolutely no requirement that it be agreed to, or signed by, the patient. It can also incorporate an “advance directive” if it is “executed by the individual”, but there’s no requirement that any other part of the “Order” has to be “executed by the individual”. And there is no limitation on what kind of treatment can be denied under the “Order.” Now I’d bet money that this was an oversight on the writer’s part (a not uncommon occurrence with foolishly trying to craft a thousand page bill in three weeks … but I digress). But unless someone can point to some part that says that the patient has to sign or at least clearly OK the “Order”, I’d have to say that (hides his face and whispers) _Sarah Palin is kinda right …_ Yikes! Can’t have that … fight my ignorance, what am I missing here? ---
**Author:** ![Lamar\_Mundane](https://avatars.discourse-cdn.com/v4/letter/l/85f322/32.png) [@Lamar\_Mundane](https://boards.straightdope.com/u/Lamar_Mundane)\ **Post date:** [August 14, 2009, 9:54pm UTC](https://boards.straightdope.com/t/are-the-deathers-gulp-kinda-right/506452/2 "2009-08-14T21:54:43Z")
> [@intention](#): > > Yikes! Can’t have that … fight my ignorance, what am I missing here? Perhaps this part: > [@](#): > > `(ii) effectively communicates the individual’s preferences regarding life sustaining treatment, including an indication of the treatment and care desired by the individual; ---
**Author:** ![MovieMogul](https://avatars.discourse-cdn.com/v4/letter/m/f08c70/32.png) [@MovieMogul](https://boards.straightdope.com/u/MovieMogul)\ **Post date:** [August 14, 2009, 9:55pm UTC](https://boards.straightdope.com/t/are-the-deathers-gulp-kinda-right/506452/3 "2009-08-14T21:55:27Z")
It seems clear to me that the Order in question is one originating from the patient him/herself, since the Order is a direct result of the consultation as listed in #4–and presumably that consultation involves the voluntary participation of the patient. Everything else as described proceeds from this premise. The “order” may be underwritten by a physician or other figure to give it the weight of additional authority, but I don’t see anywhere where it suggests that the order is imposed externally and potentially counter to the wishes of the individual in question. ---
**Author:** ![athelas](https://avatars.discourse-cdn.com/v4/letter/a/5e9695/32.png) [@athelas](https://boards.straightdope.com/u/athelas)\ **Post date:** [August 14, 2009, 9:57pm UTC](https://boards.straightdope.com/t/are-the-deathers-gulp-kinda-right/506452/4 "2009-08-14T21:57:20Z")
At least one [version](http://thehill.com/leading-the-news/finance-committee-to-drop-end-of-life-provision-2009-08-13.html)of the bill has excised the relevant provision: > [@](#): > > The Senate Finance Committee will drop a controversial provision on consultations for end-of-life care from its proposed healthcare bill, its top Republican member said Thursday. > > The committee, which has worked on putting together a bipartisan healthcare reform bill, will drop the controversial provision after it was derided by conservatives [ie score one for Palin] as “death panels” to encourage euthanasia ---
**Author:** ![intention](https://avatars.discourse-cdn.com/v4/letter/i/e95f7d/32.png) [@intention](https://boards.straightdope.com/u/intention)\ **Post date:** [August 14, 2009, 10:02pm UTC](https://boards.straightdope.com/t/are-the-deathers-gulp-kinda-right/506452/5 "2009-08-14T22:02:00Z")
> [@ArchiveGuy](#): > > It seems clear to me that the Order in question is one originating from the patient him/herself, since the Order is a direct result of the consultation as listed in #4–and presumably that consultation involves the voluntary participation of the patient. > > Everything else as described proceeds from this premise. The “order” may be underwritten by a physician or other figure to give it the weight of additional authority, but I don’t see anywhere where it suggests that the order is imposed externally and potentially counter to the wishes of the individual in question. You appear to be right regarding the intention of the section. But laws don’t run by intention. They run by exactly what is written, exactly what is required, exactly what is forbidden. If it doesn’t require the patient’s agreement, what’s to stop a Doc from ordering a DNR order? ---
**Author:** ![griffin1977](https://avatars.discourse-cdn.com/v4/letter/g/977dab/32.png) [@griffin1977](https://boards.straightdope.com/u/griffin1977)\ **Post date:** [August 14, 2009, 10:05pm UTC](https://boards.straightdope.com/t/are-the-deathers-gulp-kinda-right/506452/6 "2009-08-14T22:05:13Z")
> [@intention](#): > > You appear to be right regarding the intention of the section. But laws don’t run by intention. They run by exactly what is written, exactly what is required, exactly what is forbidden. If it doesn’t require the patient’s agreement, what’s to stop a Doc from ordering a DNR order? I’m will Lamar Mundane here its pretty clearly states: > [@](#): > > effectively communicates **the individual’s preferences regarding life sustaining treatmen** t, including an indication of the treatment and care desired by the individual; It requires a doc’s signature, but the order is a statement of the INDIVIDUAL’S preferences, not the the doctor. ---
**Author:** ![intention](https://avatars.discourse-cdn.com/v4/letter/i/e95f7d/32.png) [@intention](https://boards.straightdope.com/u/intention)\ **Post date:** [August 14, 2009, 10:34pm UTC](https://boards.straightdope.com/t/are-the-deathers-gulp-kinda-right/506452/7 "2009-08-14T22:34:55Z")
> [@griffin1977](#): > > I’m will Lamar Mundane here its pretty clearly states: > It requires a doc’s signature, but the order is a statement of the INDIVIDUAL’S preferences, not the the doctor. Again, my point is that there is no requirement that the individual signs the order. A doctor could write up anything, and might even sincerely believe it is a statement of the individual’s preferences … but it might also just be a statement of the doctor’s preferences. Without requiring that the individual read and sign the order, anything is possible. Like I said above, I think that this is merely an oversight on the part of whoever wrote the bill. But laws don’t run on anything but what is actually written … and as written, there is absolutely nothing stopping a Physician’s Assistant from writing up anything he pleases. When he does so, it becomes a legally enforceable order. Which brings up a separate issue … what if the person finds out that the order doesn’t exactly reflect their preferences? There’s no mechanism to protest, or to change the order? Look, I’m not saying that those are reasonable interpretations, they’re not. But they are most definitely possible interpretations, and as written, the bill gives the docs, NPs, and PAs huge and unchecked power. I don’t think they’d use it … but what I think is meaningless. What counts is what the bill says. As written, it says a PA can write and sign an order without the patient agreeing or signing the order. That’s a big hole … ---
**Author:** ![Fuzzy\_Dunlop](https://avatars.discourse-cdn.com/v4/letter/f/848f3c/32.png) [@Fuzzy\_Dunlop](https://boards.straightdope.com/u/Fuzzy_Dunlop)\ **Post date:** [August 14, 2009, 10:49pm UTC](https://boards.straightdope.com/t/are-the-deathers-gulp-kinda-right/506452/8 "2009-08-14T22:49:18Z")
> [@intention](#): > > Again, my point is that there is no requirement that the individual signs the order. A doctor could write up anything, and might even sincerely believe it is a statement of the individual’s preferences … but it might also just be a statement of the doctor’s preferences. Without requiring that the individual read and sign the order, anything is possible. The bill requires the advanced directive be an accurate effective communication of the individual’s preferences regarding life sustaining treatment and that it be signed by a physician. That specifically precludes the legality of an order that isn`t the individual’s preference. Nothin in what you quoted suggests the death idiots are remotely right. You’re not “crazy” but you don`t know what you`re talking about here. ---
**Author:** ![Gangster\_Octopus](https://avatars.discourse-cdn.com/v4/letter/g/a8b319/32.png) [@Gangster\_Octopus](https://boards.straightdope.com/u/Gangster_Octopus)\ **Post date:** [August 14, 2009, 10:54pm UTC](https://boards.straightdope.com/t/are-the-deathers-gulp-kinda-right/506452/9 "2009-08-14T22:54:43Z")
The order is written up by a doctor after a consultation at the patient’s request and it is kept by the patient, I believe. ---
**Author:** ![Fuzzy\_Dunlop](https://avatars.discourse-cdn.com/v4/letter/f/848f3c/32.png) [@Fuzzy\_Dunlop](https://boards.straightdope.com/u/Fuzzy_Dunlop)\ **Post date:** [August 14, 2009, 11:06pm UTC](https://boards.straightdope.com/t/are-the-deathers-gulp-kinda-right/506452/10 "2009-08-14T23:06:09Z")
> [@Fuzzy\_Dunlop](#): > > The bill requires the advanced directive be an accurate effective communication of the individual’s preferences regarding life sustaining treatment and that it be signed by a physician. That specifically precludes the legality of an order that isn`t the individual’s preference. Nothin in what you quoted suggests the death idiots are remotely right. > > You’re not “crazy” but you don`t know what you`re talking about here. I realize that people already think that dozens of professional legislative staffers and their congressman bosses working for months in consultation with major stakeholders couldn’t _possibly_ understand, know or comprehend everything written in the 1000 page bills they themselves write. But in reality, as big as they are, they’re just the beginning. Legislators don`t try to cover absolutely every minor detail in their bills an they're still that big. They cover the broad strokes and then some executive branch department is able to detail every tiny little detail. For instance, the bill mandates that the advanced directive must be the patient's accurate and clear preference, but that doesn`t mean that ultimately, in order to get reimbursement for the consultation, a copy signed by the patient won’t be required. It’s not ALL supposed to be in the legislation - they don`t work that way. ---
**Author:** ![intention](https://avatars.discourse-cdn.com/v4/letter/i/e95f7d/32.png) [@intention](https://boards.straightdope.com/u/intention)\ **Post date:** [August 14, 2009, 11:09pm UTC](https://boards.straightdope.com/t/are-the-deathers-gulp-kinda-right/506452/11 "2009-08-14T23:09:56Z")
> [@Fuzzy\_Dunlop](#): > > The bill requires the advanced directive be an accurate effective communication of the individual’s preferences regarding life sustaining treatment and that it be signed by a physician. That specifically precludes the legality of an order that isn`t the individual’s preference. Nothin in what you quoted suggests the death idiots are remotely right. > > You’re not “crazy” but you don`t know what you`re talking about here. Fuzzy, you’re not reading what I’m saying. It may well be as you say, that if a patient takes the order to court, or back to the doctor, and states and proves that it does not reflect their preferences, it will then be illegal. But until then, it is legal. The burden of proof is on the person to show that it is not legal. It has all the signatures required, from all of the officals required. It’s legal until proven otherwise. For example. Doctor X creates and signs such a “Do Not Resuscitate” order, seriously believing that’s what the patient wants … but in fact although the patient can read English, he doesn’t speak English all that well and doesn’t even want that. But the order can legally be created and become official without the patient signing it, or even reading it. The patient comes in, unconscious, to another hospital. Are you seriously claiming that the doc’s order is somehow illegal, and would not be followed? Now the patient may wake up and say “Hey, that’s not what I wanted!” And he may get the DNR order rescinded. But until then … the DNR order is legal. Remember that this document follows the patient, and can be used (even without the patient’s knowledge) to make decisions on their treatment. Once again, I don’t think that’s what the bill intends … but I can sure see how someone who doesn’t trust the Government could say “Hey, the Doc can write and sign an order I may not even agree with”. And from what I read in the bill … the Doc can in fact do that. ---
**Author:** ![TheMadHun](https://avatars.discourse-cdn.com/v4/letter/t/53a042/32.png) [@TheMadHun](https://boards.straightdope.com/u/TheMadHun)\ **Post date:** [August 14, 2009, 11:10pm UTC](https://boards.straightdope.com/t/are-the-deathers-gulp-kinda-right/506452/12 "2009-08-14T23:10:14Z")
“Are the Deathers (gulp) kinda right?” No, they are crackpots. Planning ahead by individuals is not equal to sentencing to death by the government. ---
**Author:** ![DSeid](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dseid/32/20194_2.png) [@DSeid](https://boards.straightdope.com/u/DSeid)\ **Post date:** [August 14, 2009, 11:13pm UTC](https://boards.straightdope.com/t/are-the-deathers-gulp-kinda-right/506452/13 "2009-08-14T23:13:58Z")
The key is that the order must reflect the individual’s preference. There are many circumstances in which the individual’s _signature_ would not be possible even if the individual could clearly express a preference and a signature requirement would _prevent_ the individual’s preference being respected. (Various injuries, paralysis, motor impairment, etc.) Signatures are one way to document an individual’s preference but not the only way, not enough in and of itself in any case (we docs are taught that a signature on a consent form is not enough, for example, you also need to document the conversation and the understanding expressed), and sometimes not possible. And in any case right _now_ orders for Do Not Resuscitate (DNR) are signed _by the doctor_, not the patient, reflective of the patient’s wishes and of the conversation and the understanding of the meaning of the order. The patient signature is not legally required for DNR right now. This is no change from current practice. ---
**Author:** ![Whack-a-Mole](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/whack-a-mole/32/141_2.png) [@Whack-a-Mole](https://boards.straightdope.com/u/Whack-a-Mole)\ **Post date:** [August 14, 2009, 11:16pm UTC](https://boards.straightdope.com/t/are-the-deathers-gulp-kinda-right/506452/14 "2009-08-14T23:16:03Z")
Willing to bet the doctor’s signature is to make it good for the government to pay for it. If an individual just writes one on their own they cannot get reimbursed. I cannot imagine such a document is legal and a protection from lawsuit to healthcare professionals if the patient has not signed it. Any legal eagles present? ---
**Author:** ![intention](https://avatars.discourse-cdn.com/v4/letter/i/e95f7d/32.png) [@intention](https://boards.straightdope.com/u/intention)\ **Post date:** [August 14, 2009, 11:22pm UTC](https://boards.straightdope.com/t/are-the-deathers-gulp-kinda-right/506452/15 "2009-08-14T23:22:48Z")
> [@TheMadHun](#): > > “Are the Deathers (gulp) kinda right?” > No, they are crackpots. Planning ahead by individuals is not equal to sentencing to death by the government. Look, I know they’re crackpots. I’m just saying the bill’s language is dangerously vague. ---
**Author:** ![intention](https://avatars.discourse-cdn.com/v4/letter/i/e95f7d/32.png) [@intention](https://boards.straightdope.com/u/intention)\ **Post date:** [August 14, 2009, 11:24pm UTC](https://boards.straightdope.com/t/are-the-deathers-gulp-kinda-right/506452/16 "2009-08-14T23:24:25Z")
> [@DSeid](#): > > The key is that the order must reflect the individual’s preference. There are many circumstances in which the individual’s _signature_ would not be possible even if the individual could clearly express a preference and a signature requirement would _prevent_ the individual’s preference being respected. (Various injuries, paralysis, motor impairment, etc.) > > Signatures are one way to document an individual’s preference but not the only way, not enough in and of itself in any case (we docs are taught that a signature on a consent form is not enough, for example, you also need to document the conversation and the understanding expressed), and sometimes not possible. > > And in any case right _now_ orders for Do Not Resuscitate (DNR) are signed _by the doctor_, not the patient, reflective of the patient’s wishes and of the conversation and the understanding of the meaning of the order. The patient signature is not legally required for DNR right now. This is no change from current practice. Fight my ignorance here … can you just get up in the morning and sign a DNR for me that will follow me for the rest of my life, without me ever seeing the document? ---
**Author:** ![intention](https://avatars.discourse-cdn.com/v4/letter/i/e95f7d/32.png) [@intention](https://boards.straightdope.com/u/intention)\ **Post date:** [August 14, 2009, 11:27pm UTC](https://boards.straightdope.com/t/are-the-deathers-gulp-kinda-right/506452/17 "2009-08-14T23:27:48Z")
Don’t know where you are, DSeid, but here’s Kentucky … > [@](#): > > \*\*Kentucky Emergency Medical Services > Do Not Resuscitate (DNR) Order > \*\*Person’s Full Legal Name \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ > Surrogate’s Full Legal Name (if applicable) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ > I, the undersigned person or surrogate who has been designated to make health care decisions in > accordance with Kentucky Revised Statutes, hereby direct that in the event of my cardiac or respiratory arrest that this DO NOT RESUSCITATE (DNR) ORDER be honored. I understand that DNR means that if my heart stops beating or if I stop breathing, no medical procedure to restart breathing or heart function, more specifically the insertion of a tube into the lungs, or electrical shocking of the heart or cardiopulmonary resuscitation (CPR) will be started by emergency medical services (EMS) personnel. I understand this decision will not prevent emergency medical services personnel from providing other medical care. > > I understand that I may revoke this DNR order at any time by destroying this form, removing the DNR bracelet, or by telling the EMS personnel that I want to be resuscitated. Any attempt to alter or change the content, names, or signatures on the EMS DNR form shall make the DNR form invalid. … I note that this a) requires the signature of the patient or the surrogate, and b) contains a clause to revoke it. I find neither in the health care bill. ---
**Author:** ![intention](https://avatars.discourse-cdn.com/v4/letter/i/e95f7d/32.png) [@intention](https://boards.straightdope.com/u/intention)\ **Post date:** [August 14, 2009, 11:30pm UTC](https://boards.straightdope.com/t/are-the-deathers-gulp-kinda-right/506452/18 "2009-08-14T23:30:30Z")
Here’s Illinois … > [@](#): > > **Who may consent to a DNR order?** > > Consent may be obtained from the individual, or from another person legally authorized to act on that person’s behalf such the individual’s legal guardian, agent under a power of attorney for health-care or a surrogate decision maker. A parent or legal guardian typically may consent to a DNR order for a minor. Emancipated minors also may consent to a DNR Order. > > **Does the IDPH Uniform DNR Advance Directive require the signature of the person who is consenting to the DNR order?** > > Yes. The patient or his or her authorized legal representative must sign the section of the form concerning consent to the DNR order. You note the section requiring, I say again requiring, the patient’s signature? Find me that in the bill. ---
**Author:** ![elfkin477](https://avatars.discourse-cdn.com/v4/letter/e/a9a28c/32.png) [@elfkin477](https://boards.straightdope.com/u/elfkin477)\ **Post date:** [August 14, 2009, 11:34pm UTC](https://boards.straightdope.com/t/are-the-deathers-gulp-kinda-right/506452/19 "2009-08-14T23:34:57Z")
> [@griffin1977](#): > > It requires a doc’s signature, but the order is a statement of the INDIVIDUAL’S preferences, not the the doctor. Right, but there’s nothing that follows to indicate that they must **follow** the individual’s stated preferences, is there? The word “preferences” is an alarmingly loaded one given there must be multiple treatment options under consideration if one is to prefer any. ---
**Author:** ![intention](https://avatars.discourse-cdn.com/v4/letter/i/e95f7d/32.png) [@intention](https://boards.straightdope.com/u/intention)\ **Post date:** [August 14, 2009, 11:36pm UTC](https://boards.straightdope.com/t/are-the-deathers-gulp-kinda-right/506452/20 "2009-08-14T23:36:59Z")
And Kansas … > [@](#): > > **Does the IDPH Uniform DNR Order Form require the signature of the person who is consenting to the DNR order?** > Yes. The patient or his or her authorized legal representative must sign the section of the form concerning consent to the DNR order. > > **Why does the individual (or his or her legal representative) and a physician sign the IDPH Uniform DNR Order Form?** > The law authorizing the development of the form specifies that an individual (or his or her authorized legal representative) may execute the IDPH Uniform DNR Order Form directing that resuscitation efforts shall not be attempted. Therefore, a DNR order completed on the IDPH Uniform DNR Order Form contains an advance directive made by an individual (or legal representative), and also contains a physician’s order that requires a physician’s signature. > > **Are witnesses required for the IDPH Uniform DNR Order Form?** > Yes. Two individuals, 18 years of age or older, must witness the signature granting consent on the IDPH Uniform DNR Order Form. There are no other limitations on who may be a witness. Witnesses may include family members, friends, health-care workers and others. Note that in Kansas, the DNR Order must be signed by a) the physician, b) the patient, and c) two witnesses. Where is that in the bill? [Next page](https://boards.straightdope.com/t/are-the-deathers-gulp-kinda-right/506452.md?page=2)