Yes, it would be wonderful if they could consult with someone who knows what all of these words mean. This part of the plan paid for someone to consult with you and explain things to you.
Oh well.
they can’t issue an order saying “no paxurbanitol for me”.
You know if all those “deathers” had actually mentioned “signatures” instead of “death panels” your argument would have made more sense to me.
Have you signed your Living Will, by the way? Is that allowed in your state?
The doctors here tell me that physicians aren’t allowed just to “pull the plug” at will – even for people who want it and or in terrible pain. The patient can refuse food and special treatments and ask for a DNR. Actually patients can issue orders saying “no paxurbanitol” or no whatever for me. Patients do have a say in their own health care! Doctors can sort of let them go but they can’t make them go.
Yes, it would be wonderful if they could consult with someone who knows what all of these words mean. This part of the plan paid for someone to consult with you and explain things to you.
Oh well.
they can’t issue an order saying “no paxurbanitol for me”.
You know if all those “deathers” had actually mentioned “signatures” instead of “death panels” your argument would have made more sense to me.
Have you signed your Living Will, by the way? Is that allowed in your state?
The doctors here tell me that physicians aren’t allowed just to “pull the plug” at will – even for people who want it and or in terrible pain. The patient can refuse food and special treatments and ask for a DNR. Actually patients can issue orders saying “no paxurbanitol” or no whatever for me. Patients do have a say in their own health care! Doctors can sort of let them go but they can’t make them go.
“Pulling the plug” is done only after a patient is deceased. The patient can refuse artificial means of being kept alive, but that is not the same as “pulling the plug.”
I think in some cases (may differ from state to state) you can specify you want the plug pulled.
Think of the Terry Schiavo case again. At first they did all they could to save her because it was not apparent to anyone just how much injury she incurred.
Down the road it became apparent she was totally brain dead and only autonomic functions remained.
I am pretty sure you can specify that you would want to have the “plug pulled” in such an instance (or conversely you could say leave the plug in).
No, I read exactly what you’re saying. There’s a huge difference between someone not reading what you’re saying and what you’re saying being wrong. You’re just wrong. I’d go into more detail but since I left yesterday evening there’s been 70 or so posts explaining why you’re wrong.
The bill doesn’t clearly or even vaguely say that no patient signature is required. It’s also talking about paying for consultations on advanced care, not murdering sick people.
Not quite. Currently it is decided (other than by choices that informed patients make with their doctors) by affordability and by access, of which insurance coverage for procedures is one, but not the only, factor. We irrationally ration care.
First, the proposals under discussion do not include single payor. The regulation you have expressed concern about has nothing to do with rationing resources or how decisions are made about resources.
I do believe that there should be some rational rationing of resources. But nothing in the plans under discussion for possible implementation accomplishes that. By providing closer to universal coverage (not by single payor) we will merely increase the pool who have some basics covered, we will get more people into primary care and on preventative care. It will, I think, initially increase costs not because of more MRIs etc, but because of more upfront investments in care that will prevent more costly expenses later, although perhaps not realizing that savings until the heart attack fifteen years later is averted. In any case it is a different discussion that this provsion has nothing to do with.
And you include a good example of how a scarce healthcare resource is rationed. Livers are scarcer those who both have the need and the coverage to pay for it. They are rationed anyway based on other factors. The decision now is made by teams of doctors using guidelines developed by teams of physicians in the United Network for Organ Sharing.
I have addressed already why I think a requirement for a signature is stupid several times. Please read those posts. In any case, the issue is addressed or not addressed at state levels and the Feds need not get involved.
Yes. I am. And yes I speak to patients and their parents (pediatrician here) similarly as I have spoken here to you: in a straightforward, honest, and respectful manner. Sometimes that means telling them that are mistaken about something and giving them correct information with which to come to their conclusions.
Where exactly did I call you a liar?
I have said the claim that the current proposal includes plans for panels of doctors to ration end of life care is an out and out lie, not just a misunderstanding. I have not heard you claim that. You are misunderstanding, as “intelligent” and “liberal” as you are. You have found a proposed regulation that creates a billable code for services provided creating end of life plans and order sets with patients and somehow believed that it is instead a regulation that defines what is required in order to implement those plans that would override any other current laws (which exist now at state levels).
A doctor who misrepresents a patients wishes and “pulls a plug” on a patient who did not clearly want that to happen has broken the law even if the doctor signed a form and even if the patient’s signature is on a form. That is the case now and would be the case after this regulation. It may be manslaughter or it may be murder even, but it is and will continue to be against the law.
What I have told you is that you are 100% wrong about this and that in any case your mistake about this is immaterial to the lie about “death panels”. That you choose to ignore the fact that this is merely a regulation creating a consultation code which would allow health care workers to charge for the work involved in forming these order sets with patients, that you choose to ignore the fact that the states currently have regulations in place that put legal onuses on physicians, is a bit strange is all.
**1) **Does the bill say that a Doctor, a Physician’s Assistant, or a Nurse Practitioner can issue a DNR order? I say this section says that they can:
Doesn’t this mean that they can issue a DNR order? If you disagree, please show why and where.
**2) **Does the bill require my signature on the DNR order? I cannot find that requirement anywhere. You and others keep claiming this, e.g.
You and Fuzzy seem to have it backwards. The bill doesn’t have to explicitly say that no signature is required. If the bill doesn’t require a signature, then no signature is required.
If you disagree, please show where and why.
Put those together, it says that they can issue a DNR order without my signature. Now as I said before, I may be wrong in this, and people keep claiming I am. But so far, no one has pointed out where the DNR order requires my signature. No one has said that they can’t issue a DNR order. Put those together, and they can issue a DNR order without my signature.
However, you and others seem very certain that the bill doesn’t say that, so please show me why it doesn’t.
People have said the doctors have to make the directive communicate my preferences … but that is absolutely no protection. Without requiring my signature, it is wide open to (mis-)interpretation. If I say “Doc, I’m really tired of this excruciating pain, I just wish I could end it all”, what does that mean? The doctor may honestly, truly, professionally think that means I don’t want any heroic measures to extend my life and write a DNR on that basis.
(Please be clear that I have no beef with or suspicion of doctors, my wife is a Nurse Practitioner, I know lots of docs and NPs and PAs, they’re heroes in my book … but everyone makes their own interpretations of what people say, and not all of them are right.)
Now, I may not want the DNR at all. I may have meant I just want to end the pain, not end my life. But if the law says they don’t need my signature on the DNR order, that misunderstanding could easily happen.
Now, bear in mind that I DON’T THINK THAT’S THE INTENTION OF THE FRAMERS OF THE BILL. I think it’s just poor writing on their part. I fully agree with the intention of this section of the bill. As I mentioned upstream, I’ve had to deal with this issue in my own life, and it was ugly. I strongly think that patients should receive end-of-life counseling, and I wish my folks had had it. I’m depressed that this furor has arisen because of poor writing, and I’m more depressed that the solution was to whack out the entire section.
But that’s how the bill reads, and I think that’s one reason that people are so upset. If I’m wrong, show me where.
My larger point still stands. If people are misinterpreting a bill, it is very foolish to say to them “you’re just stupid idiotic fools who are being led around by the nose by liars with evil intentions”. Even if you think it is true, it is very bad tactics. It is much better to try to figure out why they are misinterpreting the bill, then change the bill so that it is clear.
The patient. If the patient objects, that is an expression of his preferences. If the patient is incapable of expressing his preferences, his spouse, parent or other family memeber can express it for him. What the patient wants always, ALWAYS, trumps what the doctor wants. No signature is necessary, because the patient or his family can change their mind at any time.
intention, this is my last attempt to get this across to you.
As per your link this provision defines what constitutes the service of an “Advance Care Planning Consultation”. This consultation code can be used (and thereby billed for) if the provisions of the regulation are met.
To use the code the physician must be able to document having met the provisions of the section. (S)he must document having: explained the process; having explained “advance directives, including living wills and durable powers of attorney, and their uses”; document having explaining about health care proxies; document having provided “a list of national and State-specific resources”; document having explained “the continuum of end-of-life services and supports available”; document that the explanation included everything needed to make an informed choice and that the patient is able to be aware of “the requirements of the State in which such individual resides so that the treatment wishes of that individual will be carried out if the individual is unable to communicate those wishes” (which as you note often require a signed form by the patient); explicitly requires that all of the state’s “legal barriers have been addressed for enabling orders for life sustaining treatment to constitute a set of medical orders respected across all care settings”; minimally requires that the state’s program is standardized with standard requirements for the orders, that orders are accessible to those who might be providing life-sustaining care, that continuing education about the program is provided, and created with input from an exhaustive list of stakeholders.
The regulation then states that after having documented all of that (including all that compliance with state rules and regs) an order set can be included as part of that consultation code. That order set is defined as one that: is signed by the health care professional; accurately reflects the wishes of the patient; and follows state standards (which once again currently requires a patient signature in many if not most states, although some will allow a witnessed verbal consent).
So again, this section does NOT IN ANY WAY mandate that a DNR order is enforceable upon a doctors signature only. It instead explicitly requires that state laws are followed and the patient know about the state laws and about all of the options open to them. It requires that the state program be a standardized one and that it be created with full input from all conceivably relevant stakeholders.
Now you may believe that there should be a Federal law requiring patient signatures that does not currently exist and be concerned that this, to you, “egregious oversight” is not addressed in this section; that states which currently allow witnessed verbal consent be forbidden by the Feds from doing so. Fine. But this law does not change the current requirements. It merely spells out what counts for using this particular consultation code that it creates and it is a fairly rigorous bit of documentations.
It not only has nothing to do with the lie about death panels, it explicitly places end of life care decision in the patient’s hands and describes in detail that the full range of choices and tools must be explained and understood by the patient and that state rules and reg must be followed. The option of a panel of doctors, a government panel or a hospital panel, or an individual doctor, making that decision for the patient is explicitly prohibited.
Why you are persisting in claiming that this regulation’s lack of forcing states that currently do not to to require a patient signature somehow equals “death panels” is beyond odd.
To Snowboarder Bo’s point. The reason some are misinterpreting the bill is mainly that some people have lied about what it is and have engaged in huge campaigns based on those lies. Not because they read the bill and didn’t understand it. (Again your particular misinterpretation is harder to fathom at this point.)
The answer is not changing the bill in response to the lies. It is calling the liars out and explaining to those misinterpreting because of those lies the ways in which they are being lied to.
This particular section is, in fact, pretty well written and very reasonable. States have the obligation to set up their own rules regarding end of life care and order sets with full involvement of the stakeholders and in a standardized manner. Physicians can, under these regs, use a consultation code to bill for the time spent formulating order sets with patients in compliance with those state rules providing they also meet the other various requirements of the code, most of which spell out all that the patient must be informed of. An emphasis is placed on respecting the patients wishes and that their decision is made fully informed of all options and important information. The reg is written specifically to not interfere with any current state’s rules by requiring something that some individual states have decided to not universally require. But it does require that states make their rules with serious thought and input and execute them in a clear and standardized manner.
DSeid, thank you for your perseverence, and for the clarification. I finally understand what you were trying to say.
I was unaware that this is not a law. It is a definition of a service. Thank you for fighting my ignorance, this has been my misconception from the start. I thought it was a law.
So you are correct and I was 100% wrong, it’s not a law as we understand laws. It simply changes the Social Security Act to add in a new service. People had said that before, but I didn’t get any citation to Section 1861 of the Social Security Act (42 U.S.C. 1395x), so I didn’t understand the difference. My thanks to everyone involved for their determination to fight my ignorance.
This whole procedure that we have gone through here, however, merely underscores my concern about what has gone on in the larger arena. I still see this as an object lesson for us Democrats. If people say they misunderstand some part of a complex bill, abusing them is counterproductive. If we Democrats had taken the same path that (almost) everyone here has taken in patiently trying to explain to me the part I didn’t understand, rather than simply saying “you are a bunch of idiots who are all in thrall to liars”, this whole farrago might have had a different outcome.
As it is, a valuable section of the bill has been lost, the Republicans got the credit with those that opposed the bill, and the Democrats get slammed … way to go for our side …
My thanks to all for your patience in this, consider my ignorance fought. I do hope, however, that this serves as an example of how you don’t have to be stupid or credulous to misunderstand part of a thousand page bill …
You are welcome and I appreciate your acknowledgement of error. Even if we still disagree about how many people are misunderstanding part of a complex bill and how many are confused because others who do understand the bill have lied to them.
No, but you do have to be stupid and credulous if you are a person who thinks the government is trying to write a bill that institutes death panels. On the face of it the absurdity should peg everyone’s bullshit meter off the charts. If you really think anyway that it really is what they are trying to do then it behooves you to take a close look yourself and see it for yourself.
The issue is not that there are not people who will not explain it to someone who is concerned in a clam fashion. The issue is that the Deathers simply do not want to be bothered by facts whatsoever.
You sought out answers. I wish others would do the same.
Oh, I agree with you about the lying. But whether people are confused or being lied to, or as in this case a combination of both, it is foolish to denigrate and demonize them. We all have seen how well that worked. It ended with the entire section being booted from the bill, which is a loss for all of us.
Most of the so-called “Deathers” (a perfect example of the demonization I spoke of above) are senior citizens who are understandably nervous about any change in the health system. Many of them have little trust in a government which has lied to them about such trivial issues as, oh, say, reasons for a government to go to war, the actions of the CIA both now and in the past, the “Gulf of Tonkin” incident, the Iran-Contra scandal, the Watergate scandal and a host of others.
In the face of that, people’s bullshit meters are kinda busted … I mean, who would have thought that the US government would secretly sell weapons to a known enemy, and then use the proceeds to fund an illegal war? Who would have thought that the government would secretly use ATT to spy on Americans? And if the government will do those things, they reason (and reasonably so), what won’t they do?
Finally, so what if they are stupid and credulous? Do you really think the best tactic is to stand up in their face and say “you’re all just stupid, credulous fools”? We see how well that has turned out. We’ve lost an important part of the bill through trying that tactic … are you claiming that was a wise move?
To me, one of the gaping holes in the Administration’s presentation of this issue is that they don’t want to admit that they will be rationing medical care. Somebody has to. If there’s one liver available, somebody has to make a choice who it will go to. Me, I’d prefer that it be doctors rather than insurance companies. That way, it’s more likely to go to who needs it the most, rather than who can pay the most.
Now, is that group who decided that life-and-death issue a “death panel”? Well, you could certainly call it that. I’d call it a “life panel” myself … but it is definitely a panel who decides who will live and who will die. It’s a reality of medicine, an ugly reality, but a reality nonetheless.
The Administration’s unwillingness to discuss this issue has left a gaping hole that the “Deathers” have happily exploited. Call me crazy, but I’d prefer that not happen. And the opportunity for that to happen was caused by the Administration trying to avoid discussing an ugly reality. You talk about people’s bullshit meters … did you ever consider that they would be set off by people in favor of health care reform avoiding that very issue?
intention, the “Deathers” are not the people being misled; they are the ones doing the misleading. It is similar to another issue I deal with every day - the vaccine conspiracy theorists - the concerned parent who watched Oprah isn’t the problem - (s)he needs some accurate information and often can be reached - those lying about vaccine safety to the parents are the problem. Same idea and same approach. I don’t denigrate the parent who is concerned, I educate them, but I do denigrate those who have misled them. They are whackos that cause very real harm. And so are the “Deathers”.
As to rationing: again livers are rationed now - between those who have coverage for the procedure, be it private or public. And no one calls the board that issues such guidance a “death panel”.
One of the gaping holes in the Administration’s presentation of this issue is that they won’t ration care any differently than it is rationed now - other than by making sure that a very basic coverage package is available to everyone at an affordable price point. Otherwise you pay for the level of coverage you want, privately or through a competing public option. And maybe nothing wrong with that I guess as long as it is clear what you are paying for. Hopefully the public option will have more transparency as to what is and is not covered than private insurance plans do, at least at this point in time.
