Tag: United States

Nurses for Gun Control

Walmart gun control
Walmart gun control (Photo credit: tsweden)

U.S. Representative from New York State, Carolyn McCarthy, is a nurse leader to be proud of. A nurse for thirty years, a gun control advocate and Congresswoman for almost twenty years, she knows about this public policy (and health) issue first-hand. In the 1990’s her husband was killed and her son (and only child) seriously wounded in a random shooting on a NYC commuter train. Congresswoman McCarthy is a senior member of the U.S. Congressional Committee on Education and Workforce and is a member of the subcommittee on Early Childhood, Elementary and Secondary Education. She has led hearings on cyber-bullying and violence in schools. Here is part of what she wrote yesterday in response to the horrendous Connecticut school shooting:

“Leaders in Washington from both parties, and groups like the NRA, all say that now is not the time to talk about how gun safety laws can save lives in America.  I agree, now is not the time to talk about gun laws – the time for that conversation was long before all those kids in Connecticut died today.

We owe it to our children to work harder to reduce gun violence.  The Second Amendment is the law of the land but it was never intended to allow murderers to take the lives of innocent kids.  It’s our moral obligation as policymakers and as parents to do more to save lives.

I hope the President’s words about taking ‘meaningful action to prevent more tragedies like this regardless of the politics’ stay true as we continue down this road again.”

Another nurse who has recently spoken out for sane gun control, is NYT Opinion page author and nurse, Theresa Brown. In her article “The Human Cost of the Second Amendment” (9-26-12), she takes a ‘nurse’s eye view’ of the effects of gun violence by bringing the reader into the emergency department and morgue. She writes, “… because to really understand the human cost of guns in the United States we need to focus on gun-related pain and death.”

It is worth remembering that the U.S. has the highest rate of firearm-related deaths (including homicides, suicides, and unintentional deaths) of any of the world’s high-income countries. One in every five deaths in people less than 20 years of age in our country is related to firearms. Having guns stored in homes is associated with a threefold increase in risk of homicide (of the people living in the home) and a fivefold increase in the risk of suicide (especially for teenagers and young adults struggling with mental health issues.) Florida and six other states (with lobbying funding from the NRA) have attempted to prohibit doctors and nurses from asking patients (and parents of young children) about gun ownership as part of standard health and safety screening questions within a health care encounter.

The direct medical costs resulting from gun-related injuries and deaths (including suicides) in our country are over a billion dollars every year, and the cost of lost productivity is thirty-four billion (source: American Academy of Pediatrics Policy Statement “Firearm-related injuries affecting the pediatric population, in Pediatrics, vol 130/5, Nov 1, 2012).  Clearly this is a nursing and public health issue. Clearly our Founding Fathers (and the Founding Mothers who fed and supported them) did not intend to have such a “… state of enabled and murderous mayhem…” when they included the Second Amendment (quote is from Theresa Brown’s NYT article linked above).

Congresswoman McCarthy is right in stating that the time for this national conversation was before the homicides of twenty children and their teachers, or the homicide/domestic violence of the mother of the twenty year old killer, or the suicide of the young man who killed them (and who clearly had unaddressed mental health issues.) But if you weren’t part of the solution before, be part of it now.

Consider joining a national gun control lobbying and education group such as the nonpartisan Brady Campaign to Prevent Gun Violence. Consider signing a petition to ask President Obama to start a national conversation about gun control (linked from Greg Dworkin’s Daily Kos article “A national conversation about gun control” 12-15-12).

Saying “Yes Thanks” to HIV Screening

English: The Red ribbon is a symbol for solida...
English: The Red ribbon is a symbol for solidarity with HIV-positive people and those living with AIDS. Français : Le Ruban rouge, symbole de la solidarité avec les personnes séro-positives. (Photo credit: Wikipedia)

In contrast to my rejection of (or questioning the real evidence in favor of) routine cancer screening practices in U.S. health care, I embrace the new HIV screening guidelines (due out later this month) from the U.S. Preventive Services Task Force (USPSTF). Their previous HIV screening guidelines, issued in 2005, only recommended HIV screening for adolescents and adults deemed to be at increased risk for HIV infection. The about-to-be released updated guidelines recommend that clinicians routinely screen all adolescents and adults ages 15-65 years and all pregnant women for HIV infection (as well as younger and older patients who are at risk for HIV infection).

They base their new recommendations on compelling evidence that earlier identification and treatment of HIV infection (before a person begins to have symptoms of disease) improves clinical outcomes for the individual, as well as significantly reduces the chance of transmission of HIV to other people. “The USPSTF concludes with high certainty that early detection and treatment of HIV transmission would result in substantial public health benefits in the United States.”

Since 2006, the CDC has recommended routine voluntary ‘opt-out’ HIV testing of adolescents and adults in the U.S. (opt-out meaning all patients be informed of routine testing and tested unless they decline). The CDC also recommended eliminating the pre-test counseling and the signed patient consent requirement for HIV testing, pointing out (correctly in my experience) that these act as barriers to HIV screening. The USPSTF clinical guidelines carry more weight with the passage of the 2010 Affordable Care Act that has a provision requiring all health insurers to cover all preventive services endorsed by these federal guidelines.

So today, on World AIDS Day, let’s remember the estimated 30 million people worldwide who have died of AIDS and the 60,000 people in the U.S. who have died of AIDS since the beginning of the epidemic. Let’s remember that HIV/AIDS continues to disproportionately affect people living in African countries, as well as African-American, Hispanic people and people living in the ‘Black Belt’ of Southern poverty in the U.S. because of social determinants of health. Let’s stop thinking of HIV/AIDS as something shameful/stigmatizing and a death sentence. Let’s “Work together for an AIDS-free generation.” Know your HIV status and encourage others to know theirs. This is a case in which we can steal the Komen Foundation‘s slogan “Early detection saves lives” and be telling the truth.

For a unique health-related holiday gift for yourself or for your loved ones (tongue and cheek), you can order the newly-FDA approved home rapid HIV test (Oraquick/uses a swab of fluid at gum line/takes 20-40mins) directly from Oraquick. It is delivered to your doorstep in an ‘unmarked brown box.’ You can also buy it (assuming you are at least 17 years old) from your local pharmacy. List price is $39.99 (exact same test only costs ~$17 in clinics/manufacturer says the increased price goes to pay for their 24/7 information hotline with bilingual English/Spanish representatives). In contrast, I’ve read estimates of the more sensitive HIV ‘blood tests’ available in clinics as costing on average $1.50).

Additional resources: Check out the AIDS.gov website, and especially their link to CDC testing/treatment/supportive services (like mental health and substance abuse counseling, and housing). It has some cool downloadable apps for searching for HIV/AIDS related services in your area. If you don’t need to use it for yourself or your family, you can use it for patients you might work with. I’m glad to know I have 34 HIV testing sites within a 10 mile radius of my home.

Saying ‘No Thanks’ to Cancer Screening

English: Mammography in process: Shown is a dr...
English: Mammography in process: Shown is a drawing of a female having a mammogram. A mammogram is a picture of the breast that is made by using low-dose x-rays. (Photo credit: Wikipedia)

Earlier this week I went to my primary care physician for a well-woman check-up. Truth be told, I went back because she wouldn’t refill my medications without a follow-up visit. In the past two years I’ve had only nurse visits for the annual flu shots and TB tests I need for work. I’ve felt—and am—healthy.

I like my doctor. She’s a family medicine doctor who specializes in women’s health, and she ‘treats me like an informed adult’ (her words) when I politely refuse her recommended cancer screening tests, such as mammograms. Except for my age, I am in a low-risk category for most cancers. I know first-hand the cascade of negative, iatrogenic effects that cancer and other medical screening can precipitate. I also know first-hand that many doctors and other health care providers (including nurses) can take personal offense to such ‘non-compliant’ patients as myself. I’ve been scolded like a recalcitrant child and even had an angry radiologist tell me I was being stupid for declining a mammogram. I’m fortunate that I live in a large metropolitan area, have sufficient health insurance, as well as good health literacy, that I can fire these health care providers and find better ones.

But even my current ‘good doctor’ smiled at me ruefully as she said she had to keep encouraging me to have the recommended screening tests done—as she was checking off boxes on my electronic medical record. I realized I was probably reducing her monetary incentives for quality of care measures, and failing to contribute to paying off the expensive state-of-the-art mammography machines that her particular health system owns.

The day after my doctor’s visit I read the provocative NYT Op-Ed essay “Cancer Survivor or Victim of Overdiagnosis?” written by physician and Dartmouth health services researcher H. Gilbert Welch. He refers to recent results of research published in the NEJM “Effects of Three Decades of Screening Mammography on Breast-Cancer Incidence,” a paper he co-authored with Archie Bleyer, MD (11-22-12). They looked at U.S. population-based data from 1976-2008 on breast cancer screening, and the incidence of both early and late-stage breast cancer. They estimated that breast cancer was overdiagnosed (tumors detected on screening that would never progress to clinically-relevant symptoms/ ‘real cancer’) in 1.3 million women in the past thirty years. The incidence of overdiagnosis is likely to have increased exponentially in the last decade with the use of more sensitive digital mammography screening. The researchers conclude that screening mammography has little to no impact on breast cancer mortality, and indeed, is doing more harm than good as a public health measure.

They do acknowledge that breast cancer mortality has fallen substantially in the U.S. and Europe over the past thirty years (and especially so for women diagnosed before age 40 when they wouldn’t have had mammograms), but that it is due to improved treatments and not to breast cancer screening.

In his Op-Ed essay, Dr. Welch points out a health literacy deficit (or a calculated ’misrepresentation/pinking of the truth’ I wonder?) in a recent Komen Foundation campaign “Early Detection Saves Lives.” Survival rates always go up with early detection. If you tell everyone they have cancer, survival will be bound to skyrocket.

I read an interview with Dr. Welch where he urges healthy skepticism toward standard medical practice—like those listed in the check-boxes at my doctor’s office. Our tests and screenings have become so sensitive that we can find abnormalities in just about everyone. That can start a cascade of harmful events (including the stress from the ‘diagnosis’ and uncertainty), when most of those abnormalities won’t end up causing disability or death. He concludes with “Health is much more than not being able to find something wrong.”

Engage With Grace And Please Pass the Cranberry Sauce…

I keep asking myself, “What would the Pilgrims do? Would they have mixed Living Will conversations with their Thanksgiving dinners? And what about the American Indians who were there? Wouldn’t they have thought this was strange?”

Nevertheless, I do think having end-of-life discussions with our loved ones is important, so this year I’m participating in the Engage With Grace blog rally (see below).

Engage with Grace this Thanksgiving
Posted By Alexandra Drane On November 21, 2012

By Alexandra Drane

Once again we’re hosting the annual Engage with Grace blogrally. Engage with Grace aims to get people talking about their wishes for end of life and advanced care. If you want to host this on your blog please do.
One of our favorite things we ever heard Steve Jobs say is … “If you live each day as if it was your last, someday you’ll most certainly be right.” We love it for three reasons: 1) It reminds all of us that living with intention is one of the most important things we can do. 2) It reminds all of us that one day will be our last. 3) It’s a great example of how Steve Jobs just made most things (even things about death – even things he was quoting) sound better.

Most of us do pretty well with the living with intention part – but the dying thing? Not so much. And maybe that doesn’t bother us so much as individuals because heck, we’re not going to die anyway!! That’s one of those things that happens to other people …

Then one day it does – happen to someone else. But it’s someone that we love. And everything about our perspective on end of life changes.

If you haven’t personally had the experience of seeing or helping a loved one navigate the incredible complexities of terminal illness, then just ask someone who has. Chances are nearly 3 out of 4 of those stories will be bad ones – involving actions and decisions that were at odds with that person’s values. And the worst part about it? Most of this mess is unintentional – no one is deliberately trying to make anyone else suffer – it’s just that few of us are taking the time to figure out our own preferences for what we’d like when our time is near, making sure those preferences are known, and appointing someone to advocate on our behalf.

Goodness, you might be wondering, just what are we getting at and why are we keeping you from stretching out on the couch preparing your belly for onslaught?

Thanksgiving is a time for gathering, for communing, and for thinking hard together with friends and family about the things that matter. Here’s the crazy thing – in the wake of one of the most intense political seasons in recent history, one of the safest topics to debate around the table this year might just be that one last taboo: end of life planning. And you know what? It’s also one of the most important.

Here’s one debate nobody wants to have – deciding on behalf of a loved one how to handle tough decisions at the end of their life. And there is no greater gift you can give your loved ones than saving them from that agony. So let’s take that off the table right now, this weekend. Know what you want at the end of your life; know the preferences of your loved ones. Print out this one slide with just these five questions on it.

Have the conversation with your family. Now. Not a year from now, not when you or a loved one are diagnosed with something, not at the bedside of a mother or a father or a sibling or a life-long partner…but NOW. Have it this Thanksgiving when you are gathered together as a family, with your loved ones. Why? Because now is when it matters. This is the conversation to have when you don’t need to have it. And, believe it or not, when it’s a hypothetical conversation – you might even find it fascinating. We find sharing almost everything else about ourselves fascinating – why not this, too? And then, one day, when the real stuff happens? You’ll be ready.

Doing end of life better is important for all of us. And the good news is that for all the squeamishness we think people have around this issue, the tide is changing, and more and more people are realizing that as a country dedicated to living with great intention – we need to apply that same sense of purpose and honor to how we die.

One day, Rosa Parks refused to move her seat on a bus in Montgomery County, Alabama.  Others had before. Why was this day different? Because her story tapped into a million other stories that together sparked a revolution that changed the course of history.

Each of us has a story – it has a beginning, a middle, and an end. We work so hard to design a beautiful life – spend the time to design a beautiful end, too. Know the answers to just these five questions for yourself, and for your loved ones. Commit to advocating for each other. Then pass it on. Let’s start a revolution.

Engage with Grace.

Alexandra Drane is the Founder of Engage with Grace.

Article taken from The Health Care Blog – http://thehealthcareblog.com
URL to article: http://thehealthcareblog.com/blog/2012/11/21/engage-with-grace-this-thanksgiving/

Hospital Dirty Laundry Exposed

Laundry
Laundry (Photo credit: Bilal Kamoon)

Julie Creswell and Reed Abelson of the NYT are writing a series of fascinating articles exposing hospital giant HCA (Hospital Corporation of America), now the largest for-profit hospital chain in the US. Their NYT article today “A Giant Hospital Chain is Blazing a Profit Trail” finally explains to me the story behind the strange digital billboards I saw in June when I was visiting my father in Richmond, Virginia. They seemed to be everywhere along major roads, flashing obnoxious red-lighted wait times for the emergency rooms at two HCA hospitals–one being CJW, which the NYT article calls out as being one of the worst hospitals in the US in terms of bedsores (bedsores being a fairly good indicator of poor nursing care).

Last week (8-6-12, “Hospital Chain Inquiry Cited Unnecessary Cardiac Work) they wrote about a whistleblower, C.T. Tomlinson, a traveling nurse, who in 2010 worked as a cardiac nurse at the Lawnwood Regional Medical Center in Florida. Tomlinson was present in the cardiac catheterization lab when an HCA cardiologist inserted a stent into a patient who did not need it. Tomlinson reported the incident to his nursing supervisor who supposedly told him to forget about it. So he wrote a letter to the chief ethics officer of HCA’s hospitals in Florida who investigated his complaints and found them to be substantiated. Soon after Tomlinson wrote the letter of complaint, his contract to work as a nurse with HCA was terminated. It is not clear from the article whether or not he has filed a lawsuit for wrongful termination under Whistleblower protection. The HCA chief ethics officer’s investigation found that about half of all the cardiac catheterizations at Lawnwood Regional Medical Center were unnecessary, but did not alert the patients involved. It is unclear how many patients may have been harmed by the unnecessary cardiac work they had done. HCA also did not alert Medicare, state Medicaid or private insurers who were charged for the expensive procedures.

 

Blockbuster Moment

English: Camden, New Jersey is one of the poor...
English: Camden, New Jersey is one of the poorest cities in the United States. Camden suffers from unemployment, urban decay, poverty, and many other social issues. Much of the city of Camden, New Jersey suffers from urban decay. 日本語: ニュージャージー州カムデンのスラム. Svenska: Camden, New Jersey is one of the poorest cities in the United States. Kiswahili: Camden, New Jersey ni moja ya mataifa maskini zaidi katika miji ya Marekani. (Photo credit: Wikipedia)

Dr. Jeffrey Brenner, a family physician in Camden, New Jersey, talks about this as being a Blockbuster Moment in US health care in the US, a time for game changing innovations. He is the head of one such health care game-changer, the Camden Coalition of Healthcare Providers.

Camden, New Jersey is one of the poorest and most crime-ridden cities in the US. After completing his residency in family medicine here in Seattle in the late 1990’s, Dr. Brenner returned to his hometown of Philadelphia to establish a family practice. But a series of events–including the murder of young man outside his house– led him out of his private practice and into community work in nearby Camden.

Working with hospitals and local physicians, Dr. Brenner was able to map and identify the high utilizers of health care–people who were the most medically complex and the most expensive to treat. He found that 1% of the Camden residents accounted for 30% of all hospitals charges, mostly for emergency department visits for health problems that could have been treated and prevented with primary health care. After some good old-fashioned community coalition building, Dr. Brenner and his group hired a team of nurse practitioners, social workers, and community health workers to work with the “high utilizers” to help coordinate their health care, housing, benefits and other needs. The Camden Coalition model of care is showing results indicating they are able to provide better health care at lower cost to the most difficult to treat patients in one of the poorest cities in the US. As Dr. Brenner states, “If Camden can do it, it makes the rest of the country look silly.”

There is a very good 13min PBS Frontline video “Doctor Hotspot” by Atul Gawande highlighting the work of the Camden Coalition of Healthcare Providers. It features an interview with Dr. Brenner and also follows Coalition nurse practitioner Kathy Jackson on a home visit with one of her patients, a young man with asthma and a seizure disorder. Through her work with this young man, his ER visits went from 35 over six months to just 2 over six months.

In the Frontline video, Atul Gawande points out to Dr. Brenner that “there’s a catch” to the work of the Coalition being too successful. The catch is that they are taking away from the hospitals their most expensive, most lucrative patients and the hospital administrators will resist that change.

Atul Gawande also published an interesting article “The Hot Spotters” related to Dr. Brenner’s work in the New Yorker (1-24-11).

Also–for anyone with a NJ RN license, check out the two open RN positions on the Camden Coalition of Healthcare Provider’s website. They both look like exciting jobs with a terrific team. They also have volunteer opportunities listed.

Home Health

Wisconsin Home Care Victory
Wisconsin Home Care Victory (Photo credit: SEIU International)

The Department of Labor is considering expanding the Fair Labor Standards Act (FLSA) to cover the estimated 2.5 million home health aids working in the US. As its name implies, the FLSA mandates minimum wage and overtime pay for employees.

Home health aids assist elderly, ill and disabled persons with shopping, cooking, housecleaning and laundry to help them stay as independent as possible in their own homes—and out of expensive and oftentimes dehumanizing long term care institutions.

Currently, home health aids are considered companionship services, like babysitters, and as such are excluded from FLSA protections. These exclusions benefit for-profit home health and hospice agencies, an $84 billion industry—and growing, thanks to our aging (and dying) population. Republican US Senator Johanns (Nebraska) is sponsoring a bill in Congress to permanently block home health aids from FLSA protection. He is also backing repeal of the Affordable Care Act.

Home health aids are dear to me. I got my start in nursing as a home health aid in the North End of Boston, tending to several elderly first generation Italian immigrants. I was jumping out of the Ivory Tower of Harvard University at the time, on my way to becoming a Harvard dropout. One of my professors of health policy recommended I work for a home health agency to gain first hand knowledge of health care needs in the community. It was hard work and didn’t pay enough to keep me working in it for long. But it was rewarding and the experience convinced me to apply to nursing school.

Home health aids are a part of my life today. My 89-year-old father with advanced congestive heart failure is able to live at home with the help of home health aids. They are skilled, dedicated, and caring workers and not some glorified passive ‘companions’—and they deserve fair labor standards.

(see Borris and Klein’s NYT Op-ed “Home-care workers aren’t just ‘companions.'” 7-1-12)

Bedside Nursing

British nurse in nurses' station.
British nurse in nurses’ station. (Photo credit: Wikipedia)

Theresa Brown, RN has a new NYT monthly opinion piece column called “Bedside.” In a recent e-mail, Theresa describes her column as, “…a nurse’s eye view on ways to make health care better and more humane.” In her debut piece “Money or Your Life” (6-23-12/print version 6-24-12 in Sunday Week in Review section), she argues for the Affordable Care Act (ACA) based on her work as a hospital-based oncology nurse. She describes working with an uninsured male patient with leukemia who asked her about death panels, hoping they existed. It seemed he wanted to be put out of his misery, while avoiding bankrupting his family. Ms. Brown then does a good job of describing some of the complexities of–and the argument for–the individual mandate component of the ACA. This, of course, is a key element of the ACA, and one before the US Supreme Court as to its constitutionality. Their decision is due out this week.

Congratulations Theresa Brown! And thanks NYT editors for recognizing and including a nursing perspective on the continuing health care debate in our country.

Since this is a blog, and since Theresa Brown asked for feedback on her new column, I offer a few reflections. The name “Bedside,” as in bedside nursing, implies direct patient care in an inpatient hospital setting. As such, it is descriptive of the type of nursing Theresa Brown is involved with. But bedside nursing is a term often used as code for “real nursing,” as if community/public health, home health, school and occupational health, and nursing home nurses are somehow not real nurses. The name “Bedside” also perpetuates the notion that nurses spend the most time with patients of any health care team member, and are, therefore, in the best position to advocate for patient’s needs. This belief undermines patient care and safety by working against good health care team communication. It is a paternalistic (maternalistic?) belief that undermines the patient autonomy and agency central to patient-centered care. The belief is also not supported by facts.

Recent studies indicate that hospital-based nurses consistently (and significantly) overestimate the amount of time they spend on direct patient care. Whereas many nurses ‘guesstimate’ they spend over half their time during a given shift on direct patient care, national studies (sophisticated versions of time/motion studies) indicate that hospital nurses spend just 15% of their time in direct patient care. (see RWJ study by Hendrich, et al, “A 36-hospital time and motion study: how do medical-surgical nurses spend their time?” The Permanente Journal, Summer 2008) The largest percentage of their time was spent on charting and other administrative tasks. And a recent study found that physician hospitalists also spent 15% of their time in direct patient care (“Hospitalist time useage and cyclicality: opportunities to improve efficiency” Kim, et al. Journal of Hospital Medicine, July/Aug 2010). So nurses’ time-honored claim to spending the most time at a patient’s bedside is no longer true.

Then there is the fact that hospital-based jobs for nurses are rapidly disappearing as hospital administrators reduce their nursing staff, and as more hospitals merge or close altogether. Some experts claim that one-third of all hospitals in the US will close by 2020 (see David Houle and Jonathan Fleece’s post on KevinMD. 3-15-12)

Bedside nursing is probably a term that needs to be, well, put to sleep.

 

April Fool

April 16th is the fifth annual National Healthcare Decisions Day (NHDD). According to their website, the mission of NHDD is “to inspire, educate & empower the public & providers about the importance of advance care planning. National Healthcare Decisions Day is an initiative to encourage patients to express their wishes regarding healthcare and for providers and facilities to respect those wishes, whatever they may be.” Nathan Kottkamp, a lawyer who specializes in health care law is the founder and chair of NHDD. In an interview on AARP News, Mr. Kottkamp reports that he launched NHDD in Virginia in 2006 and expanded it nationally in 2008. He chose April 16th, the day after “tax day” because of Ben Franklin’s aphorism “Nothing can be said to be certain except death and taxes.”

Advance medical directives including living wills and health care proxy/agent/power of attorney (who a person wants to make health care decisions for them in case they are incapacitated), are important legal documents recognized (in differing degrees) in all 50 states. At least in theory, having an advance medical directive helps patients have more say in how they die—whether, like the emergency department physician Boris Veysman they want “Shock me, tube me, line me” (Health Affairs, Feb 2010, vol 29(2): 324-326), or like other people they do not want medical procedures that artificially prolong the dying process. And designating a health care proxy—again in theory—helps to avoid unnecessary confusion in health care communication, especially in emergency situations.

I applaud the work of Nathan Kottkamp and others like him to bring greater awareness to the general public about end of life decision making. But as I am currently experiencing, the health care system is not cooperating with sane implementation of the Advance Medical Directives.

Five blocks northeast of Nathan Kottkamp’s law office in Richmond, Virginia is the main hospital of the Virginia Commonwealth University (VCU) health System. My elderly father is now a patient there, after experiencing confusion and shortness of breath at home (from congestive heart failure) and calling the ambulance to take him to see his cardiologist at VCU. Less than two years ago I was with my father in the VCU hospital admission’s office when he was being admitted for possible cardiac surgery. My father had the original copy of his Virginia Advance Medical Directive/Living Will/Appointment of Health Care Agent. My father and I had gone over specific medical procedures—such as resuscitation, mechanical ventilation, and ‘tube’ feeding—with his wonderfully patient and competent primary care physician (who praised my father for having this important conversation and for doing his Living Will).  My father came to VCU hospital fully prepared. His Medical Directive five page document was witnessed/signed by two of the VCU Health Systems hospital admission’s office officials. They made photocopies to give to me and promised the legal document was now part of my father’s hospital medical record. My father named me as his health care agent.

Imagine my surprise yesterday when I was notified by my father’s neighbor that my father had been whisked away to VCU emergency department. But I was even more surprised when I called/talked with a clerk at the VCU ED and was told that to protect patient privacy the nurses/medical staff couldn’t tell me anything about my father—that she wasn’t even supposed to tell me if he was there or not. It did no good when I informed her I was his health care proxy—she said they had no proof of that. He was admitted to the cardiac floor and I was finally able to talk with his nurse (using a special secret HIPAA/patient privacy code—really? The lawyers interpreting HIPAA for hospitals are getting quite creative). She informed me that they had no record of my father’s Medical Directive so he was “full code.” When I told her I had a photocopy of the Medical Directive in front of me and that it was signed by their hospital admission’s department personnel she said, “That doesn’t matter. We get rid of all of that in the medical record and start all over again.” She said that my father should have brought a copy of his Medical Directive to the hospital with him—it was his fault he didn’t have it. I kept expecting her to exclaim “April Fools!” but she didn’t.

So, on April Fools’ Day, I’d like to amend Ben Franklin’s aphorism to proclaim: In this world there is nothing certain except death and taxes and the fact that our US health care system is one crazy-making system…..

(If you haven’t seen/read Atul Gawande’s terrific New Yorker Essay 8-2-10 on end of life decision making ,“Letting Go, What Should Medicine Do When It Can’t Save Your Life?” I highly recommend it. Also see the recent NYT Op-ed piece 3-30-12 “Taking Responsibility for Death” by Susan Jacoby).

The Broccoli Possibility

The United States Supreme Court, the highest c...
The United States Supreme Court, the highest court in the United States, in 2010. Top row (left to right): Associate Justice Sonia Sotomayor, Associate Justice Stephen G. Breyer, Associate Justice Samuel A. Alito, and Associate Justice Elena Kagan. Bottom row (left to right): Associate Justice Clarence Thomas, Associate Justice Antonin Scalia, Chief Justice John G. Roberts, Associate Justice Anthony Kennedy, and Associate Justice Ruth Bader Ginsburg. (Photo credit: Wikipedia)

Who knew that broccoli, cell phones, burial insurance, electric cars, blue eyes, exercise, epidemics, wife beating, and hunting licenses were all related to the Affordable Care Act (ACA)? According to our nine Supreme Court Justices—well—according to eight of the nine justices (Justice Thomas as usual said nothing on the topic)—they are related. It’s not every day that the typical US citizen can listen in on Supreme Court hearings. I wasn’t there in person, but yesterday I read through the 130 pages of typed transcript of Day 2 of the hearings on the constitutionality of President Obama’s health care overhaul law. It made for surprisingly fascinating reading. Although at the end of it I am dismayed at the types of things the Justices’ said.

For example, Justice Scalia, the most talkative Justice in the transcripts—was responsible for Justice Breyer later dubbed “the broccoli possibility.” This is Scalia’s slippery slope argument, where he asked the Justice Department’s Verrilli what would keep the federal government from requiring all US citizens to buy and eat broccoli if the ACA individual mandate for health care coverage is instituted. Since Justice Scalia looks a whole lot like Danny DeVito and is vocal in his abhorrence of broccoli (and exercise), this analogy was not surprising. It is surprising how many more times it was invoked throughout the day’s proceedings—at least eight more times by various justices and by Verrilli, who at one point stated (I imagine in a fairly frustrated voice), “Broccoli is not the means of payment for anything else,”—thus trying to end the analogy of broccoli to health insurance.

There was a brief but very disturbing interchange between Justice Scalia and Solicitor General Donald Verrilli. Mr. Verrilli was talking about the US social norm of providing health care to people regardless of their ability to pay—as backing for the US federal laws requiring hospital emergency departments to treat patients regardless of health insurance status or other payment sources. Justice Scalia interjected, “Well don’t obligate yourself. Why, you know?” Mr. Verrilli attempted to reply that it was a deeply held social value of most Americans, that’s why, but Justice Scalia cut him off. Is health care in the US a right or a privilege? It would seem that Justice Scalia believes it is a privilege.

It is fascinating to remember that when the individual mandate for health insurance was first being debated in Congress three years ago, conservative Republicans (including current Presidential candidate Mitt Romney) were its staunchest proponents —touting it as the responsible thing to do and as a way to stop the freeloading bums from getting health care at the expense of everyone else. (see “Academic Built Case for Mandate in Health Care Law” by Catherine Rampell, NYT 3-29-12). Now that the individual mandate is part of the ACA approved by Congress and signed into law by President Obama—and because it is a Presidential election year—conservative Republicans are complaining loudly about how the individual mandate is unconstitutional. And 26 states (most all conservative states with Republican governors) have challenged the constitutionality of the ACA and convinced a conservative-majority Supreme Court to decide on the issue. This seems to me to be the biggest broccoli possibility of all—to have the US Supreme Court potentially dismantling a much needed if imperfect health care reform.