Different River

”You can never step in the same river twice.” –Heraclitus

March 1, 2005

NYTimes: “How to Save Medicare? Die Sooner”

Filed under: — Different River @ 9:24 pm

From the New York Times “Economic View” column by Daniel Altman:

[H]ow can Medicare’s ballooning costs be contained? One idea is to let people die earlier.

For the last few decades, the share of Medicare costs incurred by patients in their last year of life has stayed at about 28 percent, said Dr. Gail R. Wilensky, a senior fellow at Project HOPE who previously ran Medicare and Medicaid. Thus end-of-life care hasn’t contributed unduly of late to Medicare’s problems. But that doesn’t mean it shouldn’t be part of the solution. “If you take the assumption that you want to go where the money is, it’s a reasonable place to look,” Dr. Wilensky said.

(Hat Tip: Macroblog.)

Aside from the questionable morality of this proposal, there’s another basic problem here: How do you know, for sure, when someone is at the “end-of-life”?

I’m sure everyone has heard stories like this; here’s the latest from my personal collection: A colleague of mine at my previous job was been diagnosed with a “fatal” form of leukemia over five years ago, given months to live if that, and retired from his previous job to die. He was treated, recovered, got another job (where I met him) and aside from his cancer-in-remission seems healthier than I am. He had a relapse, took two months off to get an experimental treatment, and came back hardly the worse for wear. He takes some (probably rather expensive) pills to keep the cancer from coming back, but that and monthly checkups are the only thing impinging on his quality of life.

Yet, at two points in the last five years, he could have been determined by the above-proposed Medicare rules to be at the “end of life” and thus ineligible for the chemotherapy and advanced medication that saved his life. And you know what? They would never have known they were wrong, since by denying someone life-saving medical care, you make the “end of life” determination self-fulfilling.

Even more dramatically, Rus Cooper-Dowda was determined in 1985 to be in a “persistent vegetative state” much like Terri Schindler Schiavo. She could actually hear a group of doctors (including her husband, who was a doctor) discussing when to “pull the plug” on her:

In February of 1985, I woke up in a hospital bed in Boston, MA. I couldn’t see very well and I couldn’t move much — but boy could I ever hear!

I heard a terrifying discussion then that I will never, ever forget.

Around the end of my bed were a “school” of doctors in their white coats, planning when to disconnect my ventilator and feeding tube. I immediately started screaming, “I’m here!!” No one but me heard me.

They did notice my sudden agitation. They heavily sedated me. For a time, everytime I woke up I would make as much noise and move as a much as I could to show them I was “in there.”

And they would, in response, heavily sedate me…
I then started spelling the same word in the air, “Don’t! Don’t! Don’t!….”

The doctors decided that the letters I was spelling in the air were repetitive seizure activity and just happened to occur most often when they were in my room discussing killing me…I even took to writing them backwards to make it easy for them to read…

But, the nursing staff began to believe I was really and truly with them.

One, in particular, starting bringing in a clip board and a broken pen when she talked to me. She would put ink on my fingers, the clip board under my right hand and then ask me yes and no questions in the beginning.

With her I secretly progressed to answering in sentence fragments. However, by doctor’s orders she was not allowed to document in my file what she was doing and that I was giving meaningful responses.

But…she did save my inky answer sheets and recorded the questions she asked. She got into a lot of trouble for that.

Yet, it earned me a final conference where the doctors had to prove to the nursing staff for political reasons that all my communication was just agitation and seizures.

At that meeting, my then husband, who was a doctor siding with the other doctors who wanted to let me die, held that clipboard which was my lifeline up in the air in front of me. He was not going to make it easy.

The purpose was to prove that the nurses were basically hallucinating and that I was really and truly brain-dead.

To prove I could not communicate, he then put ink on my fingers and asked while laughing, “There isn’t anything you want to tell us, is there?”

In response I spelled out, “D-I-V-O-R-C-E Y-O-U!” The laughter got very nervous then. The doctors called for medication because I was obviously having a sezure.

Then they said I couldn’t breath on my own — and I could. Then they said I couldn’t learn to eat again on my own — and I did. Then they said therapy wasn’t important — and it was. Then they said I would be dead within a year — in 1985 — this is 2003…

They also said I would never have meaningful mental function again — yet I earned another Master’s degree only a few years later.

Here’s the real medical corker though — They also said at the time that I was permanently sterile. That was a cause of great grief for me then as I had very much wanted to bear and raise a child.

But, it turned out my son, who is here at this service today, was born at the end of that year.

It turned out that I was actually pregnant at the very moment they were telling me I was sterile — a simple test at the time could have established that.

She ended up surviving, divorcing him, raising her son, and getting a job as a teacher of disabled children — from which she was fired for giving an interview on her experience in connection with the Terri Schiavo case.

These are anecdotes, but there is actual data to support the notion that this is not an uncommon occurrence. Writing in the New England Journal of Medicinein 1994, Ezekiel J. Emanuel and Linda L. Emanuel point out:

Expenditures at the end of life seem disproportionately large. Although the precise numbers vary, studies consistently demonstrate that 27 to 30 percent of Medicare payments each year are for the 5 to 6 percent of Medicare beneficiaries who die in that year. The latest available figures indicate that in 1988, the mean Medicare payment for the last year of life of a beneficiary who died was $13,316, as compared with $1,924 for all Medicare beneficiaries (a ratio of 6.9:1). Payments for dying patients increase exponentially as death approaches, and payments during the last month of life constitute 40 percent of payments during the last year of life. Identical trends and ratios have been found since the early 1960s.

Many people believe that these expenditures are for the care of patients known in advance to be dying. The time of death is usually unpredictable, however, except perhaps when the patient has advanced cancer. There is no method to predict months or weeks in advance who will live and who will die. Consequently, it is difficult to know in advance what costs are for care at the end of life and what costs are for saving a life. Only in retrospect, after a patient’s death, can we identify the last year or month of life.

This article was written during the debate over the Clinton health care plan, which, if I remember correctly, called for a cessation of all care except pain control once two doctors had determined that a patient had less than six months to live. Combine this with the provision that made seeking care outside the proposed national system a crime punishable by 10 years in jail (or a $10,000 fine or both), it is quite possible that under that plan, a person could have been told he had six months to live, somehow find treatment outside the system and live another 10 years — but spend them in prison.

By the way, if we take this proposal to it’s logical conclusion, we can save even more money. If 28% of Medicare expenditures are spent on the 5% of beneficiaries who die each year, eliminating them can save, at most, 28% of the budget. But 100% of Medicare expenditures are spent on the 100% of beneficiaries who are alive each year. So the clear solution is: Kill anyone who becomes eligible for Medicare. (This is similar to a policy enacted in the Anthony Trollope novel, The Fixed Period.)


Politics and the Oscars

Filed under: — Different River @ 8:32 pm

We all know most Hollywood folks are liberals, but other than that — and Michael Moore’s Oscar speech last year, what does politics have to do with the Oscars?

Well, it turns out that, perhaps, Hollywood fans are more likely to be liberals (or at least Democrats) also. Deacon of PowerLine points to a Zogby poll indicating that 25% of American adults planned to watch the Oscars — but that included 39% of Democrats and only 13% of Republicans. Lest you think this is merely Republican aversion to Hollywood liberalism, Independents were in between at 22%.

HindRocket of PowerLine comments:

Those numbers are stunning; wouldn’t you think that if the film industry were motivated by economic self-interest, it would try to find a way to avoid alienating the members of America’s most popular political party? Plus, I can hardly be the only viewer who turned off the telecast almost as soon as it began because of the host’s anti-Bush rant. On what theory does it make sense to put on a show that will drive away large numbers of viewers–and gratuitously, too, since Rock’s Bush-bashing had nothing whatever to do with the subject at hand? It’s more evidence that, as Michael Medved has often argued, for Hollywood it’s not about profit, it’s about ideology.

Michael Medved’s argument can be found here, and in his excellent book, Hollywood vs. America.

The Cedar Revolution and the “Arab Street”

Filed under: — Different River @ 3:08 pm

From Jay Tea via TigerHawk:

For a long time, one of the big pet phrases of the anti-war movement (also known as the anti-Israel movement, the pro-Islamist movement, the anti-American movement, and a host of other terms) has been “the Arab Street.” This seemingly-mythical creature, they warned, would rise up and strike back against the US with great wrath should we not heed their wise counsel.

But for various and sundry reasons, the beast seemed to slumber, only occasionally rousing itself for a brief, yawning squawk before returning to somnolence.

Until recently.

In the last two months, I can honestly say I have seen the Arab Street actually rise up, make its voice heard, and bring about great changes.

The first was in Iraq. There the Street, in valiant defiance to the threats of the “insurgents,” turned out and voted in the first free, democratic election in the Arab world.

The second was in Lebanon, when the Street finally stood up to Syria’s nearly-30-year occupation and demanded their freedom.

After years of warnings, the Arab Street is finally speaking — nay, shouting. And in contradiction to the predictions of the Left, it isn’t calling for Death to America, Death to Israel, Death to the Infidels, Death to the Invaders, Death to all those who oppose us.

It’s crying out for freedom.

See also this post about Lebanon and Egypt, and note that Syria’s puppet government in Lebanon resigned today, “a surprise decision greeted with jubilation by thousands of protesters in central Beirut gathering to demand the withdrawal of Syrian troops.”

Note also that anti-Syrian demonstrators in Beirut are waving the American flag. And no, they’re not burning it. This might be enough to drive Katha Pollit into the arms of Bashar Assad!

Marine convoy saved by little girl with teddy bear

Filed under: — Different River @ 2:39 pm

Unless you are of a rather extreme anti-American and/or anti-military frame of mind, it would not surprise you to hear stories of U.S. Marines handing out stuffed animals and protecting little girls in Iraq. However, occassionally the reverse it true.

Here is the story of how an Iraqi girl with a stuffed bear saved a convoy of Marines from being blown up by an land mine, as described by Gunnery Sgt. Mark Francis of the II Marine Expeditionary Force:

As you know, I asked for toys for the Iraqi children over here and several people (Americans that support us) sent them over by the box. On each patrol we take through the city, we take as many toys as will fit in our pockets and hand them out as we can. The kids take the toys and run to show them off as if they were worth a million bucks. We are as friendly as we can be to everyone we see, but especially so with the kids. Most of them don’t have any idea what is going on and are completely innocent in all of this.

On one such patrol, our lead security vehicle stopped in the middle of the street. This is not normal and is very unsafe, so the following vehicles began to inquire over the radio. The lead vehicle reported a little girl sitting in the road and said she just would not budge. The command vehicle told the lead to simply go around her and to be kind as they did. The street was wide enough to allow this maneuver and so they waved to her as they drove around.

As the vehicles went around her, I soon saw her sitting there and in her arms she was clutching a little bear that we had handed her a few patrols back. Feeling an immediate connection to the girl, I radioed that we were going to stop. The rest of the convoy paused and I got out the make sure she was OK. The little girl looked scared and concerned, but there was a warmth in her eyes toward me. As I knelt down to talk to her, she moved over and pointed to a mine in the road.

Immediately a cordon was set as the Marine convoy assumed a defensive posture around the site. The mine was destroyed in place.

Let’s recap: A little girl sat on a land mine to prevent U.S. Marines from driving over it and getting killed.

She was certainly risking her life to do so — even though anti-tank and anti-truck mines require something approximating the weight of a tank or truck, not a person, to be triggered, sitting in the middle of the road is not exactly a safe thing to do in any situation. She had to not only want to save the Americans, but trust that they would not run her over.

This is one girl who deserves a medal, and more. I hope she and her family are being protected from whoever set the mine.

Postscript: It is no surprise when bloggers report on stories and information from the mainstream press. In this case, the reverse is true. This story was originally reported on BlackFive.net and that blog was used as a source for a column in The Tennessean, the newspaper where Al Gore used to work.

Fun with balloons

Filed under: — Different River @ 2:17 pm

No comment possible or necessary … just click here, read the text, then click on the link to see the picture. ;-)

UPDATE (3/1/2005 7:50pm):

If you want to buy some of these click here.

Some people just don’t get it

Filed under: — Different River @ 2:13 pm

Newsweek is reporting — as if it’s news — that the Pope does not have a “living will.”

Gosh, pretty soon they’ll discover he doesn’t have a wife, either!

I find it rather hard to believe that any educated person (which I suppose might not include Newsweek headline-writers) would not know that the Pope’s pro-life ideology would not permit him to have a “living will,” unless it said something very different from what those documents normally say. A “living will” is, of course, one of those things that is the opposite of its name. It specifies circumstances under which one claims to want not to live. So it’s really an “anti-living will” or perhaps a “dying will.”

More Round-ups

Filed under: — Different River @ 12:05 pm

This week’s Grand Rounds, the weekly round-up of medical-related blogs is up, with a special restaurant-menu format. You gotta see it. Note especially the second item under “Beverages.”

Also, Instapundit manages to fit that plus four other round-ups into a single post:

And — since I seem to be linking a lot of these roundups today — don’t miss the shooters’ Carnival of Cordite, and the Jewish blog carnival and the new blog showcase carnival and the Asian blog roundup at Simon World.

I must point out that Simon has an absolutely stunning graphic at the top of his blog. Much better than I’ve got!

Also, don’t forget Carnival of the Liberated, the weekly round-up of Iraqi blogs (mostly in English), hosted at Dean’s World but written by our loyal reader Dave Schuler of The Glittering Eye.

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