The Public Option Death Panel

Here’s a death panel even Sarah Palin could love — but maybe we’d better not tell her. You, however, will probably understand its value and possibly want to put it to work for your own benefit. It centers around a form called POLST, for Physician Order for Life Sustaining Treatment (in New York it’s MOLST, for Medical Orders) fast catching on across the country. The panel consists, essentially, of your doctor and yourself.

Initially developed in Oregon in 1991, POLST programs are underway in a handfull of states including Washington, California, New York and North Carolina, and are being developed in over a dozen others.

Erin Henke, POLST Program Manager for the California Coalition for Compassionate Care, outlined the program for a group of healthcare professionals this week in San Francisco, part of CCCC’s efforts to get it efficiently established across the state. The key, she emphasized, is the conversation between individual patient and medical professionals. You don’t get the form signed, in other words, unless and until patient and physician have discussed what the former wants: CPR if you’re not breathing? Feeding tube? Comfort care only, if you’re in bad shape, but you’ve got a pulse and are breathing? Or perhaps every intervention possible — tubes, wires, ventilators, the works, including transfer to a hospital intensive care unit. But the point is, you make your own decisions. Once the form is completed and signed, it follows you as part of your medical record. In California it’s printed on Pulsar Pink card stock, and not easy to overlook.

Rollout of the program, Henke explained, is an ongoing process; it will only work when it is widely known and understood not only by individual patients and physicians but also by the many other members of the profession — nurses, caregivers, ER personnel and others. CCCC’s focus right now is on skilled nursing facilities and hospitals, though Henke and the teams of POLST program advocates around the state are working toward a broad educational spectrum.

The basic POLST approach, as explained in a Journal of Palliative Medicine article by Diane E. Meier, M.D. and health care journalist Larry Beresford published earlier this year, is to provide “actionable information on how to honor the wishes of a patient with a life-threatening condition” on a variety of issues. It goes farther than an Advance Directive (though if there’s a discrepancy, the Advance Directive takes precedence) and it differs from an out-of-hospital DNR (Do Not Resusitate) form because it lets you choose treatment.

I asked Henke if the patient/doctor conversation which is necessary in order for this extraordinarily useful document to be completed is covered by most insurance companies. She says that to her knowledge there is no specific code for such a conversation, although she understands there are other codes under which physicians can bill. Let’s hope Betsy McCaughey and Sarah Palin don’t find out. Or Chuck Grassley.

Though I am only terminal just now in the same sense that all of us mortals are, I talked about the POLST form with my Kaiser primary care physician just to be sure we remain on the same page. Wouldn’t it be nice if everyone had that same opportunity.

Pelosi Sticks With Public Option

Speaker Nancy Pelosi at a gathering of interfaith leaders in San Francisco today (Justin Sullivan/Getty)

Speaker Nancy Pelosi at a gathering of interfaith leaders in San Francisco today (Justin Sullivan/Getty)

House Speaker Nancy Pelosi held a press conference in San Francisco this morning at which she reiterated her commitment to a public option in the health reform bill and expressed hope, though with somewhat  lowered optimism, for coverage of end-of-life conversations. She did get in a dig at opponents of the latter: In response to a question about whether voluntary reimbursement for discussion of end-of-life care would stay in the bill, Pelosi said, “You know, the language is almost exactly the same as what the Republicans put into the prescription drug bill.”

The press conference, hosted by the San Francisco Interfaith Council, was an apparent reinforcement of the Democrats’ strategy of  broadening health reform support among members of religious communities. With leaders from the San Francisco Bay Area Christian, Muslim and Jewish communities arrayed behind her, the Speaker made repeated references to health care for all being a moral issue. Responding to the above question, she said, “People of faith, people in healthcare” and others know that “it makes life better if a person has expressed his or her own wishes. The key to this is that it is voluntary; it serves the purpose of saying what is your wish, rather than someone else having to make a decision you might not want. I don’t know what will happen (to the provision); I surely hope it will stay in.”

Pelosi was unequivocal, however, in her response to questions about the public option and to one reporter’s comment that “some Democrats and liberals are frustrated because it seems you are caving in to the far right.” “Is that you?” she repeated, pointing to herself. “The public option is the best way to go. If anybody can come up with a better alternative we’ll consider it. But the President is not backing off. The co-op might work in some states and that’s fine.  There is no way I can pass a bill on health reform without the public option.”

Pelosi was equally emphatic about her intention to retain the 400% of poverty measurement. Hesitantly using the term “seniors,” she said that many people between the ages of 50 and 65 have lost jobs, or may be making just $30,000 to $40,000 per year, and cannot afford needed medical care or prescription drugs. “I believe we have to have the 400% of poverty for them.”

Would the Democrats accept a scaled-down version of health reform? Pelosi repeated her litany of what is needed: reduced costs, improved quality, expanded coverage, affordable care for all; “What are you going to give up? At the end of the day, this is what we must have. And we must have reform of the insurance industry.”

In the small, carefully selected audience assembled at St. James Episcopal Church where her children attended preschool, Pelosi was on her own turf and among friends.  And she was characteristically upbeat. “Have we lost control of the debate? I disagree. I have 218 votes, and expect to have more. I am optimistic, and the President is committed to change.”