American rage: We the People, and our legislative leaders, are out of control

On the floor of the U.S. House of Representatives, Rep. Randy Neugebauer (R-TX), angered by Rep. Bart Stupak’s (D-Mich) support of the health reform, called the bill a “baby-killer.” Protesters screamed racial epithets at Reps. John Lewis (D-GA) and Andre Carson (D-Ind) and yelled anti-gay slurs at Representative Barney Frank (D-Mass.) This comes not that long after Rep. Joe Wilson (R-SC) shouted “You lie!” at the President of the United States during a speech to Congress.

Just in case anyone is inclined toward civility, the Rush Limbaughs (“we must defeat these bastards”) and the Glenn Becks (only “losers” need help…) of the world are fanning every little flame around. The rants and rages are not limited to right-wingers, it’s just that those are the most prominent these days, what with congressmen standing on the balcony whipping up the crowd — while anti-anti-reformers shout their own epithets.

All this rage may not be healthy. A recent ‘Personal Journal’ piece in the Wall Street Journal explored the idea that anger is, in many cases, an illness unto itself.

Scream at the boss? Snap at a colleague? Throw your cell phone into your @#$%%&* computer monitor? If so, you may find yourself headed to anger-management classes, which have become an all-purpose antidote for fit-throwing celebrities, chair-throwing coaches, vandals, road ragers, delinquent teens, disruptive airline passengers, and obstreperous employees.

Demand for such programs is coming from courts seeking alternatives to jail sentences and companies hoping to avoid lawsuits and office blowups. Aware that high-pressure jobs can make for hot tempers, some professions offer pre-emptive anger management. A few state bar associations now require “civility” training for lawyers renewing their licenses. And as of last year, hospitals must have programs for “disruptive” physicians as a condition of accreditation.

Programs run the gamut from $300-an-hour private therapists to one-day intensive seminars, weekly group sessions or online courses with no human interaction. Many advertise that they satisfy court requirements—even if all they offer is six CDs and a certificate of completion.

It’s not clear if the programs work, as few studies have analyzed their effectiveness. There are no licensing requirements for anger-management trainers—anyone can open a business. And since participants don’t usually sign up voluntarily, trainers say it’s possible to complete a program without actually changing one’s behavior.

Part of the problem is that professionals can’t agree whether a pattern of angry outbursts signals a mental illness or simply a behavior issue. As a result, people who need psychiatric help may instead get shunted into a short-term anger-management course. Employers and courts may not adequately evaluate people before sending them for anger interventions, nor provide sufficient follow-up.

There have been some notable failures—the Columbine shooters, for example, attended anger-management classes before their 1999 killing spree. Amy Bishop, the University of Alabama biologist who allegedly killed three colleagues and wounded three more last month, had been advised by prosecutors to take anger-management classes after an earlier incident in 2002. Her lawyer says he doesn’t know if she did.

It is hardly the same, but the rage that exploded into these tragedies is still akin to the shouted obscenities of recent political scenes. Maybe all those shouters aren’t mentally ill, just badly behaved. Maybe they are protected by the First Amendment. Maybe the anger and ugliness is, as more than a few defenders maintain, perfectly excusable in response to “totalitarian tactics” or other perceived wrongs. But does that make it right? Or worth the loss of civility?

Maybe a little anger management — and civility — would be a good idea.

Demand for Anger -Management Grows. But Does It Work? – WSJ.com.

Health Policy: Is Altruism Dead?

Recently in this space the me-first word was brought up. (It does not abbreviate well.) Might as well say it out loud: health reform could surely be sunk by the Me-Firsters, those who would put personal desires above the greater good, whether those desires are for better pharmaceutical or insurance industry bottom lines or for some corner of personal coverage, senior or otherwise, that might be sacrificed in the future.

I am not above having those desires. My husband and I actually have a tiny bit of stock in a drug company thanks to some mergers and buyouts I do not pretend to understand (I also don’t mess with the family stock portfolio) and thus a decline could cost household income we can ill afford. Plus, I would hate having the excellent care I get from Kaiser (thank you, Medicare) curtailed and would be seriously bummed if suddenly stuck with paying 100% of my post-cancer meds. But if that, or something equally draconian, is what it will take to get health coverage for my currently-uninsured friends, I would like to go on record as supporting whatever we must do to get access for all. This is not noble, just minimally humane.

There are noble people out there, however. They sign up for Teach for America, they volunteer in nursing homes and day care centers and hospice programs, put in long hours at food banks or take to the streets in other, similarly un-chic endeavors.

Re the current health reform brouhaha, there are also noble people, or at the very least altruistic people, all over the country; you just don’t hear a lot about them. On August 19, for example, President Obama urged supporters of health reform to “speak facts and truth” in what he said was a “contest between hope and fear,” and tried once again to refute some of the misrepresentations still widely circulating. His comments were themselves fairly widely circulated. But unless you happened to run across them in this space you would not have known they were made to 140,000 members of faith communities and/or supporters of community-organizing nonprofits. The people of Sojourners, Faith in Action, PICO and other groups that put together the 40 Days for Health Reform conference call are not in it for personal gain; they happen to believe everyone in this country should have access to health care. The next day, Nancy Pelosi held a press conference reiterating her determination to keep a public option in the final health bill. But again, unless you happened to see it here you would not have known the event was sponsored by the San Francisco Interfaith Council with a lot of help from its friends in the San Francisco Organizing Project.

When the religious right goes on a tear against abortion or end-of-life choice (or for that matter, when the religious left goes head-to-head with its ideologically-opposed brothers and sisters) it makes news. When community organizers stage high-profile protests, the same thing happens. What does not make news is the enormous effort made by people of good will just to promote the common good — most recently, health reform.

Some opponents of Obama and his reform bills even have an altruistic bone or two. The reportedly calm, if badly misinformed, Bob Collier, featured in a front page New York Times article August 25, allowed that “we’ve got to do something about those people who can’t get insurance.” He qualified that later: “There has to be a safety net there. But I don’t want that safety net to catch too many people.” Somehow, Mr. Collier wants to separate out the “truly needy” from the “lazy and irresponsible people who play the system” and wouldn’t we all. The Times said that Mr. Collier gets his information from Fox News, Rush Limbaugh and Matt Drudge, none of whom I see as particularly altruistic. I would surely welcome him to True/Slant.

But the people cited above, people in faith communities (including many I disagree with and some I can’t pronounce), progressive nonprofits, community organizing groups and others just roaming the streets being kind, these people seek access to health care for everyone without worrying about who deserves it and who does not. A great many of them worked hard to put Obama in office, and are now working hard for health reform for no reason other than it is the right thing to do for someone else. Might be unrealistic but they keep at it.

My money is still on those people.

Counseling Improves Life's End. Surprise!

Knowledge, care and compassion really do bring peace. Why should this be a surprise? And why should a few strident opponents prevent those approaching life’s end from having this benefit?

A study appearing in today’s Journal of the American Medical Association points out the benefits of end-of-life counseling, although the widespread misinformation loose in the land may have doomed what should be a significant piece of health reform.

As a political uproar rages over end-of-life counseling, a new study finds offering such care to dying cancer patients improves their mood and quality of life.

The study of 322 patients in rural New Hampshire and Vermont also suggests the counseling didn’t discourage people from going to the hospital.

The Senate bill provision axed by Finance Committee chair Charles Grassley would have allowed coverage for conversations with physicians about things like hospice care, advance directives and treatment options.  But to opponents of reform, it was a handy attack mechanism. They enlisted a few standard bearers like former Alaska Gov. Sarah Palin and media darling Rush Limbaugh to twist the issue into menacing “death panels,” and in no time at all Sen. Grassley had his excuse to excise.

Losers in this are all of us. Eventually, 100% of us will die. Aggressive treatment and expensive, futile procedures are common today to that experience; compassion and peace are harder to come by.

In the new study, trained nurses did the counseling with patients and family caregivers using a model based on national guidelines. All the patients in the study had been diagnosed with terminal cancer. Half were assigned to receive usual care. The other half received usual care plus counseling about managing symptoms, communicating with health care providers and finding hospice care.

Patients who got the counseling scored higher on quality of life and mood measures than patients who did not.

Could someone please get this information to Sarah Palin?

Study: End-of-life advice aids terminally ill.

Ethical dilemmas for one and all

In case you don’t have enough medical/political/ethical dilemmas on your plate, William Saletan tossed out a hefty bunch, in last Sunday’s New York Times Book Review, to chew on:

The most powerful revolutions of our age aren’t happening in Washington, the Muslim world or the global economy. They’re happening in science and technology. At a pace our ancestors couldn’t have imagined, we’re decoding, replicating and transforming the human body. These revolutions are changing how we live, what we think and who we are.

Bodies used to be unalterably separate. Yours was yours; mine was mine. That isn’t true anymore. Organ transplantation has made human parts interchangeable. Thanks to aging and obesity, global demand for kidneys and liver tissue is increasing. Meanwhile, anti-rejection drugs and other innovations have turned more and more of us into potential donors. But supply isn’t keeping up with demand, so doctors, patients and governments are becoming more aggressive. Death is being declared more quickly so organs can be harvested. Rich people are buying kidneys from poor people. Governments are trying financial inducements to encourage donation. The latest proposals, outlined in Sally Satel’s “When Altruism Isn’t Enough: The Case for Compensating Kidney Donors” (2008), include tax credits, tuition vouchers and cash. As pressure grows from the left through socialized medicine, and from the right through free markets, organs will increasingly be treated either as a commodity or as a community resource.

The one that catches my eye (see Looking at One’s Own End-of-Life Choices, 7/30; Palliative Care: Rush Limbaugh vs the Grannies, 7/24, and a slew of other recent posts) is confronted in a reasonable, head-on fashion.

Beyond transplantation and mechanization looms the broader question of longevity. Over the last half-century, the age a 65-year-old American could expect to reach has increased by one year per decade. In 1960, it was 79. Today, it’s 84. Life expectancy at birth has passed 78 in the United States and 83 in Japan. We have no idea where these trends will end. It’s been just six years since we decoded the first human genome and less than two years since we learned how to make adult cells embryonic.

The cost of caring for old people will be enormous, but that’s just the beginning. We’re fixing and replacing worn-out body parts for older and older patients. How much life do we owe them?

The long-run solution, outlined by Robert N. Butler in “The Longevity Revolution” (2008), is to treat longer life as a resource, not just a goal. That means exploiting its benefits, like wisdom and equanimity, while focusing medicine and lifestyle changes on extending health and productivity rather than dragging out the last bedridden months.

It is well past time for us to stop looking at prolongation of life, regardless of quality, as the be-all-and-end-all of health care. Religious groups, right-wing factions and assorted others are screaming that even coverage of honest conversation with one’s physician about prognosis, treatment and options is going to shove people into early graves. But conversations of such sort, and civil discourse in general, are desperately needed.

OK, according to the above statistics this writer still has eight years before my projected demise; but I am definitely one of the grannies Mr. Limbaugh and his ilk profess to be protecting. Thanks very much; rather than drawn-out bed-ridden months I will take wisdom and equanimity any day, if our health care reformists will please focus on addressing health and productivity for all ages. Problem is, the voices of “protection” are drowning out the voices of reason. Which makes this not just a dilemma but a potential national tragedy.

Crossroads – You – The Updated Owner’s Manual – NYTimes.com.

Palliative Care: Rush Limbaugh vs the Grannies

The patient was in four-point restraint, which means his hands and feet were tied to the bed. He was shouting over and over, in Spanish, “Help me!” but no help came. Until Diane Meier happened upon the scene.

The back story, she learned, was that the man had end-stage cancer for which he had declined treatment. After he fell at home, his adult children had found him on the floor and called 911, landing him back in the hospital. There, among other interventions that were put into play, a feeding tube had been inserted through his nose. When he repeatedly pulled it out, his hands were tied. After he then pulled it out three times with his knees, his feet were tied. You could say these treatments were being performed over the patient’s not-quite-dead-body.

“Why,” Dr. Meier asked, “is it important to have the feeding tube?” The attending physicians answered, “Because if we don’t, he’ll die.”

It was at this point that Diane Meier, M.D., F.A.C.P., already honored for her work in geriatrics and for her personal and medical skills, became a crusader for palliative care. “A light bulb went off,” she told a group of physicians and other professionals in the field today in San Francisco. “I realized it was an educational problem, and thus a solvable problem.” She saw that the doctors and nurses were only doing as they had been taught, and the results were distressing also to many of them. “All I did was say ‘It’s all right to care about your patient.'”

Meier’s pioneering efforts to shift care of critically ill patients from aggressive, often futile treatment to comfort care focusing on the patient instead led to formation of the Center to Advance Palliative Care, which she currently serves as Director. They also resulted in a MacArthur Fellowship she was awarded in September, 2008.

“The MacArthur,” says the self-effacing physician, “was in recognition of the tens of thousands of people working in palliative care.” But those tens of thousands are not enough to have eliminated the tragedies of patients such as the unfortunate man cited above. Walk the halls of almost any hospital, nursing home or similar institution in the U.S. and you will hear the incessant “Help me!” cries of people being treated over their almost-dead bodies.

Helping them with comfort care rather than aggressive treatment, though, is referred to by the Rush Limbaughs of the world as “Killing off the grannies.” It is a handy sound bite, and it is tilting the balance against sanity in our lurch toward health reform. Unless Mr. Limbaugh can convince me I’d rather be 4-point-restrained with a tube inserted in my nose than gently treated with comfort care when I encounter my next critical illness, this particular grannie would appreciate his butting out of my rights. Palliative care should be a right.

It is, unfortunately, a campaign of the political right to keep palliative care out of health reform. They will prevail, Dr. Meier said, unless voices of sanity are raised, whether Democrat or Republican. She urged her audience, representative of a wide variety of compassionate groups, to help get the message out and get the calls, e-mails and letters in. Legislators behind the three bills working their way through Congress, she said, need to hear from the citizenry.

The citizenry is unquestionably in favor of comfort, and where palliative care can be understood it is welcomed. Hosting Dr. Meier’s informal talk were the California HealthCare Foundation, the California Coalition for Compassionate Care, Archstone Foundation and the University of California, San Francisco, four of many organizations committed to making palliative care understood, available and effective.

The question of whether they or Rush Limbaugh will prevail is as yet unanswered. Having Mr. Limbaugh forming our health policy, though, is almost as scary to this granny as 4-point restraint.