Tag: San Francisco

General interest
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The Public Option Death Panel

by Fran Johns

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.

General interest/Health/Money/Politics & Causes/USA
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Pelosi Reaffirms Public Option, Insurance Reform; Healthcare "A Moral Imperative"

by Fran Johns

House Speaker Nancy Pelosi, addressing a Chamber of Commerce-sponsored Health Summit in San Francisco this morning about Obama’s health reform, stressed elements of the three House bills that might seem palatable to her audience: cost containment, IT design and integration with existing systems to create universal access to care. But she did not back down on a few other consistent statements such as the assertion that no bill will pass the House without a public option.

“We will invest in medical research and technology,” Pelosi said; and will incorporate elements such as electronic medical records for individuals to speed care.

It was clear there were mixed levels of support for reform in her audience. California Pacific Medical Center CEO Warren Browner MD, MPH drew muted chuckles and no boos with a throw-away comment that President Obama had “spent more time on choosing a dog” than on crafting a health policy. CPMC, a Sutter Health Affiliate, was presenting sponsor of the event.

Speaker Pelosi, though, hammered away at the primary intentions of reform: “improve quality, expand coverage and contain costs” while providing universal access to quality healthcare. “We will,” she said, focus on “quality, not quantity; wellness of the person not utilization (of facilities and technologies); value, not volume; and a commitment to prevention and wellness.”

San Francisco Mayor Gavin Newsom addressed the gathering earlier, touting the success of his “Healthy San Francisco” universal coverage program now in its second year. An independent Kaiser Family Foundation poll recently showed Healthy San Francisco to have a 94% approval record, prompting City/County Department of Public Health Director Mitch Katz, MD to ask when any program of any sort had ever gotten a 94% approval record. Citing the need for protection of such elements as in-home services in an aging population, Newsom said the program’s success was attributable largely to partnerships with local hospitals, clinics and medical facilities (CPMC is one), specifically singling out Kaiser Permanente, which signed on in July. The program does not offer a national model, Newsom said, but has many elements a national plan could adopt. Healthy San Francisco includes things that might not get into a national bill but are favorites with wellness proponents: community organic gardens, city-funded salad bars in schools and an ad featuring a soda-equipped young boy admitting to “a drinking problem.” Another key to the program’s success, Newsom said, is its ultra-simple one-page enrollment form.

Pelosi insisted that the final bill will include “insurance reform: no refusal based on pre-existing conditions, no co-pay for prevention, no cut-offs.”

And the major themes were reiterated: “As President Obama has said, universal healthcare is a moral imperative,” she said; “we are the only country in the developed world without it. I say to those who would have us do a little bit, and another little bit, and another little bit — Lyndon Johnson settled for half a loaf; this is the other half of the loaf.”

General interest/Health/Money/Politics & Causes/USA
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Health Policy: Is Altruism Dead?

by Fran Johns

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.

General interest
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Public Option Dead? Barbara Lee Says No

by Fran Johns

You think the public option for health coverage is dead? Try telling that to Congresswoman Barbara Lee. Never known for going along (she was the lone member of Congress to vote against giving President Bush a virtual blank check to go to war after 9/11) or for mincing words, she wants it known that no health reform battle — other than that for single-payer — is over.

“It’s all about give and take,” she said tonight; “we gave single payer.”

The Representative from California’s 9th District was at San Francisco’s Commonwealth Club to talk about her new book, Renegade for Peace and Justice.  But the conversation with KQED TV host Belva Davis and the Q&A session with a largely friendly audience tilted immediately, and  heavily, toward health reform. Has the Administration lost control of the debate? Not in Lee’s opinion. “Mainstream media coverage has been very biased,” she observed in opening the Q&A session. “The focus has been on the ruckus made by a small percentage of people, who probably didn’t vote for President Obama. I didn’t see CNN covering my Town Hall meeting.”

Because “we spent over a trillion dollars on this war that didn’t have to be fought,” Lee said, the issue of health reform is now “all about choice, and about competition.” And before either of those get to the public, congressional give-and-take will lead to a final bill. As current Chairwoman of the Congressional Black Caucus and member of several powerful committees, Lee expects to play an active part in that process. “We will insist on a bill that has a strong public option,” she says. “At least 60 members are saying the public option is key to their support.”

The new book was enjoying brisk sales, but health reform comments drew the loudest applause. One audience member told me at the end of the event that “Congresswoman Lee won’t ever get medals for moderation, but I’m not throwing in the towel if she’s not.” We were both leaving a few minutes before the final gavel; he said he was on his way home to start sending out more e-mails.

General interest
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A Story of AIDS & Living Well

by Fran Johns

As he lay dying of AIDS, my friend Michael gazed over my head in the general direction of the bathroom, managed an almost-chuckle and said, “Nahh, not yet.” This was in 1995, on a foggy gray day in San Francisco, before the discovery of protease inhibitors that would alter the course of the disease. Michael and I had sat together at a dozen similar bedsides as members of the same AIDS support group, but he knew the scene far better than I.

Michael’s sister was due in from the east coast that day. In the bathroom medicine chest were the drugs he knew could end his life in hours rather than in the days or weeks he might have left. Michael’s body had grown frail, but his mind and spirit still soared.

AIDS is a terrible way to die. So are any number of other debilitating illnesses. But many of us believe that honest discussion of prognosis, possible treatments and options are not just empowering, but sane. There is a lot of insanity loose in the land.

A study to be published in the August 15 issue of the American Journal of Respiratory and Critical Care Medicine suggests that many surrogate decision-makers actually don’t want doctors to tell them about options and potential outcomes. I say, OK, fine; don’t ask.

But for someone critically ill who wants to know, why shouldn’t physicians be allowed to tell the truth? How likely am I to regain any quality of life? While my bad cells are being destroyed, what other destruction will happen? What if I choose no treatment at all?

Throughout decades of volunteer work with hospice, AIDS and most recently Compassion and Choices (counsel and support for terminally ill, mentally competent adults) 99% of the critically ill adults I have encountered have gained both power and peace from knowing their choices. They could tell you: it is not about death, it’s about living. Dying is going to happen. Living well takes effort.

In the 1990s almost everyone I knew who had AIDS also had a stash of drugs that could bring his life to a swift end. Very few of them used those drugs. Check the Oregon statistics: far more people request life-ending drugs than ever actually use them.

It’s about safety valves. It’s about  personal choice. It’s about control of one’s own life. It’s about living well.

For anyone to oppose the piece of our complicated health reform that provides coverage for critically ill (and other) individuals to gain understanding of their conditions is irrational and unreasonable. If those opponents choose to keep their heads in the sand that’s fine with me; but why deny the rest of us the right to reason?

Michael died that night, without opening the medicine chest. He could have told you he’d had enough. He would have told you that knowing the means to end his suffering was available had given him great strength and a degree of peace for over a year. He would have told you that straight talk from his physician (who also died of AIDS a few years later) empowered and emboldened him in a remarkable battle for life.

It was never about dying; it was about living well.

Health/USA
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Beavers in Manhattan, Mink in California

by Fran Johns
Mink
Image via Wikipedia

Maybe beavers have little in common with Boomers, or Beyonders, but after reading T/S Contributor Caitlin Kelley’s Canada/NY beaver piece just now I felt compelled to respond with today’s news of California urban mink. Their newly discovered presence was documented by the San Francisco Chronicle’s Carolyn Jones:

First, there were beavers. Then otters and muskrats.

And now – as if the Martinez Public Works Department needed more cute, furry mammals paddling around Alhambra Creek – there are mink.

Ten months after the city spent $500,000 to shore up the eroding creek bank, a condition many blamed on the beavers and their obsessive handiwork, a mother mink and four babies were spotted this week cavorting near the beaver’s primary dam, just north of the Escobar Street bridge in downtown Martinez.

The silky, razor-toothed critters have apparently taken up residence in the pond created by the beavers’ dam, along with a variety of other aquatic wildlife.

But then again, maybe there IS some relevance. Recent posts re health and housing, which seem to be atop the news for over-50 generations if not everyone else too these days, have had friends asking if there isn’t something ELSE to write about? Well, yes. Exercise and fitness. The absolute best of which is snagging a half hour or two and heading out to circle the Central Park reservoir or roam around Golden Gate Park, or wherever your city walking place of choice happens to be. Mine is 16th Street, San Francisco, start at the Bay, end at Market (or continue whatever direction from there) and you’ll encounter every ethnic/social/business/industry/arts category you could want and the views aren’t bad at the tops of the hills. But back to the mink:

Mink are native to the area but are highly unusual. They’re more often spotted in the delta or the Sierra Nevada, but their population could be rising because of the decreasing popularity of mink coats, Bell said.

Maureen Flannery, collections manager for the ornithology and mammalogy department at the California Academy of Sciences, also confirmed that the animals in question are Neovison vison, a.k.a. American mink.

The babies probably were born in April or May and will stay with their mother until fall, when they will head out to claim their own territories, she said.

I’ve also had questions about food-and-nutrition writing, this being another biggie for over-50s (under-50s are either already sold on healthy lifestyles or eating pizza and sushi and fries and just not giving a damn about calories and cholesterol.) And fine dining also enters this late-breaking news:

Dan Murphy, owner of Bertola’s restaurant adjacent to the beavers’ dam, was also taking a wait-and-see attitude. Liability concerns over the restaurant’s weakening foundation were one reason the city decided to shore up the creek bank last fall.

“I don’t really care,” Murphy said. “Although I guess the creek’s becoming more and more of a habitat, which is pretty cool.”

Martinez vice mayor Mike Menesini, proclaiming his “a very welcoming city” is waiting to see how this newly-mixed community gets along.

So far, the mink, beavers, muskrats, otters and turtles have adopted an attitude of mutual indifference. The crayfish aren’t so lucky – they’re often dinner for their carnivorous creek-mates.

The Beaver Fest in downtown Martinez today features bagpipes, bluegrass and jazz bands. Dancing in the streets is good exercise too.

General interest/Health/Money/Politics & Causes
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Palliative Care: Rush Limbaugh vs the Grannies

by Fran Johns

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.

General interest
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Grassroots Healthcare Reform

by Fran Johns

If we get a health reform bill, it may be thanks in part to a push from the ground up. That belief is leading to a variety of grassroots support endeavors.

At a hospital-sponsored town hall meeting on the issue this week in San Francisco attendees were invited to take the microphone to tell their stories. Probably a bad idea at any meeting, since such an invitation guarantees off-point rambles and rages and this one certainly proved the point — but there were enough horror stories to assure everyone that our current non-system is a train wreck.

A cardboard cut-out of President Obama stood at the back of the room (there was a lot of photo-op going on before things got started) and the promise was that videos of the stories would go straight to Washington to help speed passage of the hoped-for health reform bill.

Participants told of needed care that couldn’t be found, needed drugs that couldn’t be bought and the widespread suffering of the un- or under-insured. A panel of local experts presented aspects of the hoped-for national plan and spoke of San Francisco’s own moderately successful effort to provide health coverage for all.

Speakers were asked to keep their remarks to under three minutes, another dictum doomed to failure, and a few did. My own plea (one minute, forty seconds) was for inclusion of some guarantee/protection of individual choice at the end of life. It stemmed from working for many years (as I still do) with terminally ill adults who seek options including hastening their dying. It was tempered in deference to the hosts, since St. Francis is a member of Catholic Healthcare West and the opposition of the Catholic Church was largely responsible for defeat of a widely popular physician aid-in-dying bill that narrowly failed in California two years ago. And the likelihood of such a controversial issue getting into the massively complex bill we may or may not get is somewhere between slim and none, but what the heck. With Mr. Obama standing there, I couldn’t resist.

At similar gatherings around the country, I suspect the message and the messengers are much the same. Health reform is a national need that translates in millions of heartbreaking individual stories.

My personal favorite message came from panel member Catherine Dodd, PhD, RN, District Chief of Staff for Nancy Pelosi in her pre-Speaker days. Dodd explained the current three-fold status (two in the Senate and one in the House) of the healthcare bill and defended its  probable cost. Then she threw out one new number: 19.7. After everyone had let 19.7 sink in, she told us that is the number of years it has taken this country, every time a health reform bill has been floated, to bring it up again. “We can’t afford another 19.7 years,” she said. I think she’s right.

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