Doctor David Fisher's Blog

has been moved to the following new address

Sorry for inconvenience...

David Fisher, MD, MPH: My "conversation" with Rush Limbaugh

House Calls Radio

House Calls Radio
Sundays at 10pm AM 560 WIND in Chicago

Thursday, July 30, 2009

My "conversation" with Rush Limbaugh

Today while driving between nursing homes, I heard Rush Limbaugh talking about the health care reform bill's Advance Care Planning Consultation section. He, like some other conservative talkers, was complaining that the government was mandating these consultations as a way to usher patients towards an early death in order to save money. In my previous post I explained why this was an unfair characterization of Section 1233, and that it makes sense to reimburse doctors for the time they spend talking with patients and families about their health care wishes. I decided to call in, and I actually got through. "Dave in Chicago, you're next.." Rush said.

I explained that I was a physician, and that there are many aspects of the current health care reform bill that I disagree with, but that this provision was actually a good idea. I said that I often take extra time to ask my patients about choosing their power of attorney and about their end-of-life care wishes, and that it was smart of Medicare to encourage these conversations by providing a small reimbursement to doctors who initiate such discussions, since the current structure requires doctors to essentially offer this service for free. I started to explain that the bill actually does not mandate these conversations between doctors and patients, nor does it mandate their content. Then I realized that Rush was talking and my voice was turned off. He once again incorrectly insisted that the bill will mandate a consultation promoting "death care," a term he claimed I had used. He said that I was welcome to have those conversations with my patients, but that anyone who had a doctor like Dave in Chicago who insisted on talking about "death care" should find a new doctor. I tried to protest but quickly realized that my voice was turned off and that our "conversation" was over.

Rush Limbaugh's reaction to my call was a stark reminder that many people completely misunderstand palliative medicine and end-of-life care. While he railed on about doctors being mandated to discuss death with their patients, I could sense an underlying fear, perhaps about his own mortality. Death is inevitable, and one of the greatest gifts I can give my patients is to help them look ahead to possible scenarios and to express their thoughts and wishes about their medical care while they are still able. Those of us who practice this skill do not attempt to usher our patients toward an early death for the sake of utilizing fewer health care dollars. All too often I have watched patients and families undergo painful and invasive treatments which are unlikely to extend life or provide any healing, simply because they felt they were obligated to submit to such treatments. No doctor had ever laid out the real picture, that their prognosis was poor and their choices were limited by their disease. They needed to hear that their realistic options had shifted away from the best course for avoiding death to the best way to maximize the quality of life remaining. They needed to know that there was another path, and they probably needed to hear that from a doctor. Many doctors avoid these conversations because they are uncomfortable or awkward. Doctors who talk about death with their patients are brave.

I do understand the fear that more government-sponsored health care will lead to rationing and could result in seniors being denied services simply because of their age. That is a real concern. It is a reason I am not in favor of more government involvement in health care. However, please do not make the same mistake Rush Limbaugh made today and equate coversations about end-of-life care with promoting "death care." Expressing your wishes to your doctor, and asking about options if and when you become ill, serves to promote patient choice and control, not take away from it. I still think government-run health care is a bad idea, but as long as Medicare pays for most seniors' health care, I think it is admirable that they are looking at ways to make it easier for doctors to assist their patients with advance care planning.


judygold said...

Dr. Fisher,
Thanks for trying to talk some sense into Rush, even though he chose not to listen. My son told me about a similar rant when Ann Coulter filled in for Bill O'Reilly several weeks ago. I tried to contact Fox News to get a transcript of the show, so I could find out exactly what was said, but have been unsuccessful so far. Those of us in hospice or palliative care need to just keep getting the word out and trying to correct misconceptions. Keep up the good work.


rmw said...

Printing this and taking it to doctor's offices today. Keep up the good work.

Steve Smith said...

Bravo, Dr. Fisher! What you attempted to articulate on the radio and have eloquently said in your blog in absolutely on-target. Thank you for advocating and educating others on behalf of hospice and palliative medicine physicians -- online and in the media.

Steve Smith
Executive Director, CEO
American Academy of Hospice and Palliaitve Medicine
Glenview, IL

Vince Morris said...

Good stuff, David. Keep it up.

Anonymous said...

Hi Dave,

I remain extremely wary of the "end of life conversation" clause in the new health care legislation. While the paper may state that end of life conversations will be optional, I feel that this is only a thin edge of a very thick wedge. Obama has been quoted stating that it is the older generation that is sapping medicare, and that "tough decisions" need to be made. One also has only to observe the global culture of death/assisted suicide (now practically mainstream in Europe) to wonder just how soon it will become mainstream here in the US. I am grateful for your explanation that our government is not currently pushing suicide coaching, I do think it's only a matter of time before it will mandate assisted suicide coaching. Of course doctors should be paid for time spent counceling patients, but what may happen in the future needs to be discussed in explicit terms. I would feel comfortable with wording that guarentees at no time will assisted suicide become a part of the tax payer subsidised government health plan; even for those who may request it.

Okakura said...
This comment has been removed by the author.
Okakura said...

Anonymous: Physician-assisted suicide is an legislative issue that states decide, not the federal government. It is currently only legal in 2 states and has been outlawed in dozens of others.

As for your slippery slope fears, PAS has been legal in Oregon for nearly 12 years and the number of individuals who have availed themselves of this option has remained remarkably consistent throughout: approx 36 per year. Know also that these individuals were diagnosed with an end-stage terminal illness and sought outphysician guidance and permission; not non-terminally ill elderly people being proactively "counseled" to off themselves by cost-cutting docs. No groundswell of death-seeking emigrants moving to Portland to die. There has been, I believe, an increased utilization of hospice services state-wide. I have no data on whether elderly suicide rates have fallen or not, although that would be interesting to know.

While I respect your opinion, I think it is important to base fears on facts, not assumptions. America is not Holland, nor does Holland exemplify standard end-of-life pratices through the rest of Europe.

David Fisher, MD, MPH said...

I appreciate your concerns about physician-assisted suicide (PAS). I share your concerns. I am against legalized PAS for a variety of reasons. We should not allow the intentional killing of patients, whether or not they have a terminal illness. There is a big difference between giving increasing doses of morphine for the primary purpose of treating pain at the end-of-life, and giving a prescription for a lethal dose of phenobarbitol for the express purpose of ending a patient's life. I could say a lot more about it but suffice it to say that PAS goes against medical ethics that have been held for thousands of years and upon which the patient-physician covenant is based.

Therefore, I am concerned that mandated counseling would force doctors to offer PAS even if they don't believe in it. A "right to know" law was passed in CA that requires doctors to explain the "full range" of end-of-life options to patients with a terminal illness (defined as death likely within one year). For now that includes things like hospice and palliative care, which I support, but if PAS were legalized in CA, doctors would also have to offer this to patients even if they know that their patient would not want it or if they would not agree to perfom it. This would undermine the patient-doctor relationship significantly.

As the current provision 1233 reads, the content of the consultation is not mandated and therefore I do not share the concern that this provision would start a slippery slope, in its current form.