| Today's Feature AARP Applauds
Senate for Moving Health Care Reform Forward.
AARP sent a letter to each
Senate office informing them that the Association
designated cloture vote on the manager’s
amendment to the Patient Protection and
Affordable Care Act an "AARP Key Vote."
AARP will report back to its members and the
public how each Senator votes on the procedural
measure that would allow the Senate to end debate
and move towards a final up-or-down vote on the
bill.
Voted yes: McCaskill, Claire
Voted no: Bond, Christopher
"Kit"
"AARP commends Senator
McCaskill for voting to move forward on health
care reform to protect guaranteed Medicare
benefits and help millions of older Americans
overcome the challenges of accessing affordable,
quality health services," said Craig
Eichelman. "The legislation is needed to
lower drug costs, provide relief by beginning to
limit age discrimination by health insurance
companies and strengthen our system of long-term
services and supports. We believe this
legislation can be improved even further in
conference and will be working with our state
delegation to make meaningful health care reform
a reality."
"It’s unfortunate
that an issue as important as health care reform
is subject to political delay," said
Eichelman. "We’re disappointed that
Senator Bond voted to block action on this
important bill."
AARP notified the 111th
Congress that it was tracking roll call votes on
key legislation important to its nearly 40
million members and reporting the outcomes of
these votes back to its members and all older
Americans. "When Americans understand the
issues and where their lawmakers stand, they can
make smart decisions," Eichelman concluded.
Rationing
Medical Care: Health Officials Struggle With
Setting Standards
by Sheri
Fink, ProPublica
This flu season, health
officials across the country have been grappling
with one of the most difficult questions
imaginable: which patients should be given access
to lifesaving treatments if the number in need
during a severe pandemic far exceeds the ability
of the medical system to cope?
Part of the impetus for this
worst-case planning came out of the confusion
that reigned in New Orleans hospitals after
Hurricane Katrina in 2005. Medical evacuation
helicopters were in short supply and doctors
struggled with how to prioritize—or
triage—patients. Some died, and lawsuits
followed.
While Louisiana later passed
three laws aimed at protecting health workers
from prosecution for their actions "in
accordance with disaster medicine protocol,"
the state, like many others, has not yet defined
what that protocol should be, particularly in the
case of a severe flu pandemic.
"It’s an exceedingly
ugly topic altogether," said Dr. Stephen
Brierre, an intensive care unit physician with
Louisiana State University Health Sciences
Center. He began chairing an effort to develop
such a protocol last spring in Baton Rouge after
the emergence of H1N1 "swine" flu.
Normally, Brierre works to save
the lives of each of his critically ill patients.
However, he believes a different standard, a
"crisis standard," would apply in a
dire situation where critical shortages of
doctors, nurses, medicines, supplies, and life
support machines like ventilators emerge. That
has not occurred in the U.S. during the first two
waves of the H1N1 flu pandemic, and remains
unlikely, but it could be the case during
another, future pandemic, a bioterrorist attack
or natural disaster. According to Brierre, the
plan he is helping to craft will be a significant
modification of a controversial plan drafted by
Utah officials. Utah’s pandemic triage
guidelines set out categories of
patients—including those with end stage
heart failure, incurable cancer and the
elderly—who would be denied hospital and
intensive care unit admittance during a severe
pandemic. The Utah plan also anticipates removing
certain patients from life support regardless of
their or their families’ permission to make
way for others who are expected to have a better
chance of survival. "It’s almost the
antithesis of what I do for a living,"
Brierre said.
He is concerned that
Louisiana’s draft plan, which was developed
by around two dozen hospital leaders, health
professionals and ethicists and is being refined
with input from public health officials around
the state, will be misunderstood when wider
numbers of Louisianans become aware of it. At
recent presentations to public health leaders,
Brierre flashed a ProPublica article on the
screen that revealed details of a similar draft
influenza triage plan from Florida. As in many
states, Florida officials had not made their
planning process open to the public. The
plan’s publication took residents by
surprise and stirred controversy, including
heated discussions on the internet and talk
radio, and blog posts with incendiary headlines:
"Throw Granny off the Respirator!"
Brierre challenged his
colleagues to think about ways they might inform
the public about their plan, encourage
constructive comment and, ultimately, achieve
something approaching consensus on an equitable
plan. "Everybody was kind of befuddled on
that," he said. "We are struggling with
it."
Brierre says there are no
"right decisions" about how to allocate
care in extreme disasters, but planning in
advance of a crisis will help doctors make better
decisions. "If they have to do it in real
time, there will be no justice." But
questions of government involvement in
end-of-life planning and medical rationing have
provoked shouting matches during Congress’s
development of health reform legislation. The
pandemic triage plans typically call for a
committee to decide, using guidelines and medical
expertise, which patients get life-saving care
and which do not. "Gee that sounds like a
‘death squad’ to me, maybe," said
Knox Andress, an emergency preparedness director
at Louisiana State University in Shreveport.
"There’s a big potential public
perception issue."
Some have questioned whether it
is even possible to engage Americans on the
subject. "The level of public discussion is
so poor in the U.S.," said Norman Daniels,
an ethics professor at the Harvard School of
Public Health. "The partisan attacks of the
health reform debate have set back the public
discussion of resource allocation in a very
serious way by putting things in terms of
‘death panels’ or ‘it’s
un-American to limit resources,’ as if
American insurers don’t do that all the
time."
Daniels serves on an advisory
committee to the Centers for Disease Control and
Prevention that recently approved ethical
guidance for states developing plans that would
alter standards of care during pandemics. The
committee wrote that when it comes to questions
like withdrawing life support from some patients
in an effort to maximize benefit to the
population, government and hospital policy should
be transparent and "formed with input from
the public."
At its core, such policy is
based on judgments about what the goals of triage
should be—whether maximizing lives saved,
years of lives saved, quality of life, fairness,
social trust, or other factors. The larger
community may emerge with different values from
those held by small groups of medical
professionals. In the city of Seattle and the
rest of King County in Washington State,
"Many people felt withdrawal of care was
unacceptable if the individual’s life was at
stake," according to a report of a rare
public engagement exercise on pandemic influenza
standards of care. The report cited
participants’ "aversion to creating a
system where medical professionals were
withdrawing life-saving services which would
erode trust in the system."
The Seattle exercise was funded
by the U.S. Centers for Disease Control and
Prevention, which recently gave grants to six
state and local health departments to engage the
public on controversial issues in responding to
pandemic influenza. Two, including Seattle, used
their grants to tackle rationing and resource
allocation with groups recruited from the general
public, according to Roger Bernier, a senior
advisor at the CDC.
Bernier said it is both
possible and necessary to engage the wider
community of non-experts in these discussions.
"They are the holders of our public values
and are in the best position and in the most non
partisan position to weigh competing values and
make tradeoffs to determine in a particular
circumstance which of the values are going to be
paramount."
However this type of engagement
is rarely sought. "I’m not sure we
believe in democracy in America," Bernier
said. "We don’t make good use of the
people. We don’t make good efforts to access
public wisdom on public policy choices."
Organizers in Seattle said
their effort was worthwhile. "We got some
very meaningful feedback," said Meredith
Li-Vollmer, a risk communication specialist with
the public health department in Seattle and King
County.
The county convened one forum
for experts and individuals with a "vested
interest" in altered standards of care, such
as advocates for the elderly and disabled. Three
other groups, including one conducted in Spanish,
were recruited from members of the general
public. Some important differences emerged.
"What they wanted in terms of decision
making in disasters was very similar in many
ways," Li-Vollmer said. "The way they
thought about equity issues was a little
different."
Members of the public at large
were concerned that using survival statistics to
determine access to resources might be
"inherently discriminatory," the
project report said, "because of
institutional racism in the health care system;
if some groups (e.g., African Americans and
immigrants) do not receive the same quality of
care, then their rates of recovery and other
survivability measures would be biased."
Participants supported treating
as many people as possible even if that meant
compromising the normal standard of medical care,
and they wanted a fair and widely accessible
prioritization system. They said that saving the
greatest number of people should drive medical
decisions, with some priority given to health
care providers and others contributing to the
disaster response, and, to a lesser degree when
all other factors are equal, children and
pregnant women. Ability to pay was ranked among
the least important considerations. "They
really did deliberate in a very thoughtful
way," said Li-Vollmer. "They listened
to each other."
Another CDC-funded public
engagement project initiated by the Minnesota
Department of Health included both a state-wide
media campaign and day-long gatherings of large
and small groups conducted at nine sites
including a depressed mining and lumber area, a
farming community, a wealthy suburban
neighborhood, a center serving people with
disabilities, a Native American reservation and
an area adjacent to the Red River that had been
devastated by flooding. "Our small groups
were winding down at the same time we were having
these extraordinarily rancorous conversations
about national healthcare reform breaking down in
anger and vitriol," said J. Eline Garrett,
an assistant director at the Minnesota Center for
Health Care Ethics in St. Paul, which facilitated
the groups with the Center for Bioethics at the
University of Minnesota in Minneapolis. "I
was truly, truly impressed with the manner with
which people were willing to hear different
opinions, disagree, convince each other. It was
democracy in action and it worked, it really
did."
Garrett said participants
agreed that the goals for medical rationing in
disasters should include protecting public health
and critical infrastructure and striving for
fairness. The groups supported randomly
distributing resources in cases where doctors
could not predict which people were more at risk.
Most participants said age could be used as a
factor in deciding which patients get treatment
when all other factors are equal, with lower
priority for older individuals. However some
participants strongly opposed age-based
rationing.
The extent to which the
public’s views will be used by health
departments to inform policy is still unclear.
According to Garrett, findings from the public
engagement project have
"cross-pollinated" an expert group
developing clinical guidelines for triage in
disasters in Minnesota. She said knowing that the
public placed a high value on fairness and
non-discrimination in resource allocation during
a pandemic helped state officials shape the H1N1
response. That included the establishment of a
toll-free number aimed at ensuring that all
Minnesotans, including those without health
insurance, could access potentially life-saving
anti-viral medicines.
In Louisiana, public health
officials are developing a plan to reveal their
draft crisis standards of care to the public,
including outreach to the media and a version
written in layman’s terms for community
members who want more information. While they
worry about the reaction, they also see potential
benefits. "As physicians, when we’re
afraid to share, I think we’re leaving the
burden on ourselves," said Dr. Jimmy Guidry,
Louisiana’s state health officer. Broadening
the discussion of goals and values is a way of
dividing responsibility for some of the toughest
decisions in medicine.
|
