I am a doctor and I agree end of life care gobbles up more health care dollars than any other health care issue and I also agree callous doctors enrich themselves at the end of patients' lives. But what is the solution when superstitions and myths abound about end of life decisions? We also live in a country where new immigrants, people who don't speak fluent English, African Americans, the elderly and the poor are suspicious of the entire health care system and the government. Do not forget the shame of Tuskegee or the recurrent attacks of hepatitis C when doctors or other health care workers did not follow proper sterilization procedures. Do not also forget the abuse of the elderly in nursing homes or the outright killing of the extremely ill by misguided health care workers who think their patients need to be put out of their misery and pick homicide to consummate this "kindness". Patients are also agitated about what they perceive as an eagerness among overworked health care workers to shunt them into "do not resuscitate orders" and bear deep in their hearts a suspicion that they are merely numbers, that an unethical health system may want to gorge on their organs and declare them dead prematurely for the happy harvest when there is nobody to advocate for them. Many of the elderly are debilitated, confused and depressed. They are asked to make living wills and specify exactly what they want: food when they are dying, antibiotics for infection, IV fluids for dehydration, coding for cardiac arrest, respirators for ventilation--the specifics are overwhelming. What do you say "yes" to and what deserves a"no"? Would a blanket request for nothing curtail your life and leave you dying of starvation, or a raging infection?
When are you really too far gone? Can you trust a doctor to make these decisions? And remember nowadays, your trusted doctor with whom you may have discussed these issues may not even be the one to see you in the hospital. Instead in most cases you will be admitted and treated by an unfamiliar "hospitalist" in hospitals where living wills may be misread or misinterpreted and end of life care meted out, not exactly the way a you intended. Besides the government cannot pretend that it is not concerned about the endless dollars cast at end of life care and the futility of such extravagant spending. But when the government incentivizes discussions about this matter by suddenly deciding to pay doctors for it and when it does so even as it indulges in a huge overhaul of the system; the combination makes it incendiary. It brings to the consciousness of patients all the atavistic fears deep inside them and when they imagine the grotesque and the worst in human nature culminating at their own bedsides as they lie dying,
they are shocked to action even by the remotest possibilities. Hence the placards, and the shrill cries about eugenics. The government is staring down at a black hole and so are the patients. These agonies will come back to haunt America as the aged increase, the tax base shrinks and everyone just cannot be allowed to live for ever. We are simply postponing the truth about what we must do to husband our finite resources to another painful day.

Thanks for the thoughtful comment, doctor. Stephanie

As governor of Alaska, Sarah Palin declared April 16, 2008 Healthcare Directives Day to promote the neeed for advance healthcare directives. Advance heath care directives is end of life counseling, living will, etc. I guess she was for death panels before she was against them.
http://www.gov.state.ak.us/proclamations.php?id=1094
On July 2, 2009 Newt Gingrich wrote an op-ed in the Washinton Post in support of advance healthcare directives. Advance healthcare directives consists of end of life counseling, living will, etc. He opined that this measure would save medicare of $33 billion. Now it's being called death panels and being distorted by the Right wing to mislead the uneducated voters. Shameful. I wish folks would get educated first before they act like they know something about HR3200.

http://views.washingtonpost.com/healthcarerx/panelists/2009/07/right-gingrich.htmlul.

Hey annonymous Doctor. There is a HUGE difference between a FAMILY and Doctor working together to explain end of life procedures under capitalism, then there is when the GOVERNMENT mandates it. I went through this very thing 6 years ago with my dad who was terminal with alzheimers, but as I said WE, meaning, MY FAMILY and the Doctors discussed the end of his life, NOT THE GOVERNMENT mandating it.

Also, in response to this article about "Death Squads" being removed from the bill by the seanate. Uhh, excuse me, but would this be the same bill that Obama said there was no such language in? If so, how can you remove something that was never there in the first place according to Obama? Obama is a LIAR!!! Worse than Bill Clinton. This guy will go to any lengths to push his Saul Alynsky rules for radicals agenda on America. Everything he does is nothing but a HUGE POWER GRAB to take control of every aspect of your life, and you lefties refuse to admit it, cause that's what you want.

So Sarah Palin is the "failed 2008 vice presidential candidate". Do you always make sure you describe Bill Clinton as 'impeached former President"?

Bill Clinton was not impeached, Sarah Palin did fail. first of all. second of all, the government mandates that youth under 16 must attend school, they mandate that everyone who drives must have car insurance, they mandate tolls on certain roads and bridges, they mandate that hospitals must help those in the emergency room, even if the folks don't have health insurance. health insurance companies are, and have been for a while, our very own personal death panels, squads, etc. i remember when my father had cancer, no insurance would allow any 'alternative treatment' but they did allow for every part of his body to be cut into and operated on. who profited on those surgeries, do you think? i will not allow you right wingers to BULLY the rest of americans into being uninsured and continue to be exploited by our unethical health care system of today. we want a change. change is always scary at first, but we need it. STOP bullying others by calling end of life counseling death panels. my father never had end of life counseling, and he should have. i wish someone would have put that in front of him, so that he had to address it, instead of denial, surgery after surgery, even until the very end. you bullies should be ashamed of yourselves and do some research of your own.

Concerned-- Bob K, whose reading comprehension suffers from myopia, because he misread the anonymous doctor, will tell you he hates government mandates 1-2-3-4-5 and so on and he does not want government to mandate one more thing in his life--in fact, he may want government to repeal all the mandates in the book and start over with the republic.

There is no winning this argument. Plans public or private will cost a mint. Americans are getting fat and fatter, getting diabetes by the scores, the environment is sweeping over them as cancer and they want all kinds of care so they can go on living.

Unless Americans get off their obese butts, stop smoking, stop blasting their brains with marijuana, cocaine, alcohol, and heroin--the conservatives insisting that fat is not bad even as they ooze it over their deteriorating knees and hips, the liberals insisting that weed and cocaine are harmless excursions into the subconscious--unless the toxic work atmosphere in America changes wherein bosses are mini dictators who stretch their obese workers like rubber bands, causing them inordinate stress, driving them to insomnia, insanity, disability, degenerating discs, chronic pain, sleep apnoea, violent outbursts, bipolar disorder, heart attacks and scores of other diseases; unless we stop our gun violence on each other, stop texting while driving, having sex without condoms, plopping illegitimate babies galore, turning guns on each other, unless we are compliant about prescribed treatments, our health care system will be broken not by politicians, not by policy makers, not by outside forces nor by industry experts--it will be broken to pieces by us.

We are the the enemies brothers and sisters--if you look down and you can't see your privates, if you are a fifty year old man and you look like you are in the third trimester of pregnancy, if your blood sugar is 200 and you are the best patron Dunkin Donuts ever had and you tell your doc that you are an American and you can do damn well as you please because the framers of the constitution have given you that freedom; if you scream discrimination because your doc has dared to call you fat when he could not weigh you on the scale in his office; when you come in with chest pain because you were sniffing cocaine and you wave your arm in the air and pronounce your habit an occasional recreation; when your cholesterol is above 200 and your doc gives you a statin to prevent your brain from mushing up with yellow plaques due to your diet of butter and steaks, eggs and bacon, sausage and hot dogs and you throw away the statin-- it just doesn't fit your fancy or a little twinge in your left foot you imagine is a major side effect of the drug or you've always had high cholesterol-- you argue-- you were born fat--you don't believe in treatments-- you want no medicines, thank you-- that's your right under the constitution--or you are on dialysis and oxygen but you keep smoking even as the health care dollars go up in smoke for your repeated admissions with shortness of breath to area hospitals--hundreds of ways to sabotage the system-- screw all this debate about health care; who should pay for what, when,where and how; why should anyone, the government or the private insurers, the doctors or the nurses do anything for you when you won't allow a fruit or a vegetable to pass your lips, when cheese and chocolate are the mainstays of your life, when you eat salted pretzels late at night even as your blood pressure teeters 200/ 100, or 5 slices of pizza as darkness falls is the fulfillment of your fantasy or your romantic adventures at midnight are always in the nearby Chinese take out that never sleeps nor closes--I think the only winning system is one that will function like auto insurance--the higher the risk the higher the premiums, add up for fat, for uncontrolled high BP, high cholesterol, repeated admissions, smoking, drinking and other addictions, each individual paying according to income; no income then government should subsidize for no more than basic care and threaten to cut the subsidy for non compliance with letters of warning--three strikes and no subsidy being the rule; cover only for 2 pregnancies for those on government dole, not for the endless increase in population brought about by those who think nothing of a dozen children plopped--seeds sown on a nomadic quest for sexual gratification--let us not pretend that the public-- screaming bloody murder about a public plan or about the private insurers-- does not have a responsibility--find out what is wrong with you and your family history--do what you can to keep out of harm's way--be responsible for your own health and use the health care system sparingly-be a well informed customer--learn the cost of all the meds you buy and the procedures you undergo--when you are a doddering old fool and your body is not limber, don't go straight from your couch to the jogging track, or the ski slopes, or go play volley ball with your teenage granddaughter, then go to your doctor with a broken knee or a ruptured tendon--again look before you leap--if the American health care consumer is less of an idiot any system will do just fine. If not the cost will balloon, no matter the system and the whole damn shebang will swirl into an abyss.
Bucinum

To "concerned" who posted a comment at August 17, 2009 11:29 AM: you say that Bill Clinton was not impeached? He was impeached in 1998. Impeachment is the power of the legislature allowing for "formal charges to be brought against a civil officer of government for conduct committed in office". His being acquitted of the charges is a separate matter and does not undo the fact that he was impeached.
I am very sorry for your father's suffering. Clearly, some things need addressing in our health care system. However, this bill approach, by this administration, is not the answer. I don't know that a solution really exists on this issue. I sense that a lot of people "want something done now" but that is not what should motivate us here. I keep hearing from supporters of the Obama administration that Europe provides free health care. It is not free, it is not at the forefront in terms of quality, and it is rationed. The European government taxes the life out of everything, makes a citizen participate in a program, then tells that citizen to choose from a (limited) list of options. I may not think our system is perfect, but it's better than what they have.

Robert, you talk about rationing as though the private insurers don't ration at the current time. Yes, they do and in a very big way.

As time progresses, and people age, as people don't take charge of their own health and do all the wrong things, there will be even more rationing in the US.

Rationing is not a function of the type of delivery of health insurance, public versus private option, rationing is a function of the wealth or lack thereof in a nation, recognition that resources are finite, that spending on diseases after they have taken root is an expensive proposition, that it is morally wrong to spend trillions on people who abuse the health care system by violating every code of good health in the books while innocent poor children and potentially compliant patients cannot even get basic health care.

Rationing also reins in the doctors who blame the malpractice threat for expensive and unnecessary tests and futile treatments but who do as they please to increase their own reimbursements.

But the cycle is vicious. Medical education is prohibitively expensive. Docs are in debt up to their gills when they graduate from med schools. They also imagine, wrongly, they should belong to a privileged and elite class of people and they expect to make money commensurate with this imagined standing in society.

They are indeed afraid of malpractice suits and whether this fear is exaggerated or irrational, they practice defensive medicine and escalate cost unwittingly in the process.

So in come the insurers with their rationing. An action on the part of the docs creates a reaction or may be even a chain reaction.

Thinking people like you Robert, should not be wearing blinders. The cause for increasing health care costs is what I have already posted. It is the patients, the complexity of the diseases, the apathy, the medical illiteracy, the defiance and the sheer arrogance of the consumers that have also contributed to the current crisis.

American consumers are immune and blind to their own follies. Private or public you'll get rationing-only way to go as both options see it. I know because I am on the inside and a witness to what is happening.

That said you are partially right about European health care. Europeans are taxed the hell out. They have chosen health security over more money in their pockets. European countries cater to their lower echelons quite well. The upper echelons can get private health care- boutique care- and the middle class can buy medigap insurance for fancier care and shorter waits.

You would say on top of the taxes that kind of extra spending for extra care is criminal. The Europeans don't seem to mind. They find the single payer system the lesser of all the evils out there when it comes to the disbursement of health care dollars. They like the fact that there are not too many players, that they have one organization doing the job and this organization is the government. To them a single payer is less confusing, less messy, more reliable and more accountable.

Europeans don't like choice. They don't like to pore over many options, break their heads over what is right and what is better. They have picked safety over plenty, they have chosen basic over the frills. They may regret the waits but Europeans are very much into preventive health to avoid too many encounters with the health care system. Unlike the Americans they don't medicalize common conditions.

Notice how everything in America is a disease. You get up one morning and you are out of sorts. You pick a quarrel with your husband and he tells you, you may have a mood disorder and you should go get a medicine from your doc for possible menstrual dysphoria syndrome.

There is a medicine for every condition here. Huge swathes of children are on Adderall for ADHD which is nothing more than an amphetamine; adults unable to cope with their stresses, constantly under time pressure to keep on producing and striving so the capitalist wheels are churning, are on anti-depressants galore and on pain medicines for fibromyalgia and chronic fatigue. Our rivers have Prozac in them and our fish are receiving treatment by default for depression.

The obese who simply won't get up and move are getting expensive bariatric surgeries. Guess who invented this surgery? An American surgeon called Edward Mason.

Europeans, unlike Americans, tough it out. They don't have the luxury of social, visits to their doctors; they have to ask themselves if a visit is really necessary and they exercise prudence in when and why they utilize their health care dollars.

Our health care system has led to massive hypochondria, and not necessarily to good health. Our infant mortality is high and our longevity is low. Our quality of life, our job satisfaction and our public health indices are steadily deteriorating due to obesity and diabetes. For the first time our next generation will have a shorter life span than the generation immediately before it. This is a shame.

The European model may not be to your taste Robert, but it has its positive points and many Europeans accept their model as befitting their cultural and health care needs more than the other private models out there. But we obviously are not that sure.

While many of us claim we are happy with our own insurance, we are not getting health care results that are optimal; there are so many of us uninsured, we scream that we don't want to be taxed but we pay heavily when our uninsured flood our emergency rooms and get treatment anyway as mandated by government.

In the shouting matches that are going on and in the hallways of Congress, the doctors and other health care workers have been left out. The consumers who don't take responsibility for their own health and the policy makers, politicians and health insurers behind the scenes, who don't see patients, are driving the discussions and the acrimony.

If you told me Robert that you do not want your government to get too big and be in every aspect of your life I would understand. If you told me that you want government to do a better job with Medicare before taking on another health care option I would understand. If you told me that the government's nonchalance toward our ballooning deficits galls you and you don't want this health plan to to make government more insolvent I would understand. But this rationing argument on the part of the people who are against the public plan I don't understand.

I also don't understand the American consumers' imperviousness to or lack of insight about their own role in what has come to pass.

That said you are right about Bill Clinton. There is misconception, among some in this country, that acquittal and impeachment are one and the same; that if a person has been exonerated that person has not been impeached, and this, as you have rightly pointed out, is wrong.
Bucinum

Alright, Bucinum, I take your point. "Rationing" does exist in our current system of health care and private insurers. I addressed that angle of this (very complex) topic because of a point made by a previous respondent and did not address other angles. But, since you point it out, I will say that I do not want the federal government controlling any more of my personal life and forcing me into a system I choose not to be a part of. I am young, healthy, and I take care of myself. I haven't been to a doctor in several years and, barring an accident (which I know is a possibility), I have no need for health insurance. Forcing me into a system that does not serve my needs and taking my money in the process, while promising that the day WILL come when I can be able to benefit, sounds a lot like our now-bankrupt Social Security system. I would do better to be encouraged through a government-designed plan to save $X per month/year in an account I cannot touch unless I need it for medical purposes. Much like an IRA. The government doesn't tax it and it is there for an expressed purpose, not to be used until such-and-such a time. I look at the Social Security system and see exactly what the federal government does so badly. All the promises and pay-offs are front-loaded. Those lucky enough to start drawing benefits when the program was initiated thought the program was swell, whereas those of us who pay into it our entire lives know that it won't exist when we need it. SS is bankrupt. Medicare is bankrupt. The Post office is bankrupt. Why would a federal government take-over of the health care industry appeal to anyone? And I agree with you about people taking better care of themselves, taking personal responsibility with their own health. I know several obese people who want government controlled health care. A person's health is "society's responsibility" but not their own, I suppose.

Yes, Robert now I see where you are coming from and I see that your idea makes sense too. The more ideas are laid on the table the more confusing it gets but that is also the good part of the American way. What you are saying is that you don't mind saving up for a catastrophe but you would like that money set aside for your own future care to be under your control and you don't want to be taxed on it--which I actually think is reasonable. Also all your examples of how the government has screwed up are spot on. And the fact that you are paying attention to your health--that's great.
It has been a pleasure chatting with you and I will look out for other posts from you. I actually discovered more new things about this subject today. Don't have the time now--got to go and make a living. But I will post some other time.
Bucinum