AAPS News April 2016 – Death Care

AAPS News April 2016 – Death Care
Apr 9, 2016
Volume 72, no. 4 April 2016

In the post-Hippocratic, post-Christian, post-modern era, facilitating or even causing death is becoming a form of treatment, often called “end-of-life” care. This is now supposed to be voluntary, although the decision might be made decades prior to the event. There is a continuum, and it is “evolving.”

The leading edge is in Canada, which is the first jurisdiction in the world to require physicians to perform assisted suicide or euthanasia or make an “effective referral.” This is considered “an appropriate balancing of the rights of patients and the conscience rights of physicians” (http://tinyurl.com/zguwa7s). A government panel also recommends forcing all publicly funded institutions, including Christian hospitals and nursing homes, to kill patients on demand (http://tinyurl.com/ztpc35h).

Mental illness, even treatable depression, can make one eligible for death. Quebec doctors are reportedly withholding life-saving treatment after a suicide attempt, interpreting the attempt as a refusal of treatment (http://tinyurl.com/jp7m2nb).

The Canadian parliament worries about disparities—the indigenous populations might not have equal access to death. Statistician William Briggs worries that intransigent Christians might be diagnosed as having a mental illness, Christianity being perceived as the major stumbling block to acceptance of the utilitarian view (a religion not called religion) that life is not worth living unless useful to society (http://wmbriggs.com/post/18172/).

Euthanasia has been legal in Belgium since 2002. A new draft law would require all physicians to accede to a euthanasia request within 7 days, or refer the patient to a physician who will. It would also eliminate the 5-year “sunset clause” to living wills, making them valid indefinitely (http://tinyurl.com/z3rget2).

In the U.S., the debate over physician-assisted dying (PAD) is at a “turning point,” writes Zosia Chustecka. A 2015 poll in the United States found that more than half of physicians surveyed favored medical assistance in dying. During 2015, 23 states sought to codify PAD, and eight of these states have done so. This unprecedented legislative wave represents six times more such bills than in 2014 (MedScape 1/21/16, http://tinyurl.com/zgmpx9j).

While public opinion is also shifting in favor of assisted death, the percentage of people who think everything possible should be done to save a patient’s life increased from 15% in 1990 to 31% in 2013. Families often disagree with physicians about whether care is “futile,” and families may prove to be correct. There is good reason to fear that a “do not resuscitate” order will lead to poorer care. A 2015 study showed that when cardiac patients with the best prognosis had a DNR, their survival rate was poorer than that of similar patients without one. (Leigh Page, MedScape 3/16/16, http://tinyurl.com/zm83cex).

The Third Path to Death

Death can be hastened without active physician help by simply withdrawing “treatment,” now defined to include food and water, perhaps aided by “terminal sedation.” The Robert Wood Johnson Foundation and George Soros’s Open Society Foundation are among the advocates of this path, having between them pumped at least $40 million into transforming “healthcare” into “managed death care,” writes Mary Ann Kreitzer of the Fitzgerald Griffin Foundation (http://tinyurl.com/jaog92t).

Medicare’s paying for “conversations” about end of life is “Just the First Step,” according to a Health Affairs headline. Doctors need to be trained in how to deliver the message (Kaiser Health News 3/16/16, http://tinyurl.com/jtkmzyw).

Better interoperability of electronic health records is needed to assure that doctors know the patient’s end-of-life wishes “in a split second” (KHN 3/23/16, http://tinyurl.com/z9s2khf).

As AAPS president Melinda Woofter, M.D., points out, another means of end-of-life planning is being developed or implemented in all but five states: Physician Orders for Life-Sustaining Treatment (POLST) or a variant (J Am Phys Surg, spring 2016).

The ObamaCare mandate to keep medical spending below a predetermined level could spell premature end of life to patients who have a good chance of recovery and want to live. Starting as early as this year, federal standards on “quality and efficiency” could limit care that hospitals or doctors could offer even to patients willing and able to pay. Violating standards could mean ineligibility to contract with any qualified health plan, according to a Mar 6, 2014, report prepared for the National Right to Life Committee (http://tinyurl.com/jglpxfd).

Redefining Death

The legal definition of death has been revised to include “brain death,” which is also assumed to be final and irreversible. There are supposedly rigorous standards, but hospital policies are inconsistent and may omit procedures intended to prevent errors (NPR 12/28/15, http://tinyurl.com/p4uduvw).

Many errors have occurred. One was in the case of George Pickering III, whose father held off medics at gunpoint for some hours when they tried to turn off his life support. While his dad served an 8-month prison term, his young son recovered fully from the mistaken diagnosis of brain death.

Since her diagnosis of brain death 2 years ago, when her family was pressured to donate her organs, Jahi McMath has gone through puberty. She responds to commands from her mother and has brain wave activity. Her family is still fighting in court to void her death certificate (http://tinyurl.com/h5gkmys).

Psychiatrist’s Response to “Want to Die” Consults

Samuel Nigro, M.D., writes of his experience doing ICU consults at St. Vincent’s Hospital. When the patient said the equivalent of “I want to be put out of my misery,” he replied, “We do not do that here. We can arrange hospice in due time if indicated.” This generally seemed to lead to a clear sense of relief and no more talk of death-causing acts. To engage may be to promote. Doctors should not become entrapped in self-fulfilling dialogue.

Dr. Nigro would confirm that the patient was very sick and might not make it, but he had seen some walk out after a similar illness. He said, “I know we we’re doing something wrong that was upsetting; please tell me what that is and what we could do to make matters better.” Most said it was torture to be confused and bewildered about who people were and what they were doing.

“Despair and other affects are contagious. Medical care must be immune to patients’ affects.” He instructed staff, even housekeeping, to respond brightly and positively, and to engage and explain, every time, who they are and what they are doing. They should find out the patient’s interests and provide distractions from despair—say a virtual tour of Rome or Las Vegas.

Unless medically contraindicated, he prescribed low-dose lithium, “the only medication documented to reduce suicide and death ideation” (also see http://tinyurl.com/gqf7olx).

The results: “Some got their wish and died naturally. Most were transferred glad to be alive still.”

The right to life means the right to a natural death, Dr. Nigro writes. “To violate the right to natural death is to violate thousands of years of medical tradition and the Oath of Hippocrates.”

The Death Bed

An anesthesiology resident describes meeting her first organ donor in a dimly lit ICU room (JAMA 3/15/16). The electronic medical record warns her she is about to enter the record of a deceased person—but he looks very much alive, young and handsome, his hand warm and soft. Later in the OR, the team reads aloud farewells from the family—[to him, as if he could hear, or just to themselves?] She reminds herself that there is no need for pain medicine, and vital signs do not change while surgeons open the chest. Then, the vital signs are gone, as is the glow of life. The skin is gray and cold. Dead.

Futile Care in Texas While 46-year-old Chris Dunn prayed for his life, Houston Methodist Hospital went to court to try to wrest custody from his mother so it could remove his ventilator. Under the Texas Advance Directive Law, patient consent is not required for discontinuing support, only 10-days notice so family could seek alternate care (http://tinyurl.com/z75dd5g). Dunn died a natural death about a month after the hospital declared treatment to be futile.
♦ ♦ ♦
“[A] systematic training in objectivity must be given to you. Its purpose is to eliminate from your mind one by one the things that you have hitherto regarded as grounds for action. It is like killing a nerve. That whole system of instinctive preferences, whatever ethical, aesthetic, or logical disguise they wear, is to be simply destroyed.”
C.S. Lewis, That Hideous Strength, 1945

The Trouble with VSED

Compassion and Choices (formerly the Hemlock Society) is an advocate for suicide by voluntary stopping eating and drinking. But most demented patients continue to eat willingly, despite wishes formerly expressed in an Advance Directive: hence the idea of VSED-by-proxy, whereby a proxy can ensure that no one offers a patient spoonfeeding (http://tinyurl.com/j4m9vh7).

Profiting from Death

Soon after California proposed its aid-in-dying law, Valeant Pharmaceuticals hiked the price of a lethal dose of Seconal to $3,000 (in 2009 it cost less than $200). Medicaid and most private insurers will cover it, though coverage (and physicians’ prescriptions) remain voluntary (http://tinyurl.com/jabyxme).

Physician Manpower

  • 900,000 licensed physicians in U.S. (280 MDs/100,000)
  • 76% certified by an American board
  • Average age 51; 26% are older than 60
  • Physicians under age 39: 34% of female, 18% of male MDs
  • Growth in population of actively licensed physicians: 11% in those over age 60, 1% in those under 49 (JMR 2013;99(2):11-24).


Economic Metrics

  • Price of barley: In ancient Babylonia, 0.171 g silver/qt. About the same in U.S. today (http://tinyurl.com/z3qpw23).
  • Debt/GDP: Since 2008, global debt has ballooned from $145 trillion to $225 trillion, (an $80 trillion increase) while nominal GDP grew by $16 trillion ($1 per $5 of new debt). Virtually all “growth” could be a pass-through of borrowings enabled by central bank money printers (http://tinyurl.com/gwc2lga).
  • U.S. 2015 financial statement: Total assets $3.2 trillion, including aircraft carriers and federal highways. The biggest single asset (35%) is student loans, one of the most precarious bubbles in finance (http://tinyurl.com/gukky4z).
  • Economic Death: Total American consumer debt exceeds $17 trillion. “Our debt addict society is dying of an overdose.” More than 20% do not believe they can pay off their debts in their lifetime (http://tinyurl.com/zeqcnrl).
  • Fiscal Armageddon: http://www.visualcapitalist.com/all-of-the-worlds-money-and-markets-in-one-visualization/

AAPS Calendar

May 20. Thrive Not Just Survive XXIV, Dallas, TX
May 21. Board of Directors meeting, Dallas, TX
Sep 22-24. 73rd annual meeting, Oklahoma City, OK
Oct 5-7, 2017. 74th annual meeting, Tucson, AZ


Do you feel like Charlie Brown with Lucy holding the football? Come to our 24th Thrive, Not Just Survive Workshop in Dallas, May 20. Or help a physician-in-training attend! http://aapsonline.org/dfw

Watch for Dual-Eligible Patients

Medicaid beneficiaries cannot be billed for Medicare cost-sharing under any circumstances. Qualified Medicare beneficiaries (QMBs) cannot waive this status. Physicians who bill Medicare must be sure to check for changes in the patient’s insurance status on every visit. But doctors cannot rely solely on the patient’s account because some become Medicaid-eligible without their knowledge. Note that the patient may be a QMB in a different state (Medicare Practice Compliance Alert, March 2016).

Retired, but Still Subject to Clawback?

The 60-day “look-back” rule change for reporting Medicare overpayments “creates challenges for providers” (http://tinyurl.com/jv8atzq). Medicare may demand repayments of funds paid as long as 6 years earlier. What will be the obligation of physicians who have already retired? Should group practices be setting up a fund to cover this contingency? Should you opt out?

Tip of the Month: Gregory Zydiak, M.D., explains how to reduce the burden of prior authorizations—and bill for them (http://tinyurl.com/zh3ty36). The form he uses is posted at: http://tinyurl.com/gv8w8sz. In a 2008 decision in Gibson v. Medco Health Solutions (case no. 06-CVF-106), Judge
Thomas A. Campbell wrote: “The defendant acknowledges that…[it] now sends out Forty Thousand (40,000) such inquiries in the same time period that it would send out Seven Hundred (700) such inquiries ten years ago.” He asked why the physician should have to bear the burden of these inquiries, which are designed for the benefit of the insurer (http://tinyurl.com/hzvgwrx).

Dr. Jaime Salas Rushford Sues ABIM

One of more than 2,700 physicians sanctioned by the American Board of Internal Medicine, Dr. Jaime (“Jimmy”) Salas Rushford has filed a countersuit against ABIM and individuals including Richard Baron, M.D., and Christine Cassel, M.D. Most of the targets, like Dr. Salas, were just finishing their residencies and had no resources to fight.

In 2012, Dr. Salas received a letter and 600 pages of unlabeled and unexplained documents, alleging that he had participated in a board-review course “with the objective to conspire with the course director to collect and disseminate the ABIM’s secure examination test questions.” He was given 10 days to answer this letter, or the ABIM “will notify the Medical Board in every jurisdiction in which you are licensed.”

Despite his answer and with no due process, ABIM posted a “revocation recommended” notice on its publicly available website. When asked how to appeal, ABIM told him of a 3-tier process, which was nowhere defined on its website. After 2 years, his status was changed from full revocation to “suspension” with multiple contingencies. Just before sending him a “final decision,” ABIM filed a copyright infringement suit against him in New Jersey (he practices in Puerto Rico). He learned of this only when a D.C. law firm offered him his services to defend.

Dr. Salas was apparently the last of many physicians attacked because an email from him was allegedly found on a computer that U.S. marshals had seized from Dr. Rajender K. Arora, who had offered a highly respected board review course for 20 years.

Dr. Salas’s story and many legal documents are available at http://www.doctorsjustice.com. The ABIM even opposed motions for Dr. Salas’s attorneys to appear pro hac vice.

His countersuit alleges more than $15 million in damages plus at least $1.5 million in lost income. He asks for his board certification to be restored. His case illustrates ABIM’s ruthlessness in harming the livelihood of young physicians. It is skilled at litigation, and intends to recoup its enormous legal fees from those who do not capitulate. Dr. Salas writes: “As they have clearly explained to me they [ABIM] are not bound by any technical rules of evidence. They [ABIM] have shown through my hellish ordeal with them, that they function as the accuser, judge and executioner all in one and that if we physicians do not abide by their ever changing, entangled and confusing regulations they have the resources to overpower any physician.”

“Dr. Jimmy’s” case has implications for all physicians.

ABIM revenue from certification and Maintenance of Certification® since 1998 totals more than half a billion dollars. The yearly amount has nearly quintupled from 1999 to 2015.


Prescription Database in Effect in New York Mar 27. Progressives in New York State, including Gov. Andrew Cuomo, used abuse of prescription drugs by drug addicts as the reason the state needed to have a database and monitor all prescriptions for controlled substances. As part of the new I-STOP law, they included an e-prescribing mandate for non-controlled substances as well. There is no risk of abuse of drugs like Sinemet (for Parkinson’s); they just wanted to be able to control and monitor all prescriptions. Perhaps not coincidentally, in the same year (2013) that Cuomo signed the I-STOP into law, he also signed the SAFE Act into law—the toughest gun control law in the U.S.

The NYS Dept. of Health plans to monitor the new database to detect any violation of I-STOP or breach of professional standards (Public Health Law Sec. 3343-a (7)). Failure to comply with the I-STOP will be deemed willful misconduct, which is grounds for revoking a medical license. Failure to comply is also punishable by a fine up to $2,000 per incident and up to one year in prison (Public Health Law Sections 12-b (2), 3396).

In summary, NYS defines “quality healthcare” as total loss of privacy for patients (everyone’s prescription history will be in a state-run database accessible to the state), loss of the ability of patients to shop for price and convenience (as they would be able to do with a paper prescription), risk of good doctors losing their license because they refuse to compromise patient privacy, and ruinous fines and prison time for doctors who refuse to participate in the total destruction of patient privacy.
Lawrence R. Huntoon, M.D., Ph.D., Lake View, NY

Disenrollment. Complete disenrollment as authorized on CMS form 855, to be distinguished from “opting out,” does not require ongoing obedience to Medicare rules of patient engagement (see Ocular Surgery News 2/10/16, http://tinyurl.com/jq6b546). A number of ophthalmologists have “opted out” of Medicare but are still enslaved by the rules of a complex and prosecutorial program, such as the need for written contracts approved by Medicare. They may wish to convert to disenrollment. For discussion of this topic contact me on the ASCRS ListServ.
Jeffrey Liegner, M.D., Sparta, NJ

Soliciting Your Patients. Horizon Blue Cross Blue Shield of New Jersey notified me that my newly enrolled patient had “care management” needs. If I don’t respond in 5 days, they assume I agree with their plan. Amerihealth is soliciting patients to call them to be directed away from my practice into telehealth.
Craig Wax, D.O., Mullica Hill, NJ

What the Healthcare Dollar Pays For. Imagine owning a restaurant with 10,000 items on the menu. Your job is to guess supply, demand, and quality each item will be perceived to have in a pseudo-market funded by a jack-pot of “free money” collected from taxpayers. This is impossible, yet government has been doing it for years–assigning dollar units to every item in the Byzantine cipher system it has endorsed for medical billing. Other insurance companies have merely followed suit. Transaction costs are huge. Every dollar put in the bucket loses about two-thirds of its value immediately: you must put in three of your own dollars so that someone like Dave can get one dollar back out.
Rocky Bilhartz, M.D., http://bilhartzmd.com/?p=2649

Where Does the Money Go? It is estimated that the health insurance industry takes 40% out of every dollar for expenses. At least six CEOs earn more than $8 million per year; Stephen Hemsley of UnitedHealth makes $66 million ($254,328 per day). Hundreds of executives making more than $1 million report to each CEO. Rents from hundreds of empty office buildings (claims adjustors have been replaced by software) are paid to each subsidiary—an expense used to justify premium increases. In government, billions vanish without being accounted for.
Stanley Feld, M.D., Dallas, TX

Hospital Consolidation in the UK. The hospital system is the epitome of bureaucratic imperialism…. The obscure almoner’s clerk evolved into a controller of huge hospital empires. People had fought in vain to preserve their much loved local cottage hospitals, but they were not compatible with the bureaucratic ideal, and they had to go. The new, large, soulless, distant edifices with their shiny new equipment were the future. Forget the fact that some of them turned out to be systematically torturing patients to death by hunger and dehydration…. The bureaucrats reward each other with enormous salaries and outrageous pay-offs; the bigger the enterprise, the less noticeable are the bureaucrats’ rake-offs.
John Brignell, http://numberwatch.co.uk/BIG.htm

Obama’s Ethicist. Princeton philosopher Peter Singer, a vociferous advocate of infanticide, was selected by President Obama to head up his bioethics committee and was then appointed as a consultant to the committee that wrote the Affordable Care Act. Singer believes that an infant has no legal rights, including the right to life, before age 28 days. The media is reluctant to mention Singer’s infamous position on infanticide or his affiliation with the Obama presidency. No Republican has challenged Singer’s advocacy of infanticide or Obama’s association with him.
Mason Rigsby

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