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Civility is the ability to disagree with others while respecting their sincerity and decency. Civility begins with understanding. We can best understand our political differences by first understanding the moral foundations upon which political views are built. This site features research, resources, and commentary related to the pursuit of Civility through understanding.


End of life care is the subject at the heart of the notorious comments made by she that shall not be named (the original facebook post can be found here).  Though she does not refer to it, it is alleged in the media that she was referring to HR3200‘s section 1233, Advanced Care Planning Consultation.   The reading of the bills is quite involved and I will not try to retrace the path.

Section 1233 provides funding for end of life planning every five years, or more frequently if health changes suddenly.  While such counseling is not itself required, the Act does require “quality” measurements of physicians regarding their end of life care practices and whether or not they are following such guidance.   It also provides for the optional issuance of medical orders resulting from the consultation, subject to the patients approval, including control of nutrition and hydration.   Overall, Section 1233 does not strike me as overtly threatening.

More concerning is the Independent Medicare Advisory Council Act of 2009, endorsed and proposed separately by the administration.   This Act provides for a 5 member commission, appointed by the President and approved by the Senate, to recommend changes to Medicare each year.  Subject to the Presidents approval, the recommendations would automatically become law unless Congress intervenes.  Once enacted, the Councils actions are not reviewable in court, with very narrow exceptions.  The main intent is to control costs, and most of the bill is concerned with the details of payment schedules.  However, the Council may also “…submit, under separate cover, a report containing recommendations for reforms to the Medicare program…”.  There follows a long list of specific regulations the Council may not review.   The Congressional Budget Office’s review essentially concludes the Council is not likely to save much money, if any at all.   To increase the chances of the IMAC effecting real results, the CBO is recommending “Providing clear authority for the council to recommend broad changes in coverage, benefit design, and payment and delivery systems”, and “Expanding the council’s mandate to include making recommendations for changes to the broader health care system”.

And finally, there is the “Health Choices Commissioner“, who would determine, well, our choices.

For many the concerns are intuitive, almost gut felt.  For the rest of us, here’s a presentation of the concerns that these proposal’s may lead us toward:

Step 1.  Advance Care Planning in a compassionate voice. The webpage helping us to understand might look like this…


Advance Care Planning

Caring for people at the end of their lives is an important role for health and social care professionals. One of the elements to support people at the end of their lives is to find out what their preferences and wishes are in relation to their future care.

Advance Care Planning

Advance Care Planning (ACP) is a voluntary process of discussion between an individual and their care providers irrespective of discipline. If the individual wishes, their family and friends may be included in the discussions. With the individual’s agreement, this discussion should be recorded, regularly reviewed and communicated to key persons involved in their care.

An ACP discussion might include:

  • the individual’s concerns
  • their important values or personal goals for care
  • their understanding about their illness and prognosis
  • preferences for types of care or treatment that may be beneficial in the future and the availability of these



Step 2.  The development of end-of-life protocols.  Perhaps the webpage would be thus…


Compassionate Care Pathway

The Compassionate Care Pathway (CCP) for the dying patient has been developed to transfer the hospice model of care into other care settings.

The Ronald McDonald Hospice Care Institute  has pioneered the implementation of the Compassionate Care Pathway for the Dying Patient (CCP). This program is recognised nationally and internationally as leading practice in care of the dying to enable patients to die a dignified death and provide support to their relatives.

The CCP provides a useful template to guide the delivery of care for the dying to complement the skill and expertise of the practitioner using it. Once commenced the goals of care prompt staff to consider the continued need for invasive procedures and whether current medications really are conferring benefit. The health care professional is free to use his or her own clinical judgment in this process.

The use of the CCP does not preclude use of antibiotics or artificial nutrition or hydration but it does ask the professional to consider an appropriate decision for that moment in time and document the reason for decisions made.


Step 3. Outcomes we didn’t expect.  The headlines might look like these….

Sentenced to Death on CCP

The Compassionate Care Pathway may be the slippery slope to backdoor euthanasia

Terminally ill care crisis


You just can’t make this stuff up.  Step 1 can be found here,  Step 2 is here, and Step 3 is here and here.

No Healthcare bill has passed, it’s unclear exactly what is proposed and who is supporting it.  But it is difficult to read the hundreds of comments on the Liverpool Care Pathway article and not feel empathy for those whose fates were decided by a distant committee/council/agency/department/commission.   Think what you will about the present proposals, none of us want to be placed on the Liverpool Pathway without our consent.   The sequence of events that led Britain to it’s present circumstance were not carried out by evil men and women, those involved in hospice care may be the most compassionate among us.  But if we are to avoid a similar fate, doesn’t it seem we need to pay attention now?

Update 9/3/2009- See new post on The Danger of Ambiguous Legislation

Update 9/18/2009 – Administrator of Liverpool Care Pathway response to media reports.  Feel better?

Update 9/30/2009 – Wisconsin solves the problem, this will make you feel better…End of Life Care That Works

  4 Responses to “Is “end of life care” pro end of life?”

  1. [...] Everett presents the following articles,  posted at Honest Inquiry. Is “end of life care” pro end of life? [...]

  2. [...] begs the question why couldn’t Britain’s government run health care get this right (see Is ‘end of life care’ pro end of life)?  Mr. Gingrich suggests: We don’t think the politicians can ever fix this because the [...]

  3. Nothing very
    earthshaking. Just good practical stuff.

  4. [...] of life?  Britian’s experience is that state control diminishes individual freedom, with horrifying consequences at end of life. Post Published: 24 September 2009 Author: Everett Found in section: [...]

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