The advertising by the American Association of Retired Persons during the Democratic and Republican conventions echoed the constant refrain of politicians and advocacy groups that say our healthcare system “is broken.” Patient advocacy is suffering in the clutches of decreased Medicare/Medicaid reimbursement rates, increased health insurance premiums, and more physicians forming “boutique” practices where clientele get exclusive access by paying extra monthly fees.
Both quality of care and accessibility have declined dramatically, especially for those who are struggling fi nancially. The US Census Bureau reported in August 2008 that although the number of Americans without healthcare insurance dropped by 1.3 million since 2006, there were still 45.7 million Americans without health insurance coverage in 20078.1 million of them being children. And dangerous trends in legislation, such as the drive to legalize euthanasia, continue to threaten vulnerable patients at the end of life.
How best to address the healthcare crisis in America is a tricky question, but the Church may hold part of the answer. With its Christ-centered mission of care for the least among us and its ethical standards, Catholic healthcare faithfully practiced may be our last hope for the future of medicine in this country.
As far as the influence of the Catholic medical community, the statistics speak for themselves. The Catholic Health Association of the United States (CHA), the national leadership organization for Catholic healthcare, represents the largest not-for-profit provider of healthcare services in the nation. One in six people in the United States is cared for in a Catholic, acute-care facility each year, or more than 5.5 million patients.
There are 557 Catholic hospitals in the United States presently, treating 83,795,186 patients. There are 417 other Catholic healthcare centers treating 7,271,716 patients, and 1,538 specialized homes caring for 756,902 residents, according to the 2008 edition of the Official Catholic Directory.
The CHA Web site notes that “Catholic hospitals across the United States contributed more than $5.7 billion in services identified as community benefits during the last fiscal year,” adding that “Catholic healthcare providers are the ‘safety net’ to thousands of patients who cannot afford healthcare coverage.”
That “safety net” is now trying to raise awareness to resolve the growing healthcare crisis under the umbrella of the CHA, with the help of other national organizations, including the American Cancer Society Cancer Action Network, the American Hospital Association, Families USA, and the National Federation of Independent Business.
During the Democratic and Republican conventions, these groups aired a multi-million-dollar television ad campaign urging the next administration and Congress to put healthcare at the top of the domestic agenda.
A recent study on the emergence of palliative care in hospitals across the country brings some hope that such concern belongs not merely to the few in the medical community, but is shared by many.
THE TREND TOWARD PALLIATIVE CARE
According to an analysis of the latest data in the 2008 American Hospital Association (AHA) Annual Survey of Hospitals provided by the Center to Advance Palliative Care (CAPC), US hospitals are implementing palliative care programs “at a rapid pace.”
The study describes palliative care as “the medical subspecialty focused on relief of the pain, symptoms, and stress of serious illness.” Palliative care “ensures the highest quality of life possible for patients and their families… [treating] serious illness regardless of prognosis, [allowing patients to] receive it at any point in their illness, with or without curative treatment.”
Nationwide, 1,299 hospitals (31 percent of national hospitals) provide palliative care programs, compared to just 632 programs in 2000. Hospitals with over 50 bedsthe most likely to have a programshow a rate of 47 percent instituting palliative care programs.
Dr. Diane Meier, director of the CAPC, remarked that “palliative care represents a paradigm shift in how we treat serious illness in America.”
There were “almost no hospital palliative care programs in the US” 10 years ago, according to Meier. But in order to “meet the needs of an aging population, it’s going to be necessary for every hospital to have a program,” she suggested.
The CAPC report states that by 2030, “the number of older Americans will have more than doubled to 70 million or one in every five Americans.” The study suggests that improving “physical and psychological symptoms, caregive well-being, and patient/family/doctor communication, palliative medicine is widely viewed as an important solution to the mounting problems faced by patients, families, and the healthcare system.”
According to the AHA statistics, one characteristic that many of the hospitals with palliative care programs seem to share is that they are run by Catholic healthcare organizations.
CONTINUING MEDICAL EDUCATION COURSES
After Washington state’s first attempt to pass a physician-assisted suicide initiative, the American Medical Association (AMA) initiated courses available for physicians across the United States on end-of-life care issues. That initial response by the AMA has continued to gain interest.
Linda Wrede-Seaman, MD, a fellow of the American Academy of Hospice and Palliative Medicine, presently works in Washington as a consultant for the Palliative Medicine Program for Yakima Physicians, Inc. She believes there has been “a lot of work done to address pain management, specifically in the last decade, with continuing medical education (CME) courses.”
“The Academy of Hospice & Palliative Medicine, which I have worked with since the early 90’s, has created a specialty for board certification in the field,” Wrede-Seaman stated. “That number of trained physicians is now rising exponentially since the first board exam in 1997.” From 1996 to 2006, 2,883 physicians were board certified in palliative care. In 2007, the AMA recognized palliative care as a subspecialty.
She emphasized that physicians are trying to meet the demand, “but the lead was taken after public outcry.”
Dr. Kathleen Raviele, MD, an obstetrician-gynecologist in Atlanta and president of the Catholic Medical Association (CMA), agrees that pain management and palliative care have become important areas in medicine recently. “We (CMA) have annual educational programs that cover end-of-life care. We feel it is possible to control a patient’s pain without directly killing them,” she stated.
But Drew Carlson, the director of public affairs for the Federation of State Medical Boards, reported that “only a handful of states require any sort of continuing education in pain management or palliative care.”
Those states with such requirements include: California for pain management, Florida for end of life/palliative care, and West Virginia for both pain management and palliative care. Washington, which recently passed an assisted suicide initiative, is among the majority of states not mandating “subject- specific” CME course updates [in pain management, palliative care, or end-of-life care], according to Taj Warren, involved in government relations for the Federation of State Medical Boards.
IMPROVED PALLIATIVE CARE, BUT NOT FOR ALL
Dr. Marie Hilliard, RN, PhD, JCL agrees with the importance of continuing education, saying that “the need remains” for CME classes in palliative medicine and pain control.
However, she pointed to a report by the American Pain Society (APS) that indicates that there is inadequate management of relievable pain for those at the end of life. The APS has stated: “Pain and other symptoms at the end of life can usually be relieved if clinicians have the training and resources to focus on this goal.” The APS believes that “current treatment often falls short.”
Hilliard, who is the director of bioethics and public policy at the National Catholic Bioethics Center in Philadelphia, noted that “welltrained clinicians can provide adequate pain relief for more than 90 percent of dying cancer patients. Patients can be reassured that in the occasional case where the best treatments cannot allow the patient to be alert and relatively comfortable, intravenous sedatives can relieve all symptoms in the last days of life.”
Unfortunately, not everyone is receiving that level of care. Hilliard said that “a substantial proportion of patients, particularly those in minority groups, receive inadequate analgesic (pain relief) treatment.” She also mentioned that when patients with advanced disease express suicidal wishes, it can be “closely linked to unrelieved pain and to mood alterations such as depression and anxiety.” Like those suffering physical pain, those suffering psychological pain will respond well to treatment “if the clinician identifies and addresses it,” she said.
Before joining the NCBC, Hilliard was one of the founding members of the Connecticut Coalition to Improve End-of-Life Care, receiving a Robert Wood Johnson grant. The coalition’s primary focus is in educating “healthcare professionals and the public as to the availability and appropriateness of adequate treatment of pain and depression,” she said. Conferences have been held on a wide range of topics, including the importance of treating pediatric pain and emphasizing the need for faith-based care.
Mandating CME courses, she believes, “would be very difficult to regulate [as] much of healthcare is specialized and the needs for continuing education within the specialties can vary.” For specialties requiring board certifi - cation, which include renewals (e.g., oncology), it would be appropriate to require a certain number of contact hours in pain and depression management, Hilliard said.
THE TROUBLING OREGON EXPERIENCE
Ironically, one of the few states to require courses in both pain management and palliative care is Oregon, one of two states with legal physician-assisted suicide. The medical board has recently mandated that physicians receive six hours of coursework on palliative care and pain management by 2009.
Dr. William Toffler, MD, national director of Physicians for Compassionate Care Educational Foundation, believes that as far as the quality of palliative care and pain management in Oregon goes, “we were doing a good job in the state before physician-assisted suicide was legalized.” He stated that recent surveys show that the perception of available pain management “was better before assisted suicide was practiced.” But in Oregon, “pain relief has not improved,” he stated.
Toffler, who both practices medicine and is a professor of family medicine at Oregon Health and Science University in Portland, believes that Catholic healthcare “has lost its bearings” following the passage of the assisted suicide law. He sees no “consistency of ethics” apparent in Catholic health organizations in Oregon since legalization of assisted suicide.
Dr. Charles Bentz, MD, FACP, president of Physicians for Compassionate Care, has experienced that inconsistency fi rsthand. He is in private practice, as well as being a clinical associate professor in the Division of General Medicine and Geriatrics for the Oregon Health and Science University, but was previously a physician working for a Catholic hospital in Oregon.
Officially, the hospital has always been anti-assisted suicide. But the slow erosion Bentz witnessed of ethical standards once held by his fellow Catholic doctors is not so much the fault of Catholic healthcare institutions, he believes. Rather, it is “the insidious nature of assisted suicide that encourages doctors to take shortcuts, no longer wanting to walk with their patients” struggling through their illnesses.
The whole organized effort behind the legalization of physician-assisted suicide in Oregon has basically “sidelined” and “silenced” Catholic healthcare institutions, Bentz said. Although they are less likely to speak out publicly against the practice, the hospitals continue to put forth good palliative care practices. But increasingly physicians in the system are working at cross purposes to the hospital’s religious and ethical directives.
Bentz experienced this when a 76-year-old patient of his was discovered to have a malignant melanoma. Bentz referred him to both medical and radiation oncologists in the hospital for evaluation and therapy. The radiation oncologist reported that the man was becoming increasingly depressed as he received radiation and chemotherapy. At his final visit with his medical oncologist, the cancer sufferer expressed a wish for doctor-assisted suicide.
Rather than taking the time and effort to address his depression, or to ask Bentz to respond to the patient’s depression as his primary care physician and as someone who knew him, the medical oncologist called Bentz and asked him to be the “second opinion” for the patient’s assisted suicide. Bentz was appalled at her suggestion and refused. Soon after, the man died of a prescription for lethal overdose.
Asked if he thought the hospital could have prevented this outcome, Bentz said that improvement within the hospital could occur “with tighter rules, certainly. But what is important is enforcement.”
“It needs to start at the very top. There needs to be clear leadership from the chief administrator, the heads of all departments, including pharmacy and the president of the medical staff,” he emphasized.
“Any policy to protect the vulnerable at the end of life needs to focus on those providers caring for patients who are terminally ill (oncology, internal medicine, family medicine, hospice, palliative care) and include comprehensive evaluation and improvement of endof- life care,” Bentz explained.
But the increase in prescriptions for lethal overdose is not the only disturbing trend. Hospice care in Oregon has been subverted as well, Bentz said. Physicians decide they don’t want to continue care for certain “high cost” patients so they “hospice them”a term used for placing patients into lowcost comfort care. He believes this trend demonstrates that there exists “a second tier approach” in medicine, abandoning the most vulnerable and depressed patients for cost-cutting purposes.
“This experience has affected me, my practice, and my understanding of what it means to be a physician,” Bentz stated.
FAMILY AS THE BEST MODEL FOR HEALTHCARE
The family may be the best model for healthcare, sharing a concern for the one who is ill, and working together to find solutions.
Raviele recalled that a family member dying of AIDS 20 years ago became for her family a rallying point. As they joined efforts to help him get through the illness and resulting death, there was an unexpected return on their investment of time and concern for him.
“Our love and care for him cemented our family in a way nothing else could have done and was an important lesson to our children that this is what families dothey care for one another,” she said.
She said the experience of dying is not unlike giving birth. “The process of dying is a struggle and is often more difficult to watch than to actually experience, as any husband who has sat through hours of labor with his wife can attest,” Raviele explained.
“What our society has forgotten is that there is value in suffering,” she continued. “It is redemptive, united to Christ’s suffering, and may be of great value both for ourselves and others,” she suggested. This redemptive quality of suffering is not just for the patient’s benefit, but also “teaches patience to the caregivers.”
She added that “caregivers want to rush things, intervene to get it over,” deciding for others when and how they will die, giving the impression “that we are too busy to help them.”
As she pointed out, “We will all be dependent at some point on someone else. We hope we will have loving family members around us to help us in that final passage into eternity with their care and prayers, not with neglect.”
She continued, “Many false notions have come up today because we have become a selfish culture, centered on personal pleasure and fulfillment, rather than love of our fellow man.” Her hope for the future is that “Catholic physicians will be beacons of light to those that they care for in the dying process.”
Recalling the words of Pope John Paul II, she suggested to her fellow physicians: “Be not afraid!”