The Coronavirus and Advance Directives

Sometimes, the right policy can come at the wrong time. Consider an article on how the coronavirus has upended nursing homes, hundreds of which have at least one—and in many cases far more than one—case among residents.

A Politico newsletter discussing the article last Monday included an ominous blurb: “The National Hospice and Palliative Care Association has been pushing Congress to give more support to advance care planning, perhaps in the next stimulus bill.” While the advocates may have the best of intentions, discussing advance care directives in the context of a global pandemic raises serious ethical questions.

Planning for Worst-Case Scenarios

End-of-life care remains a touchy political subject. In 2009, following comments by Gov. Sarah Palin (R-Alaska) about “death panels,” she defended her characterization of Democrats’ health care effort by pointing to a provision in a House draft allowing Medicare to cover end-of-life counseling. While the controversy prompted congressional Democrats to drop the provision from the bill that became Obamacare, the Centers for Medicare and Medicaid Services (CMS) in 2015 approved regulatory changes allowing Medicare to pay physicians for end-of-life consultations with their patients.

In most cases, talking through options and allowing patients to determine their intended course of treatment gives patients a voice in their own care. Advance care planning—whether through a formal directive, or even informal conversations amongst family members—also takes a weighty burden off of loved ones at a time of immense stress and emotional anguish.

My mother has told me throughout my adult life that, in extreme circumstances, she does not want medical personnel using extraordinary means to extend her life. Heart-breaking as it would be for me to relay that decision to her doctors, I could at least know I did not make that decision, but instead merely relayed a wish that my mother has expressed, consistently and repeatedly, over many years.

The Power of Persuasion

Under most circumstances, encouraging individuals to have these types of end-of-life conversations with their family members and physicians represents sound medical practice and wise public policy. But the middle of a global pandemic by definition does not constitute ordinary circumstances.

Here’s one telling example from Britain’s National Health Service. The BBC obtained a document from a regional medical group based in Sussex. The document, which sets out guidance for treating coronavirus patients in nursing homes, prompted one care manager to become “deeply concerned that residents and families are being pushed to sign” do-not-resuscitate forms:

The…guidance even provides a suggested script for GPs [general practitioners] to use in conversations with residents and families, part of which says ‘frail elderly people do not respond to the sort of intensive treatment required for the lung complications of coronavirus and indeed the risk of hospital admission may be to exacerbate pain and suffering.’

It goes on: ‘We may therefore recommend that in the event of coronavirus infection, hospital admission is undesirable.’

One care manager…[said] their GP had even told them ‘none of your residents aged over 75 will be admitted to hospital.’ They said they felt ‘shocked and numb’ to hear that. Another said: ‘We have been told flatly that it would be highly unlikely that they would be accepted into hospital.’

Put aside for a moment the fact that Britain’s system of socialized medicine has prompted at least some physicians to believe they should flatly refuse medical care to senior citizens (even though Health Secretary Matt Hancock denied such a policy exists). That such a system has also pressured family members to sign do-not-resuscitate orders for their loved ones speaks to the potential dangers of combining end-of-life counseling with the pressures faced by health care providers during a pandemic.

Preserve a Culture of Life

A content-neutral conversation among a doctor and a patient about constructing an advance directive, and what instructions to put in that advance directive, is one thing, but pressuring vulnerable patients to sign do-not-resuscitate orders during a global pandemic is quite another. Common sense, confirmed by the example from Britain, suggests that given the current medical crisis, the conversations could easily veer off-track from the former to the latter.

Advance care planning has its place in health care, but now seems an inauspicious time to push for its more widespread adoption. At present, our efforts should focus not just on preserving life, but on preserving a culture of life—and hurried conversations about end-of-life care in the current pandemic could undermine that culture significantly.

This post was originally published at The Federalist.

Is Controversy Over Mammograms Looming?

The issue of mammogram coverage is about to return to the Washington agenda.

draft recommendation from the U.S. Preventive Services Task Force last month echoes a similar recommendation made in the fall of 2009. Namely, the task force recommends mammogram screening every two years for women ages 50 to 74 but does not recommend universal screening before age 50: “The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account.”

That contradicts guidelines issued by the American Cancer Society and other groups for women in their 40s and is part of a long-standing debate about whether the benefits of early detection and treatment offset the costs, including false positives and additional radiation exposure.

Obamacare moved that debate from the clinical realm into the policy world by giving the task force jurisdiction over which preventive services insurers must cover. The law references the task force more than a dozen times. Any preventive service the task force grades “A” or “B” must be covered by private insurers, Medicare, and Medicaid without cost-sharing such as co-pays or deductibles. Because the draft recommendations give a “B” grade only to biennial screening between ages 50 to 74, insurers would not be required to cover mammograms for women younger than 50 or screenings more frequent than the every-two-years regimen recommended by the task force.

When the task force issued its recommendations during the fall of 2009—at the height of the Obamacare debate—critics of the bill questioned the task force’s role in the proposed regime. Sarah Palin wondered whether cutting costs played a role in the recommendations, and a group of Republican congresswomen called them a “slippery slope” on the way to rationing. Then-Health and Human Services Secretary Kathleen Sebelius issued a statement and said that the task force had no policy-making role—statements belied by the text of the bill before Congress.

In the end, the law explicitly instructed the Department of Health and Human Services to disregard the controversial 2009 guidelines, reverting instead to a prior series of recommendations that allowed for annual coverage of mammograms for all women 40 and older. If, however, the task force re-issues the same recommendations later this year—as its April draft suggested–that would supersede all its prior reports, again raising questions about coverage of annual mammograms.

A bipartisan group from Congress has already written to HHS, asking that the draft mammogram recommendations be disregarded. Congress may in time take more explicit action to overrule the task force. But the controversy in 2009 showed that the final recommendations issued by the U.S. Preventive Services Task Force are not likely to go unnoticed—in Washington or around the country.

This post was originally published at the Wall Street Journal Think Tank blog.