Monday, August 09, 2010

End of Life: Concerns & Costs

Last week Elwood Raber, an uncle of my wife and a long-retired science teacher, died at 86 in the Masonic Village in Elizabethtown, Pennsylvania, after his body finally shut down in slow motion, like a clock not wound -- an agony for relatives to witness while recalling active times. The health care providers and hospice servants steadied that process with awareness, knowledge, and connection. In some ways, he was blessed while dying.

Twelve years after publication of a definitive study, with recommendations, by the
Institute of Medicine, entitled Approaching Death: Improving Care at the End of Life (12/01/98, 437 pages), there have been many advancements in multi-faceted care provided to those who are dying, and tangentially to their loved ones. You can read the entire report and recommendations online, free. See also: When Children Die: Improving Palliative and End-of-Life Care for Children and Their Families (07/25/02), and Describing Death in America: What We Need to Know (04/07/03), both issued by the National Cancer Policy Board.

Florence Wald, once Dean of the School of Nursing at Yale University, started the hospice movement in the United States in 1971, which now has grown to over 3,400 hospice organizations nationwide. See: Hospice founder leaves legacy (11/28/08) by Florence Dethy, published by the Yale Daily News.

Her Alma Mater, Yale University, through its medical, nursing, and theological graduate schools, has offered courses for inter-disciplinary, specialized study about all aspects of dying. See: End-of-Life Care Gets Emphasis in New Yale Curriculum (06/28/08), published in the Yale Bulletin.
The Yale School of Medicine has worked with the Schools of Nursing and Divinity, Yale Religious Ministries, and the Palliative Care Services of Yale-New Haven Hospital to develop an interdisciplinary program that will focus on symptom management, culture and spirituality, and the importance of a multi-disciplinary team approach to patient care. * * *
Still, the issue of cost expended in the treatment of those in a dying process remains largely unaddressed, because traditional medical services to those likely to die remain uncontrolled for the majority of Americans.

The staggering costs of end-of-life medical services were considered in an article originally posted Nov. 22, 2009, and updated on August 6, 2010, by CBS online in conjunction with a 60 Minutes video report (broadcast on Sunday, August 8, 2010), entitled
The Cost of Dying: End-of-Life Care Patients' Last Two Months of Life Cost Medicare $50 Billion Last Year; Is There a Better Way?
Last year, Medicare paid $55 billion just for doctor and hospital bills during the last two months of patients' lives. That's more than the budget for the Department of Homeland Security, or the Department of Education. And it has been estimated that 20 to 30 percent of these medical expenses may have had no meaningful impact. Most of the bills are paid for by the federal government with few or no questions asked.

Now you might think this would have been an obvious thing for Congress to address when it passed health care reform, but as we reported last November in the midst of the debate, what use to be a bipartisan issue has become a politically explosive one - a perfect example of the rising costs that threaten to bankrupt the country and how hard it is to rein them in.* * *
The future for many people who face death in hospitals is chilling, and so are the bills left behind:
[I]t costs up to $10,000 a day to maintain someone in the intensive care unit. Some patients remain here for weeks or even months; one has been there for six months.

"This is the way so many Americans die. Something like 18 to 20 percent of Americans spend their last days in an ICU," [Dr. Ira] Byock told Kroft. "And, you know, it's extremely expensive. It's uncomfortable. Many times they have to be sedated so that they don't reflexively pull out a tube, or sometimes their hands are restrained."

"This is not the way most people would want to spend their last days of life. And yet this has become almost the medical last rites for people as they die." * * *
While end-of-life patients are suffering from such therapies, medical resources become directed from progressive healing to simply sustaining, and the patient or relatives may not consider alternatives that may be more "multi-disciplinary" and personal.
After analyzing Medicare records for end-of-life treatment, Fisher is convinced that there is so much waste in the present system that if it were eliminated there would be no need to ration beneficial care to anyone.

Multiple studies have concluded that most patients and their families are not even familiar with end-of-life options and things like living wills, home hospice and pain management.* * *
My friend, Ron Grenoble, a kind, intelligent, and quiet man, had sent the link for this article to me earlier today in an email.

He highlighted one quote, noteworthy for him, and now for me too:

Dr. Byock . . . says "modern medicine has become so good at keeping the terminally ill alive by treating the complications of underlying disease that the inevitable process of dying has become much harder and is often prolonged unnecessarily. . . . This is a hard time in human life. But it's just a part of life," Byock said.

"Collectively, as a culture, we really have to acknowledge that we're mortal," he said.

Tuesday, August 03, 2010

"Wills for Heroes" Workshops Multiply in PA & DE

The Pennsylvania Bar Association presses forward on its successfully-sponsored "Wills for Heroes" program, promoted by its Young Lawyers Division.

The program is described by the PBA-YLD as follows:

“Wills for Heroes” provides police, fire and emergency medical personnel -- those on the frontlines for our personal safety -- the tools they need to prepare adequately for the future.

Programs are staffed by lawyer volunteers and are conveniently offered to first responders at meeting halls and police and fire stations.

The PBA and the Wills for Heroes Foundation are hosting upcoming events to provide free wills and powers of attorney to first responders -- police officers, firefighters, paramedics and other men and women who risk their lives every day to make sure our communities are safe.* * *

The PBA's Wills for Heroes program is also described in a flyer for volunteers (PDF) posted online.

In two blog posts over the past two years, I tracked such personal and estate planning services offered free to certain first responders in Pennsylvania, beginning at a county bar association level and then advancing into statewide PBA sponsorship. See:
Firefighters, First Responders, and Free Wills (05/15/08) and PBA's Young Lawyers Sponsor "Wills for Heroes" (05/09/09). That organized effort now has strengthened and matured in Pennsylvania, which was the 21st state to endorse and implement the national Wills for Heroes program.

n September, 2009, that effort was cited nationally as a model and symbol of volunteerism. See: Pennsylvania Governor Ed Rendell and U.S. Transportation Secretary Ray LaHood honor the Wills for Heroes Foundation.

Pennsylvania Governor Ed Rendell's Press Release, entitled Governor Rendell Commends Volunteers on National Day of Service and Remembrance (09/11/09), as posted by, stated, "There is no better example of the spirit of volunteerism than the Wills for Heroes project that we are seeing in action today, and it is especially appropriate as we observe the anniversary of the terrible events of 9/11."

Law school students, such as those I teach at Widener University School of Law (Harrisburg Campus), and those at
WLS (Delaware Campus) joined the movement in public workshops held Saturday, April 17, 2010. The Harrisburg (Dauphin County) event is the subject of an online photo gallery posted by the PBA.

WLS-Delaware students held their second "Wills for Heroes" event on July 10, 2010, when "nearly 60 clients turn out to receive pro bono legal services." See: Delaware Campus Hosted Another Successful Wills for Heroes Event (07/27/10).

The event saw volunteer attorneys prepare wills, advance health care directives, and financial powers of attorneys free of cost for Delaware firefighters, paramedics, police officers, corrections officers, probation officers, and their spouses or partners. * * *

The law school places such an emphasis on public service that it just made sense to bring the two together. Everyone quickly became committed to the idea of Widener being the vessel that makes this opportunity available to Delaware’s emergency service workers.”

Widener Law’s Delaware campus hopes to coordinate a Wills for Heroes document-preparation event once a semester. Subsequent events will move around to the First State’s three counties. Widener Law, the official Delaware affiliate of the Wills for Heroes program, ran its first event on April 17th. * * *
The effort in Pennsylvania still appears rooted in practitioners and their staff. In its August 2, 2010 electronic bulletin to members, the Pennsylvania Bar Association requested assistance for further workshops scheduled around the state:
At least 10 to 20 lawyers, three or four notaries (who aren't required to be lawyers) and several witnesses (anyone over the age of 18) are needed for each event.

Lawyer volunteers do not need to practice trust and estate law. A mini-course will be given the morning of the event to familiarize volunteers with what they need to know. Also, several lawyers well-versed in estate planning will be available during the day to answer any questions that may arise. * * *

New volunteers are asked to complete the
online registration form
. * * *
That bulletin noted upcoming Wills for Heroes events in Pennsylvania:
Bucks County (Contact coordinators Lisa A. Shearman and Jennifer Murphy)
  • Aug. 7: Trevose Fire Company, Trevose
  • Aug. 28: Trevose Fire Company, Trevose
  • Sept. 11: Public Safety Training Center, Doylestown
Lackawanna County (Contact coordinator Jason Morrison)
  • Oct. 2: Scranton Police Department, Scranton
Montgomery County (Contact coordinator Shearman)
  • Sept. 25: Montgomery Township Fire Department, Montgomeryville
York County (Contact coordinator Mac Brillhart)
  • Sept. 18: York Township Emergency Service Personnel, York
According to the PBA's bulletin, "For more information about the Wills for Heroes program, send an e-mail to Dan McKenna or Lisa A. Shearman and visit the Wills for Heroes Foundation website and the PBA Young Lawyers Division website."