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MORTALITY, MORALITY & HONOR: THE END-OF-LIFE PARADIGM.

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1 MORTALITY, MORALITY & HONOR: THE END-OF-LIFE PARADIGM

2 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level DA VINCI’S VITRUVIAN MAN VITRUVIUS 25 B.C. THE CIRCLE REPRESENTS THE COSMIC & THE DIVINE THE SQUARE, THE EARTHLY & THE SECULAR

3 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level THE GOAL: LINEAR TO CIRCULAR THE LONG FLAT TABLE NO LONGER

4 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level ANOTHER “DR DEATH ?” MY MANTRA GROW OLDER & DIE YOUNG AS LATE AS POSSIBLE PLAN ON IT PLAN FOR IT

5 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level AND MY WISH? TO WRITE MY LAST CHAPTER…. AND WHEN IT IS READ, A LONG TIME FROM NOW, HAVE IT BE RECOGNIZED AS A WORK OF NON- FICTION

6 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level A CONSTANT ? OR AN EVER-CHANGING LANDSCAPE ? IF YOU WANT TO HIT A BIRD ON THE WING YOU MUST HAVE YOUR MIND IN FOCUS. YOU MUST HAVE THAT BIRD IN YOUR MIND’S EYE. EVERY GREAT ACHIEVEMENT IS A BIRD ON THE WING. OLIVER WENDELL HOLMES Jr

7 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level IF YOU A WANT “BEST” READ A “MUST” READ ATUL GAWANDE MD “LETTING GO” NEW YORKER AUG 12, 2010

8 WHY NOW ? WHY HERE ? A BIG ISSUE A DIVISIVE ISSUE A “CIVIL” RIGHTS BATTLE

9 What Percent of People Will Eventually Die?

10 AND IT WON’T BE EASY GALLUP’S VALUES AND BELIEFS POLL - MAY ‘10 DWD - PAS 45 % - IT’S MORALLY ACCEPTABLE 32 % - IT’S MORALLY WRONG

11 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level “IT” THE RIGHT, IN ADULTS OF SOUND MIND, TO EXERCISE CHOICE AND CONTROL FOR THEM- SELVES AT THE END OF LIFE

12 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level DOES THIS MAKE A DIFFERENCE ? NATIONWIDE, RECENT POLLS SHOW THAT >70% OF AMERI- CANS BELIEVE THAT TERMIN- ALLY PATIENTS SHOULD HAVE THE RIGHT TO SELF-ADMINISTER A LETHAL MEDICATION TO ACHIEVE A PEACEFUL DEATH.

13 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level I KNOW- POLLS ! ‘05 GALLUP 75% SAID YES TO DOCTORS BEING ALLOWED TO HELP THE TERMINALLY ILL DIE BUT ONLY 58% SAID YES WHEN THE WORD SUICIDE WAS INCLUDED

14 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level BUT INCREASINGLY THE COURTS AND THE PUBLIC RECOGNIZE THAT TERMINALLY ILL PATIENTS ASKING FOR AID IN DYING ARE NOT “SUICIDAL” AND PROVIDING SUPPORT IS NOT “ASSISTING SUICIDE.”

15 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level SO WHO IS AGAINST PHYSICIAN ASSISTED DEATH ? THREE BROAD CATEGORIES: SANCTITY OF LIFE MUST BE PRESERVED THE SLIPPERY SLOPE MUST BE PREVENTED THE MEDICAL SYSTEM CAN ELIMINATE OR ALLEVIATE END-OF-LIFE SUFFERING

16 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level WITH ALL DUE RESPECT U.S. CONFERENCE OF BISHOPS –‘11 “ALL PATIENTS – INCLUDING THOSE IN THE SO-CALLED PERSISTENT VEG- ETATIVE STATE – BE PROVIDED WITH ARTIFICIAL HYDRATION AND NUTRITION IF SUCH CARE COULD EXTEND LIFE, EVEN INDEFINITELY.”

17 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level CATHOLIC ETHICAL & RELIGIOUS DIRECTIVES – (CERD’s) “VIRTUE IS PROTECTING & PRO- LONGING LIFE, OVER ALL VIRTUES, OVERRULING PATIENT CONCERNS ABOUT THEIR QUALITY OF LIFE.” “PATIENTS EXPERIENCING SUFFER- ING THAT CANNOT BE ALLEVIATED SHOULD BE HELPED TO APPRECIATE THE CHRISTIAN UNDERSTANDING OF REDEMPTIVE SUFFERING.” IRONY TO ANXIETY: 40 % OF HOSPITALS…… IRONY TO HYPOCRISY: IF WE ARE GOING TO A BETTER PLACE ?…..

18 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level THE HIPPOCRATIC OATH ORIGINAL ENGLISH TRANSLATION: “I WILL NOT GIVE A LETHAL DRUG TO ANYONE IF I AM ASKED” MODERN TRANSLATION: “I WILL REMEMBER THAT THERE IS AN ART TO MEDICINE AS WELL AS SCIENCE, AND THAT WARMTH, SYM- PATHY AND UNDERSTANDING MAY OUTWEIGH THE SURGEON’S KNIFE OR CHEMIST’S DRUG”

19 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level THE MANTRA – THE MYTH DOES PAD, (DWD), CONTRA- DICT A PHYSICIAN’S RE- SPONSIBILITY TO PRESERVE LIFE? COMPASSION: THE HUMANE QUALITY OF UNDER- STANDING THE SUFFERING OF OTHERS AND THE DESIRE TO DO SOMETHING ABOUT IT

20 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level IRONY WHAT WOULD HAPPEN IF THERE WERE NO MORE DEATH ? WE WOULD HAVE NO NEED FOR PROGRESS OR ART, FAITH OR FAME WE WOULD HAVE LITTLE TO DO YET IN THE GREATEST OF IRONIES, HAVE ENDLESS EONS IN WHICH TO DO IT. ACTION WOULD LOSE IT’S PURPOSE, TIME ITS VALUE

21 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level THE “SLIPPERY SLOPE” WILL ADVANTAGE BE TAKEN NO, ABSOLUTELY NOT! RATES OF ASSISTANCE IN STATES, (COUNTRIES), WHERE DWD IS LEGAL SHOW ABSOLUTELY NO BIAS AGAINST THE ELDERLY THE UNINSURED THE UNEDUCATED THE MINORITIES THE POOR A REVERSE SLOPE ? THE W & W - THE D & A

22 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level AND AS FOR COMPLETE RELIEF LET US ASK WHY PALLIATIVE CARE HAS EMERGED AS A RESPECTED & ESSENTIAL PART OF OUR MEDICAL LANDSCAPE - ONLY RECENTLY ! COLORADO SB

23 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level PAIN & COMPASSION (PLEASE REFLECT ON IT)

24 WHAT ARE WE GOOD AT ? OUR MEDICAL SYSTEM IS EXCELLENT AT TRYING TO STAVE OFF DEATH WITH: ICU CARE $5,OOO+/DAY CHEMOTHERAPY $8,OOO/MO SURGERY $5,000/HR BUT ULTIMATELY, THE OWL CALLS OUR NAMES

25 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level AND NOT SO GOOD AT ? “AGAINST OTHER THINGS IT IS POSSIBLE TO GAIN SECURITY, BUT WHEN IT COMES TO DEATH WE HUMAN BEINGS ALL LIVE IN AN UNWALLED CITY.” “NO ONE WANTS TO DIE. EVEN PEOPLE WHO WANT TO GO TO HEAVEN DON’T WANT TO DIE TO GET THERE. YET DEATH IS THE DESTINATION WE ALL SHARE.”

26 AND DOES OUR MEDICAL PROFESSION HAVE A PROBLEM WITH THIS ? JENNIFER TEMEL MD – MGH NEJM 2010 (RANDOM ASSIGNMENT OF 151 ADV LUNG CANCER PTS TO “REGULAR CARE OR CARE & EARLY DISCUSSIONS WITH PALLIATIVE CARE GROUP TWO: BETTER QUALIITY OF LIFE & LESS TROUBLESOME SYMPTOMS IN TIME REMAINING PHYSICIANS SHOWED A BETTER APPRECIATION OF PT’S WISHES & WERE MORE LIKELY TO RECOMMEND CARE CONGRUENT WITH THOSE WISHES FAMILIES SHOWED LESS GUILT & DEPRESSION AFTER THE DEATH. GROUP TWO LIVED A LITTLE LONGER TOO (2.7M)

27 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level MORE ? - THE KEATING STUDY (CANCER ) NANCY L KEATING MD, MPH HARVARD MEDICAL SCHOOL BY QUESTIONAIRRE, (4,000+ PHYSICIANS CARING FOR CANCER PATIENTS LOOKED AT TIMING OF DISCUSSIONS ON 1. ACCURATE PROGNOSIS 2.WISH FOR “DNR” 3. NEED FOR HOSPICE 4. PREFERRED SITE OF DEATH CONCLUSIONS: MOST PHYSICIANS REPORT THEY WOULD NOT DISCUSS END-OF-LIFE OPTIONS WITH TERMINALLY ILL PATIENTS WHO ARE FEELING WELL. “THERE WILL BE TIME FOR THAT LATER.” BE ADVISED, TALKING ABOUT DYING WON’T KILL YOU, THOUGH…………………

28 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level A DOUBLE STANDARD ? “WHY DOCTORS DIE DIFFERENTLY” KEN MURRAY CAP - FAMILY MEDICINE UNIV SO CAL WSJ 3/10/12

29 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level HONESTY – THE BEST POLICY ? HEALTH AFFAIRS JOURNAL FEB, 2012 POLL OF 2000 MD’s MORE THAN HALF HAD FRAMED A PROGNOSIS IN A MORE POSITIVE LIGHT THAN WAS WARRENTED

30 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level SIGNS OF CHANGE ? 2011 SURVEY BY THE REGENCE FOUNDATION ON BEHALF OF THE NATIONAL JOURNAL FOUND THE 96% OF MD’s BELIEVE IT’S MORE IMPORTANT TO IMPROVE PATIENT’S QUALITY OF LIFE THAN TO PROLONG THEIR LIVES. 79% OF MD’s SURVEYED SAID: “U.S. SPENDS FAR TOO MUCH TRYING TO EXTEND LIVES”

31 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level ALZHEIMER’S DISEASE “A DEGENERATIVE DISEASE THAT IS 100% INCURABLE AND 100% FATAL, WHICH ROBS ITS VICTIMS OF MEMORY, JUDGEMENT & DIGNITY, LEAVING THEM UNABLE TO CARE FOR THEMSELVES, AND DESTROYING THEIR BRAIN AND THEIR DIGNITY, OFTEN DEPLETING THE RESOURCES OF THEIR CAREGIVERS AND THEIR FAMILIES – BOTH EMOTION- ALLY & FINANCIALLY. JUSTICE SANDRA DAY O’CONNOR OCTOBER 27TH, 2010 NY TIMES

32 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level AND A SOBERING THOUGHT STARTING ON JAN 1, OUR 79 MILLION STRONG BABY BOOM GENERATION WILL BE TURNING 65 AT THE RATE OF 1 EVERY 8 SECONDS ! AND THE REALITY IS THAT THE INCIDENCE OF DEMENTIA DOUBLES EVERY FIVE YEARS AFTER 65

33 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level KAREN KEHL – Am J Hosp & PC “MOVING TOWARD PEACE” A GOOD DEATH BEING COMFORTABLE BEING IN CONTROL HAVING A SENSE OF CLOSURE MAKING MOST OF RELATIONSHIPS HAVING FAMILY INVOLVED

34 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level IN WHICH IS THERE TIME FOR…

35 MORTALITY, MORALITY & HONOR CHOICES AT THE END OF LIFE

36 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level THE SEMINAL CASE KAREN ANN QUINLAN CHRONIC VEGATATIVE STATE PARENTS REQUEST “WITHDRAWAL” NJ SUPREME COURT RULES IN FAVOR OF THE “RIGHT TO REFUSE ARTIFICIAL VENTILATION”

37 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level KAREN ANN QUINLAN THE FATHER, A FIRM CATHOLIC, AND THE ASSIGNED GUARDIAN, WAS A POSITVE FORCE IN THIS CASE, FOR ADDRESSING HIS CONSCIENCE AND MOTIVATIONS THE FIRST CASE ABOUT THEOLOGY, BIOETHICS, EUTHANASIA, LEGAL GUARDIANSHIP AND CIVIL RIGHTS POSITIVES: BIOETHICS COMMITTEES ADVANCE DIRECTIVES

38 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level TERRI SHAIVO – CVS – 1990-’05 ESSENTIALLY, A TRAGEDY: OF PERSONAL LIVES OF THE LAW OF POLITICS ULTIMATELY, AN EMBARRASSMENT ( READ “USING TERRI”)

39 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level THE HISTORY OF END-OF-LIFE CHOICES IN THE UNITED STATES ‘87, ’89, ’91: OREGON WRITES LEGISLATION GRANTING INDIVIDUAL OPTIONS FOR END- OF-LIFE (SS FRANK ROBERTS) NO BILL LEAVES COMMITTEE ROBERTS DIES A HARSH DEATH AT HOME AT LEAST – OCT ‘93 ‘94 OREGON PASSES VOTER INITIATIVE TO ALLOW DWD (51 TO 49 %) (SIGNED INTO LAW BY ROBERT’S WIFE & GOVERNOR, BARBARA ROBERTS )

40 INTERCONNECTIONS APRIL, ‘93, AT THE PEAK OF THE AIDS EPIDEMIC, ACTIVISTS ESTAB- LISH “COMPASSION IN DYING” IN SEATTLE, WASHINGTON, PUBLI- CALLY DECLARING THEIR INTENTION TO COUNSEL MENTALLY COMPETENT, TERMINALLY ILL PATIENTS ON AID-IN-DYING. PUBLISHED WERE SPECIFIC ELIGIBILITY CRITERIA, GUIDELINES AND SAFEGUARDS AND VOLUNTEERS TO ATTEND DEATH. A MEDICAL MODEL EVOLVES WITH CLIENT ASSESSMENT, PROFES- SIONAL REFERRALS, AN INTERDISCIPLINARY TEAM OF VOLUNTEERS AND SELF-ADMINISTERED MEDICATION.

41 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level Ninth Outline LevelClick to edit Master text styles JUNE, 1997   “THROUGHOUT THE NATION, AMERICANS  ARE ENGAGED IN AN EARNEST AND PRO-  FOUND DEBATE ABOUT THE MORALITY,  LEGALITY AND PRACTICALITY OF PHY-  SICIAN AID IN DYING. OUR HOLDING  PERMITS THIS DEBATE TO CONTINUE,  AS IT SHOULD IN A DEMOCRATIC SOCIETY.”

42 Median Age 70 (25-96) White % Education - 67% had attended college Suffering from cancer % Enrolled in hospice % Insurance % Sex % Male % Female 94% died at home Facts on Use of Oregon Law

43 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level OREGON AT 14 YEARS I CONTEND NO “SLIPPERY SLOPE” BUT AN AGING POPULATION WITH MORE CHRONIC DISEASE AND MORE KNOWLEDGE

44 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level “REASONS FOR ‘CHOICE’” LOSING AUTONOMY 89.9 % CANNOT ENGAGE IN PLEASURABLE ACTIVITIES 87.4 % LOSING CONTROL OF BODILY FUNCTIONS 58.7 % BURDEN TO FRIENDS 39.3 % INADEQUATE PAIN CONTROL 23.9 % FINANCIAL CONSIDERATIONS 2.8 %

45 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level THE “HOW TO” A TERMINALLY ILL, COGNITIVELY SOUND ADULT, MAY OBTAIN A Rx FOR A LETHAL DOSE OF MEDICINE, PROVIDED THE PATIENT: 1. HAS BEEN ADVISED OF OTHER OPTIONS 2. HAS MADE TWO VERBAL APPEALS / 15D 3. HAS MADE A WRITTEN REQUEST 4. WITNESSED BY TWO WHO ARE NOT CARETAKERS OR FAMILY 5. ORAL, NOT IV MEDS / HELIUM

46 OUR GOVERNMENT IN MEDICINE

47 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level OBAMA CARE & “DEATH PANELS” FROM AN OFTEN CITED PROVISION OF THE UNPASSED BILL WHICH WOULD HAVE AUTHORIZED MEDICARE REIM- BURSEMENT FOR PHYSICIANS WHO WOULD PROVIDE VOLUNTARY COUN- SELING ABOUT SUCH SUBJECTS AS PATIENT & FAMILY WISHES, LIVING WILLS, AD’s………….. CHOICES…….. AT THE END OF LIFE

48 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level AH…. WHAT TO MAKE OF IT BETSEY McCOUGHEY VP CANDIDATE PALIN “MY PARENTS & MY BABY WITH DOWN’S SYNDROME WILL HAVE TO STAND IN FRONT OF OBAMA’S DEATH PANAL SO BORED BUREAUCRATS CAN DECIDE, BASED ON SUBJECTIVE JUDGEMENT, ON THEIR ‘LEVEL OF PRODUCTIVITY IN SOCIETY’, WHETHER THEY ARE WORTHY OF HEALTH CARE.” “NULLIUS IN VERBA”

49 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level THE FALLOUT STUDIES SHOWED THAT 30 TO 45 % OF AMERICANS BELIEVED THIS RHETORIC

50 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level MORE GOVERNMENT JANUARY 1, 2012 – CREATION OF “INDEPENDENCE AT HOME ORGANIZATIONS” – GROUPS OF DOCTORS & NURSES TO Rx PTS AT HOME & INCENTIVES TO MAKE THAT WORK APPEALING. PAID FOR BY SAVINGS FROM DIMINISHING HOSPITAL STAYS AND PROCEDURES

51 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level AND AGAIN ? IN THE AHCA, IN 2014, THE INDEPENDENT PAYMENT ADVISORY BOARD, (IPAB), MAKES RECOMMENDATIONS ON COST SAVINGS, YET IS EXPRESSLY PROHIBITED FROM TAKING ANY ACTION WHICH WOULD RATION CARE. BUT…………..

52 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level AN INTERESTING POLL FIFTY-THREE % OF AMERICANS WOULD JUST AS SOON SEE THE HEALTH CARE BILL REPEALED. FORTY-THREE % SUPPORT IT. OF INTEREST, 70% OF THE 53% OPPOSED, FAVOR 2/3 OF THE BULLETS CONTAINED IN THE BILL.

53 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level THERE’S AN ARGUMENT ANY CENTRALLY ADMINISTERED HEALTH-CARE SYSTEM WILL, INEVITABLY, MAKE “COST-MINDED JUDGEMENTS ABOUT WHAT TYPES OF CARE” SHOULD BE PRO- VIDED TO WHICH CATEGORIES OF PATIENT ALREADY HAPPENING ARIZONA: THE STATE CUT OFF REIMBURSE- MENTS FOR ORGAN-TRANSPLANTS FOR THE POOR

54 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level NEVER TALK ABOUT THE COST (BUT BE REMINDED) 25 %OF ALL MEDICARE SPENDING IS FOR THE 5 %OF PATIENTS WHO ARE IN THE FINAL YEAR OF LIFE, AND MOST OF THAT MONEY GOES FOR CARE IN THEIR LAST MONTHS OF LIFE WITH LITTLE BENEFIT IN TERMS OF LONGEVITY OR QUALITY OF LIFE. (ABOUT 60 BILLION) AND THE PSYCHOLOGICAL, PHYSICAL AND FISCAL COST TO FAMILIES ? OF COURSE, WE DON’T KNOW IT’S THE LAST MONTHS

55 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level CURRENTLY THE LEGAL RIGHT OF EVERY CITIZEN IN EVERY STATE A COMPETENT ADULT PATIENT HAS THE RIGHT TO REFUSE UN- WANTED MEDICAL TREATMENT THAT COULD INCLUDE DIALYSIS, SURGERY, BLOOD TRANSFUSIONS, ANTIBIOTICS AND ARTIFICIAL LIFE SUPPORT, EVEN WHEN REFUSAL MIGHT LEAD TO DEATH. THIS RIGHT EXISTS EVEN IF THE PATIENT IS NOT TERMINALLY ILL.

56 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level WHAT ABOUT OUR CITIZENRY ? “DO YOU APPROVE OR DISAPPROVE OF LAWS THAT LET PATIENTS DECIDE ABOUT BEING KEPT ALIVE THROUGH MEDICAL TREATMENT?” 84% APPROVE PEW RESEARCH CENTER ’01-’05

57 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level WHO’S SIDE ARE YOU ON? (IS IT NOT PART OF OUR LEGAL DNA?) “THE ROOT PREMISE IS THE CONCEPT, FUNDAMENTAL IN THE AMERICAN JURISPRUDENCE SYSTEM THAT EVERY HUMAN BEING OF ADULT YEARS AND SOUND MIND HAS A RIGHT TO DETERMINE WHAT SHALL BE DONE WITH HIS OWN BODY.” JUSTICE BENJAMIN CARDOZO NY COURT OF APPEALS 1914 (US SUPREME COURT )

58 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level A DEVIL’S ADVOCATE – MAY I ? A FEW THOUGHTS ON END-OF-LIFE PLANNING

59 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level STEPHEN JAY GOULD BROOKLYN/HARVARD PALEONTOLOGIST ‘85 ESSAY:« THE MEDIAN & THE MESSAGE » Dx; ABDOM MESOTHELIOMA - ‘85 THE LITERATURE: BRUTAL (8MO’s) BUT THE CURVE BEYOND THE MEDIAN WITH A LONG, ALBEIT, SLENDER TAIL INTERESTED GOULD GOULD GETS SURGERY & CHEMO - AND TWENTY YEARS – D ‘02

60 A NATURALIST SPEAKS “IT HAS BECOME, IN MY VIEW, A BIT TOO TRENDY TO REGARD ACCEPTANCE OF DEATH AS SOMETHING TANTAMOUNT TO INTRINSIC DUTY. OF COURSE I AGREE WITH THE PREACHER IN ECCLESIASTES THAT THERE IS A TIME TO LIVE AND A TIME TO DIE, AND WHEN MY SKEIN RUNS OUT I HOPE TO FACE THE END CALMLY AND IN MY OWN WAY. FOR MOST SITUATIONS, THOUGH, I PREFER THE MARTIAL VIEW THAT DEATH IS THE ULTIMATE ENEMY AND I FIND NOTHING REPROACHABLE IN THOSE WHO ‘RAGE MIGHTILY AGAINST THE DYING OF THE LIGHT.’” STEPHEN JAY GOULD 1985

61 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level SO WHAT IS IT WE REALLY WANT SIMPLY, NOTHING MORE THAN YOU WANT CHOICE AND CONTROL AT THE END! HENCE: ADVANCE DIRECTIVES EUREKA!!!

62 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level AD’S & THE ULLYSES PACT A FREELY MADE DECISION THAT IS INTENDED TO BIND ONESELF IN THE FUTURE IN MEDICINE, WITH AD’s & LW’s, THERE EXISTS CONTROVERSY OVER WHETHER DECISIONS MADE BY ONE IN ONE STATE OF HEALTH CAN BIND ONE IN ANOTHER WHEN AM “I” NOT “ME” ?

63 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level COMPASSION & CHOICES WHO WE ARE AND WHY YOU SHOULD GET TO KNOW US

64 ABOUT US Compassion & Choices is the oldest and largest nonprofit organization advocating for comprehensive end-of-life care and treatment options. Founded in 1980 as the Hemlock Society, and merged with Compassion in Dying in 2004, over the years the organization has grown, become more mainstream and now focuses on improving care and expanding choice at the end of life.

65 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level A YOUNG ORGANIZATION – WITH TIMELESS CHALLANGES 1980 – HEMLOCK SOCIETY 2003 – FOUNDER, DH, LEAVES TO FORM “FINAL EXIT” 2004 – “COMPASSION & CHOICES”

66 Clients need not be members Clients need not be “terminally ill” Services may include referral to other specialists, organizations, or officials We never charge for services Eligibility for Services

67 DYING USED TO BE ACCOMPANIED BY A PRESCRIBED SET OF CUSTOMS REAFFIRM ONE’S FAITH REPENT ONE’S SINS LET GO OF WORDLY AFFAIRS LAST WORDS

68 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level AND A COMFORT TO ALL - A WORD ABOUT HOSPICE BRITISH MD – DAME CICELY SAUNDERS 1940’S ST. CHRISTOPER’S – LONDON 1964 YALE SCHOOL OF NURSING THE CONNECTICUTT HOSPICE 1974 “WE DO NOT HAVE TO CURE TO HEAL” US MD – ELISABETH KUBLER-ROSS “ON DEATH AND DYING” FIVE STAGES OF GRIEF “IT HAS BROUGHT DEATH OUT OF THE DARKNESS”

69 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level HOSPICE - A COMFORT TO ALL ? MEDICARE COSTS FOR HOSPICE HAVE INCREASED MORE THAN IN ANY OTHER HEALTH CARE SECTOR ‘05 TO ‘10 – 70% !! IN 2010, 42% OF DEATHS OCCURRED IN HOSPICES (22% IN ICU’s) MEDICARE PAYS FOR 84% OF ALL HOSPICE PATIENTS - (<6 MOS & ACCEPTANCE)

70 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level “AMERICAN” HOSPICE PROBLEMS ON THE HORIZON ? HOSPICE NOW A $4.5 BILLION PER YEAR INDUSTRY 40% OF HOSPICES ARE NOW “FOR PROFIT” AND COSTS ? 29% HIGHER/PT AND NOW ? FRAUD ? LAWSUITS ?

71 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level IS THERE ANY CHANCE THAT WE CAN COME TOGETHER AND ALL BE OF ONE “MIND” - BE IT AS ZEBRAS OR HORSES?

72 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level CAN IT BE DONE ? YES, IF WE RECOGNIZE THAT…. “EVERY GREAT ACHIEVEMENT IS A BIRD ON THE WING.”

73 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level JOHANN WOLFGANG von GOETHE “AS LONG AS YOU ARE NOT AWARE OF THE CONTINUAL LAW OF DIE AND BE AGAIN, YOU ARE MERELY A VAGUE GUEST ON A DARK EARTH.”

74 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level HEMINGWAY “THE WORST DEATH FOR ANYONE IS TO LOSE THE CENTER OF HIS BEING, THE THING HE REALLY IS” IS THERE A TIME AND A PLACE HERE TO SAY………………… % OF DEATHS OCCURRED IN AN ICU

75 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level THE GRATEFUL DEAD STANDING IN A SHAFT OF LIGHT RISING UP TO PARADISE, I KNOW I’M GONNA SHINE

76 ACCEPTANCE OF DEATH WHEN IT ARRIVES IS ONE THING, BUT TO ALLOW IT TO UPSTAGE THE JOYS OF LIVING IS INGRATITUDE

77 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level LIFE – A CIRCLE OR A LINE ? “ I LIVE MY LIFE IN WIDENING CIRCLES THAT REACH OUT ACROSS THE WORLD. I WILL NOT COM- PLETE THIS LAST ONE, BUT I GIVE MYSELF TO IT” RANIER MARIA RILKE

78 MORTALITY AND MORALITY HONOR CHOICE AT THE END OF LIFE

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80 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level SO THE QUESTION IS NOT “WILL I DIE?” BUT “WHEN AND HOW?” NO, LIFE & DEATH ARE NOT “THE FLAT TABLE”

81 Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level  Ninth Outline LevelClick to edit Master text styles – Second level  Third level – Fourth level  Fifth level THERE ARE TWO KINDS OF LIGHT THOSE THAT GLOW AND ILLUMINATE AND THOSE THAT GLARE AND OBSCURE

82 “ NOT A SHRED OF EVIDENCE EXISTS IN FAVOR OF THE ARGUMENT THAT LIFE IS SERIOUS, THOUGH IT IS OFTEN HARD AND EVEN TERRIBLE. SINCE EVERYTHING ENDS UP BADLY FOR US, IN THE INESCAPABLE CATASTROPHE OF DEATH, IT SEEMS OBVIOUS THAT THE FIRST RULE OF LIFE IS TO HAVE A GOOD TIME; AND THE SECOND RULE OF LIFE IS TO HURT AS FEW PEOPLE AS POSSIBLE IN THE COURSE OF DOING SO. THERE IS NO THIRD RULE.”


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