Tuesday, April 29, 2008

Back to St. Andrew's

It’s time to return again to the St. Andrew’s Draft of the Draft Anglican Covenant. (I know that repeating Draft might seem redundant. Since even acceptance that there will, much less should be, an Anglican covenant, I think we need to emphasize that we are dealing with drafts of a proposal, rather than drafts of an agreed goal.) It’s time again because Bonnie Anderson, President of the House of Deputies of the Episcopal Church, has asked deputies to study and reflect, and to inform their bishops of their reflections, before the bishops come to Lambeth. Since sometimes I reflect best through my fingers (and am less likely to lose those reflections), I’m going work out some of the reflections here. I realize I have already written some reactions to the St. Andrew’s Draft. On the other hand, it can’t hurt for me to work through the process. I expect I’ll notice some things I’ve missed before.

The recommended process is a bit different this time. The structure speaks of three “levels of engagement.” So, to begin at the beginning, let me start with the first. These are the instructions:

I. First Level of Engagement with the Text
Read the Saint Andrew’s Draft Covenant in its entirety: Introduction, Covenant, and Appendix.1
After reading, consider the following initial questions:
• What in the document did you find compelling? What resonated with you and why?
• What in the document caused you the most concern and why?
• What in the document surprised you the most and why?

My first reaction to the Introduction? That it would be an interesting “covenant” in and of itself. It is interesting to think we might “covenant together as churches of this Anglican Communion to be faithful to God’s promises through the historic faith we confess, the way we live together and the focus of our mission,” although I admit some concern about what “the need for mutual commitment and discipline” might mean. I find attractive the sentence, “We seek to adore God in thanks and praise and to make intercession for the needs of people everywhere through a common voice, made one across cultures and languages,” as a description of “common prayer.”

I am struck, too, by the mention of “a special charism and identity” for the Anglican Communion. My hope would be that those would be addressed. After all, the intent of our beloved Chicago-Lambeth Quadrilateral was not to describe Anglican identity, but those characteristics that would identify other Christian bodies as sufficiently similar as to make possible full communion.

Then, too, there is paragraph 7, written as one long, convoluted sentence:

Our faith embodies a coherent testimony to what we have received from God’s Word and the Church’s long-standing witness; our life together reflects the blessings of God in growing our Communion into a truly global family; and the mission we pursue aims at serving the great promises of God in Christ that embrace the world and its peoples, carried out in shared responsibility and stewardship of resources, and in interdependence among ourselves and with the wider Church.

There is an interesting lean here toward our cherished “three-legged stool” in beginning with reference to “God’s Word and the Church’s long-standing witness.” In that light, though, is “our life together” intended as a description of what we might mean by “reason” in the Anglican triad? If so, I’m not sure I think it sufficient.

Looking now at the Covenant draft, what strikes me generally is that there is much in the sections of Affirmations that I can agree with. As I have written before, I think the section intended to reflect the Quadrilateral is weak in its reference to the Creeds. I think, too, there is a general preference for the past over the present. That is, there is much focus on guidance from Scripture and Tradition, and little explicit incorporation of Reason.

The difficulties (I will not speak of the devil here) are in the details, and especially in the details of the Commitments. This is, I think, where the most difficulties in discussion and reception will come. I don’t think it’s a matter of rejecting the idea of commitments (notwithstanding that a few want to do just that). Rather, I think it’s about how we will negotiate apparent contradictions. For example, of what value is “respect [for] the constitutional autonomy of all of the Churches of the Anglican Communion,” or “spend[ing] time with openness and patience in matters of theological debate and reflection to listen, pray and study with one another in order to discern the will of God,” if the ultimate results are “to be willing to receive from the Instruments of Communion a request to adopt a particular course of action in respect of the matter under dispute,” potentially to accept or be shunned?

So, on to the Appendix: and here I am most struck by a strong desire not to live in tension, and a sense of haste in resolution. Resolution here has displaced our previous understanding of reception, in that no one province need tolerate difference with another and discover whether there is something there to be learned. The longest process for decision takes perhaps three years – and that’s if previous efforts fail and referral is made to the Anglican Consultative Council. Yet, as I have often repeated (in that I’m sure it’s not original with me), “We think in years, but the Church thinks in centuries.” I grant you that none of us these days are comfortable with that. However, I think haste is a serious issue here.

I have written before about one concern here: that the various timetables envisioned here might prevent (and might be intended to prevent) the constitutional processes of the Episcopal Church. If primacy is held here by the General Convention as a whole, and our bishops cannot speak for the whole church, but only of their commitments to one another, any process that does not allow that time frame simply does not respect our constitutional processes. Given the statements made about respecting the integrity and authority of individual provinces, this seems incongruous.

I have written about what has struck me, and what has concerned me, but I have written little about what has surprised me. Also, I have written little about the work as a whole. Some of that is because this isn’t my first reading of it, and I’ve found it hard to go back. And, this doesn’t seem all that different that the first, or Nassau, Draft. There are differences there, and I think when I get into details I will see and honor them. However, this still seems oriented toward uniformity, discomfort with disagreement, and centralization of, if not power, certainly authority. That disappoints me, more than a little; but it doesn’t surprise me.

Monday, April 28, 2008

A Word From the Prairie

At a recent meeting representatives from the Kansas Hospital Association (KHA) presented information from a recent public opinion survey. The 2007 Kansas Resident Survey contacted 611 households, and at least 100 in each district of KHA. (You can link to an executive summary at the KHA site. My comments today are based on a more detailed report.)

I found some of the results quite interesting, especially coming from Kansas. First and foremost, Kansas is prominent as a "red state." That's not so much about one political party, as it is about the values that lead folks to lean toward one political party. Conservative and "traditional" values are the norm here.

Most striking to me was the response to the question, "Do you think the government should offer an insurance program, like Medicare, to all Americans?" 59% said "yes," a result much higher than I would expect. When asked how to pay for it, the largest response, at 39%, was "Have government spend less on other programs." With that and other tax-oriented choices (tobacco, gaming, or payroll), 87% of respondents preferred a tax-based solution. So, a significant majority would prefer some form of government-supported universal health insurance; and a significant majority of them would prefer supporting the program through taxes. Moreover, when asked, “When voting for a political candidate, how important is the candidate’s position on health care to the way you vote?” a combined total of 87% responded Important, Very Important, or Extremely Important.

Some other results were also interesting. When asked, “Do you think all hospitals and health care facilities where surgeries are performed should be required to treat patients regardless of their ability to pay?” some 86% said Yes. For those of us whose community hospitals face competition from “boutique” specialized surgery centers, this was very interesting. The smaller specialty centers tend to “cherry pick” patients with insurance, so their reimbursement is more secure. In addition, they don’t have the additional overhead expense of Emergency Departments, full staffing for 24-hours, etc. On the other hand, the reimbursement they receive is the same as “full-service” hospitals. Community support for a position that the smaller specialized centers should take on a greater share of the economic risks is, understandably, of great interest here.

Some results seem to indicate interesting trends. The survey asked, “Do you think the amount HOSPITALS are reimbursed by insurance providers (like Blue Cross, Preferred Health, etc.) is too high, about right, or too low?” They compared the results in this survey with the results of a similar survey in 2006. The numbers of those who thought reimbursement was Too High didn’t change significantly (19% in 2006, and 16% in 2007). However, numbers changed significantly for About Right (46% in 2006 vs. 38% in 2007) and for Too Low (14% in 2006 vs. 24% in 2007). The same trend was visible with the question, “Do you think the amount HOSPITALS are reimbursed by government programs like Medicare and Medicaid is too high, about right, or too low?” (About Right: 38% in 2006 vs. 34% in 2007; and Too Low: 21% in 2006 vs. 32% in 2007) These numbers suggest that more of our patients are aware of the reimbursement difficulties for hospitals.

Respondents were also asked which health care issues “were the biggest problems in Kansas,” and asked to choose three. Of those chosen, the top three were health care costs, the number of uninsured, and, interestingly enough, “Insurance company “red tape.” When asked what factors contributed most to the high cost of health care (and, again, asked to choose three), the top three choices were insurance companies, lawsuits and legal costs, and drug costs. In this conservative, and in some ways libertarian state, it was interesting to me that all three of those exceeded “Unnecessary excessive use of health services,” even though that is a concern expressed often by more conservative legislators.

In one sense, these results are small. Kansas is a relatively small state, with a large rural constituency, and so not necessarily typical for the wider American society. At the same time, it is often held up as typical of political conservatism in the United States. If that is meaningful, than these results are very interesting. If in this conservative state there is strong support for a government-provided, tax-supported health insurance plan, then there may well be stronger support for it nation wide than some conservative officials appreciate. If there is rising concern about adequacy of reimbursement by insurance programs and by Medicare and Medicaid, then these are not simply “liberal” issues. Perhaps Kansas is too “red state” to be entirely typical. That, however, would make the point more clearly: if there is support for and concern about these issues in Kansas, then it’s quite likely there is support and concern in the larger conservative community. And for those of us who were already concerned about these things, perhaps this supports hope that we can get broad support in this country for making some important changes.

Thursday, April 24, 2008

Just a Brief Thought....

The President and Congress are arguing about changes in Medicaid funding.  That raised a brief thought, not about the specific argument today, but pertinent to Medicaid in general, and to my concerns about health care:

If you pay enough, you may not get what you pay for
If you don't pay enough, you most assuredly will.

Tuesday, April 22, 2008

Where Have All the Scholars Gone? 3: More Scholars

Updated 4/24/08

Many of you know already about the recent conference held at General Theological Seminary titled, "An Anglican Covenant: Divisive or Reconciling?." The topic was, obviously, the process for developing a covenant for the Anglican Communion, and particularly the most recent St. Andrew's draft from the Covenant Drafting Committee. You can find audio files of the presentations here (or at least of most; as of this writing some have still not been linked, but the Seminary promises to link the rest as soon as possible).

You can read what others have written about the Conference (for example, here , here, and here). However, those posts have focused on the addresses of the keynote speakers. I would encourage you to spend some time with the shorter presentations by various panelists. The conference scheduled panel groups after each keynote presentation. Most Episcopal seminaries were represented, as well as several Canadian seminaries. As with the keynoters, there is a spectrum of opinions, from "we need a written covenant, and this draft needs consideration;" to "the last thing we need is a covenant, much less this draft.” From my listening, most were somewhere in between – somewhere along the line of “we expect that some form of covenant will be developed, and so the important issues are what sort do we already have, and what sort do we want.”

Take some time to listen to the various voices. At twelve to fifteen minutes apiece, they are quite manageable. All are well prepared, and provide good food for thought. As we consider where we think God is leading the Anglican Communion and the Episcopal Church, listening to all these perspectives is worth the effort.

UPDATE: Today posts that are not available as audio files are now available in print and can be read on line. All presentations, as well as other materials, are available here.

Wednesday, April 16, 2008

Ethics Committees: Where Have All the Consults Gone?

I have finally turned over my responsibilities as Chair of my hospital's Ethics Committee. It's about time. I've been Chair ever since the Committee was formed, and there needs to be turnover.

Reflecting on my chairmanship has me thinking about how ethics committees work, and what they do with their time. I'm also watching to see what others have to say about this. Two staff members of the Center for Practical Bioethics are planning to look into this, but they're just getting started.

It does appear that the functions of ethics committees have changed. They originally came to be for clinical consultation - to help clinical staff and families sort out conflicts over appropriate goals and means of care - but there's some evidence that the number of consultations has gone down. Some have begun to wonder why.

I don't have my own research on this, but I have noted a couple of things. First, there is the apparent ascendancy of the patient's autonomy over other principles of clinical ethics. I have written before of the "Georgetown Mantra," the principles that have most shaped clinical ethics in this generation: autonomy, non-maleficence, beneficence, and justice. In theory they should arguably be considered equally in any ethics discussion. In practice, however, autonomy has come to be not only first but also foremost. If clinical staff have some sense that they know what the patient would want, they tend not to think any further. Indeed, all too often they seem to believe there is nothing more to be thought about, as though the patient had a right to whatever the patient wanted regardless of the clinician's best professional judgment of what might harm or benefit the patient. The availability of Health Care Treatment Directives and of Durable Powers of Attorney for Healthcare, with their legal imprimatur, has contributed to this, of course. Whatever the reasons, autonomy has largely trumped other principles.

As a result, I think, when the patient's wishes seem clear, even if only in the minds of surrogates, almost no one questions them. They may, of course, agree with the patient's wishes. Even if they disagree, clinicians may think they can't question them, or that questioning them would be more trouble than it's worth. In either case, believing the matter settled, they don't think about consulting the ethics committee. Granted, there are probably still some clinicians who think consulting the ethics committee may be more trouble than it's worth. I suspect the belief that there's nothing more to talk about is a more pervasive problem.

A second issue is the growth of an "alternate provider." Many of the early questions brought to ethics committees were about care at the end of life: helping clinicians communicate hard news to families, or to build consensus with families about appropriate goals for treatment. My experience is that clinicians have a rather narrow perspective about where ethical issues might arise. They seem to see them in end of life issues when they don't see them anywhere else.
But more and more, palliative care committees are addressing those issues. Issues of communication, and even differences between clinicians and families, are addressed less as relational and ethical issues, and more as functional and procedural issues. This is, I think, comforting to clinicians. They fear having nothing to offer, nothing to do. A palliative care program, even if it's no more than an order set and a checklist, feels more controlled, more predictable, than the interpersonal openness of an ethics screening. Again, clinicians think of the ethics committee when they're not sure what to do. Give them a set of procedures to follow, and they don't feel the need.

Now, I'm aware that not all institutions have official palliative care programs, or even checklists. At the same time, this has been a frequent topic in journal articles, conferences, and other continuing education. The information is out there; and, empowered with information, clinicians don't feel the need for the consultation.

So, these are two of my thoughts about why ethics committees are doing fewer ethics consults. And it's not necessarily bad. Respect for the patient's autonomy and palliative care resources are both good things. At the same time, either one might seem to give a simple answer to situations that can in fact be quite complex. If these resources make ethical consultation necessary less often, that's all well and good. If, on the other hand, they lead us to skip over clinical and family issues that need more time and care and exploration, no one involved is truly well served; and that's my concern.

Latest at the Episcopal Cafe

Once again, I have a new post up Episcopal Cafe. The subject is current issues in research, and how they reflect on what we think it means to be human, and to be a person (and how those are not the same question). I hope you'll take the time to read and respond to it.

While you're there, take time to read and respond to the works of my colleagues. Episcopal Cafe is a place to find Episcopal news and views, and those of us who write there hope many will spend some time with us, and then let us know what they think. As the Episcopal Church is saying, "Come and see."

Monday, April 14, 2008

The Out-of-Hospital DNR - But, How Far Out?

I talk a lot about Advance Directives and Do Not Resuscitate orders. I teach clinical staff in the hospital, and I preach “my second sermon” during the announcements when I do supply services. And one of the frequent questions I get is, “Do people really follow Advance Directives?”

Well, yes, mostly, when we can. Advance Directives in the hospital, whether the Health Care Treatment Directive, with its instruction set, or the Durable Power of Attorney for Health Care, designating the patient’s Agent, get a lot of respect from staff. That’s not an absolute guarantee, and sometimes it takes some negotiation. I regularly tell new clinical staff, “It’s worth extra time, effort, and expense to work for consensus with the family. It’s good for your soul, a phrase I don’t take lightly.” But, still, in the hospital the documents, and indeed, the patient’s wishes (if we know them) are taken seriously, and followed as best possible.

But, what about outside the hospital? That’s a different story. Outside the hospital Health Care Treatment Directives in particular have limitations. The reason is that Health Care Treatment Directives specifically, and to a lesser extent Durable Powers of Attorney for Health Care, depend on a physician determining that the patient lacks capacity to make decisions, and also will not recover to an acceptable quality of life. The thing is, in the field there’s no physician to make that decision. Paramedics and EMT’s can’t make that determination, so they have to do their best to stabilize the patient and get the patient to an Emergency Room, where a physician can. That may not be what the patient wants. It may not be what the family wants. But since for those documents that assessment is critical, there’s nothing that paramedics or EMT’s or family can do. (Thus one person I know has instructed those who care that if found down, those who find her are to wait 20 minutes before calling anyone so that there will be no question of putting her through a code when her brain is probably already gone.)

Which is why we frequently recommend to patients an Out-of-Hospital Do Not Resuscitate order. The Out-of-Hospital DNR is a physician order that paramedics and EMT’s can follow. It says much the same thing as a DNR order in the hospital: if the patient has an arrest staff are instructed not to resuscitate with chest compressions, electric shock, or medications. We recommend it for hospice patients and others who, while not necessarily expecting to die, would not survive an arrest (nor probably the resuscitation process itself). It allows for patients to die at home and peacefully, without inappropriate medical intervention.

Now there is this story from the Detroit Free Press. It tells of a young man who has survived into young adulthood with a severe, mentally and physically debilitating disease. He has lived longer and accomplished more than anyone ever suggested his parents might hope. He continues to attend a special education facility, part of the local school district, for what social and behavioral interaction he can maintain. But, he is physically frail. His parents understand that he could never survive resuscitation. He might survive being intubated, but he would never be extubated. He would probably not survive chest compressions. And so his parents have obtained for him an Out-of-Hospital DNR order.

Which is fine enough at home; but his parents wanted his school to honor it as well. At first, the school simply refused. However, with persistence by the parents and support from his physicians, the school district was convinced, and now has a policy in place to allow staff to honor the DNR.

The article speaks of other school districts in the Detroit area that have considered this question. Some will honor Out-of-Hospital DNR orders, and some will not. But as the article notes, as our medical technology has supported children in surviving conditions that used to be fatal and fatal young, we have raised to older and older ages children who are medically frail. As the article says, “No one tracks how many students have such orders, but anecdotal evidence suggests that there are dozens in Michigan. And as more children with severe health problems reach school age because of medical advances, the number of DNR orders is expected to increase. In some districts, children who are terminally ill also have DNR orders.” If there are dozens in Michigan, there may be hundreds throughout the country. And if there hundreds who have DNR orders, there are arguably thousands who might but don’t.

The article deals specifically with public school systems. To some extent, then, these are public agencies wrestling with how to address these very private issues. This young man is in a special setting, one in which it might be easier to educate staff and with a smaller student body. At the same time, the school system had to develop a system-wide policy; that’s the nature of such decisions. Conceivably, this could be an issue at the local middle school, supporting the child who’s managed to stay in school despite leukemia. With a larger faculty, and much larger and perhaps more aware student body, the consequences would ripple more widely.

Are there limits to accommodation to this need? I say “need” advisedly, because, again, putting such a patient through resuscitation would cause pain and injury with virtually no hope of success (in the sense of return to baseline, as we say – to something like the condition of the patient at the time of the arrest). It is a need; but is it one we are prepared to meet outside the privacy of the home? Personally I think it should be, but I don’t think we’ve thought about it much, not as a society. What do you think? How should we care for this young man and others with similar needs?

Friday, April 11, 2008

Bringing Victory Out of Defeat

Some years ago, when I was a priest in the Diocese of Michigan, Old Mariners Church decided to leave the Diocese.

I write that as if the events related to that were simple. In fact they weren’t. The Diocese sued for control of the property, and lost. The Diocese appealed, and lost. As I recall, it cost the Diocese something on the order of $75,000, and there was certainly disappointment within the Diocese, both at the losses and at the expenditure.

The Diocese lost because the founding of Mariners Church was unique. It was founded with funds donated by two sisters as an independent congregation. It later requested to join the Diocese, apparently in keeping with the wishes of the sisters; but it had retained in its corporate bylaws some unique characteristics that were meaningful in Michigan property laws. The congregation won because of certain unique and very specific characteristics.

Which ultimately served the Diocese. I have long felt that the Diocese lost the battle and won the war. You see, there were a number of other congregations in the Diocese watching all this closely. They largely agreed with the folks at Mariners Church (in this case, about continued use of the 1928 Book of Common Prayer, and about the social agenda of the Episcopal Church), and they were considering themselves leaving the Diocese.

What they discovered was that they couldn’t. They didn’t have the specific and unique characteristics of their foundation that Mariners Church had. As was made clear by the court decisions, without those characteristics there was no question that the Constitution and Canons of the Episcopal Church applied, and that in any legal dispute the Diocese would win. So, the Diocese lost one case, and so was spared another five or six. What seemed money lost was actually well invested.

I find myself thinking about this as I look at the initial court decision regarding the congregations in Virginia that have left that diocese to join the Anglican District of Virginia and the Convocation of Anglicans in North America (CANA), a ministry of (or a boundary violation by, depending on perspective) the Church of Nigeria – Anglican. That case also has aspects of uniqueness. First, there is the assertion by some of those congregations that their histories predate the founding of the Diocese of Virginia – a characteristic that must certainly apply in limited cases (if perhaps not as limited in Virginia as in other states). Second, there is the uniqueness of the Virginia law on divisions within congregations, a law not shared by any other of the United States.

I’m not an attorney, much less a Virginia attorney. On the other hand, I did read the appellate opinion in California which included that court’s detailed review of relevant cases in the federal courts. I personally don’t think it likely the Virginia congregations will win in the end, although I do expect it to take a while, including some time in the federal courts.

But, suppose they do? If they win based on those unique characteristics, they will also demonstrate how few other congregations can follow their lead. The state judge in Virginia has indeed decided that this specific law does apply; but there is no such law anywhere else. Nor do I think it likely that any other state could get such a law through legislatures these days. In no other state could congregations make such an assertion.

And, if they win based on assertion of historical precedence, that the congregations predate formation of the diocese: that, too, will offer little comfort outside their own region. There are certainly more such congregations along the Atlantic coast, and some may also think about departure. But, that won’t apply to most along the East Coast, and there will be none west of the Alleghenies. Even if some were founded before a diocesan structure existed, they were founded under the jurisdiction of missionary bishops elected by and serving under the General Convention of the Episcopal Church. It would be hard to argue that the Constitution and Canons don’t apply.

So, it seems to me quite possible that a victory for the Anglican District of Virginia and CANA would be Pyrrhic: in defining why they might leave, they would define clearly why the vast majority of congregations couldn’t. It’s certainly too soon to tell, and the legal process in California is also going to be interesting. But it seems to me that in pressing on the Diocese of Virginia and the Episcopal Church can win the war, even if they lose this battle.

Assessing Organ Donation Efforts - and Asking the Right Questions

The Joint Commission is coming. Well, no, not this week. But it's our year - our third year in a 3-year cycle. So, sometime this year surveyors from the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) will arrive on our doorstep, with a mandate to assess how we do what we do, from the bedside to the boiler room. (And we pay them for this!)

Ours is a small hospital, and many of us in leadership have multiple roles. One of mine is to oversee our compliance on organ and tissue donation. That involves a number of things: reviewing policies, teaching nurses, monitoring charts, and keeping statistics. It definitely involves preparation for one question: "What is your conversion rate?"

"Conversion rate" is the percentage of severely brain-injured, ventilator-dependent patients eligible to donate organs, whose families do consent to donate. It is a statistic monitored by the Center for Medicare/Medicaid Services (CMS), and so on their behalf by the Joint Commission. It's considered a measure of the institution's commitment to organ donation efforts; and institutions not sufficiently committed can lose Medicare funding. It is the one question related to donation that I know the surveyors will ask.

And, based on past experience, it's the only question the surveyors will ask; and that troubles me. You see, I think that can be a misleading statistic in a hospital like mine.

First and foremost, my hospital is a small, suburban community hospital. We're not a trauma center or a major stroke center, so most patients who might be eligible - severely brain-injured and needing a ventilator - pass us by. In the last two years we had only a handful of brain-injured, ventilator dependent patients, and all but one were ineligible to donate for medical reasons. So, we had one patient who might have been eligible. His family chose not to donate; so, our “conversion rate” for that period of time was 0%. Of course, that wasn’t the fault of our hospital. The death was appropriately reported, and the family was appropriately approached. They simply declined to donate; but their decision is somehow a reflection on us. And, of course, with so few patients in the “eligible” group (N=1), the statistical consequences of even one family’s decision to decline are significant.

Second, the family’s decision isn’t really reflection of the process of the hospital or the organ procurement organization, much less the hospital’s commitment to that process. The process functioned, but wasn’t really measured. Only the outcome was measured, and that, again, was largely the result of factors beyond our control. We can offer families the opportunity to donate. We can discuss the need, and the generosity the gift would demonstrate. We can describe it as a service to the family, and as a gift that brings some blessing in their grief. What we can’t do is control their decision. Indeed, to suggest we could control the decision would be to imply coercion, or, worse, to encourage it.

There are other questions that might be asked, and these would provide a much better, and certainly more complete, perspective on the institution’s commitment to donation. The first would be to ask about the hospital’s “referral rate.” We, like other hospitals, are required to inform the organ procurement organization (OPO) of every death. So, a good measure would be how consistently we make that required phone call, and make it in the appropriate time frame (a measure that in my hospital is, by the way, 100%). Hospitals with lower referral rates would certainly demonstrate less commitment to donation.

The second question that might be asked would be about the conversion rate for donation of tissues. Skin, long bones, heart valves, corneas, and other tissues that aren’t directly sustained by blood flow, can be donated by patients who have died cardiac death, and so have not been severely brain injured, or sustained on the vent. The corollary to the low incidence of deaths of severely brain-injured patients in my hospital is that all the other deaths were cardiac deaths. Those patients were appropriately assessed for their potential for tissue or cornea donation; and when the patients were eligible, their families were appropriately approached. For hospitals like ours, with so few patients who might even be assessed for organ donation, eligibility for tissue donation and tissue conversion rates would seem more appropriate measures.

Now, the number of families who choose to donate is certainly a relevant number. Even with recent questions about the accuracy and adequacy of the lists of patients who would benefit from transplants, there is agreement that there are many more patients who might benefit from transplant than there are organs currently being donated. And for large hospitals, and especially those with transplant services, trauma centers, large stroke programs, or other factors that would suggest larger populations of patients who might be eligible, perhaps there’s some reason to measure the conversion rate. However, that number is really controlled by families making decisions in emotionally difficult times. That means the number is really more a factor of discussions that happen over the dinner table than of discussions, however persuasive, at the bedside in ICU. Rates of donation will be affected much more by education and information in the community than by even the best recovery processes of hospitals or organ procurement organizations. That doesn’t mean hospitals and OPO’s shouldn’t be involved; but perhaps the questions need to be about their educational and public service efforts, as well as rates of appropriate referral. Those activities will have a better effect on how many families are willing to donate. So, those questions would say a lot more than conversion rates about an institution’s support for donation efforts.

Monday, April 07, 2008

Getting Ready for Anaheim: Commission on Health

As I write this, I'm on my way home from a meeting of the Standing Commission on Health of the General Convention. I have written before that the General Convention in 2006 reestablished the Commission as part of an extensive reorganization of Convention Commissions. Actually, it was reauthorized in 2003; but in 2006 they also approved a budget, which makes a big difference.

Mind you, it wasn't a big budget, and so this may be the only face to face meeting between Conventions. So, Commission members and invited guests like me discussed what issues the Commission might address in 2009, both in their Commission report, and also in resolutions.

There were many ministries discussed, addressing many different facets and issues in health care. Some seemed suitable for resolutions and simply for inclusion in the report. Some seemed to be more in line with the mission and resources of another commission or committee. Some we just weren't sure how to deal with, as valid as the concerns might seem. Issues that seemed within the mission of the Commission were delegated to various persons, both members and guests, for further work. I have some work to do myself on universal access to health care, and on care at the end of life.

Which brings me to you, faithful reader. What are the issues that you might want the Standing Commission on Health to address? I'm not a member of the Commission, but I know who to call. And if perhaps it doesn't really fit within the mission and resources of the Commission, I know how to pass the word along.

So, tell me what you think. What should the Commission on Health address at the 2009 General Convention? I can't wait to hear your ideas.

Tuesday, April 01, 2008

What, Annunciation? Now?

I have to admit that this has been something of an odd day for me. It may be April 1, but it’s also the Feast of the Annunciation.

I know, I know: the Feast of the Annunciation is March 25 (Nine months to the day from Christmas! Isn’t that an interesting coincidence?) However, this week, with our early Easter, March 25 feel during Easter Week. In the calendar of the Church, nothing else takes priority over Easter Week; and so the Feast of the Annunciation was, as we say, transferred to the first available day. (Note that the first available day wasn’t Monday. That went to the transferal of the feast of St. Joseph, which this year fell during Holy Week – another week over which nothing else can take priority.)

This caused me some small distraction in part because I was ordained a deacon years ago on the Feast of the Annunciation. In those days I was in my first CPE Residency (for those unfamiliar, a year of clinical education in pastoral ministry, serving as a hospital chaplain) at Children’s Memorial and Grant Hospitals of Chicago, two fine hospitals joined in those days only by a shared Pastoral Care Department and a long block of Lincoln Avenue. (The Avenue remains; the department is long gone.) I was from the Diocese of Tennessee, much less Anglo-catholic than my surroundings in Chicago, and much less Anglo-catholic than I am now. I had had a confrontation with both rector and organist of the parish I attended over a hymn to the Blessed Mother sung on the previous Fourth Sunday of Advent (for which the lesson that year was indeed the Annunciation). I had no problem with the first verse speaking of the Blessed Mother as witness to the Incarnation; nor to the second verse speaking of her as witness to the Crucifixion; nor even to the third verse speaking of her as witness to the Resurrection. However, when the fourth verse referred to her bodily Assumption, I almost walked out. Granted there are many who believe in it, and even in the Episcopal Church there were some who held to it as a part of their private piety. But, not being based in Scripture, it couldn’t be taught as doctrine in the Episcopal Church (who says I don’t love the 39 Articles?), and certainly shouldn’t be used in worship. I phoned that afternoon to express my concern to both the rector and the organist, each of whom proceeded to blame the other.

So, when I announced to the rector the date of my ordination to the diaconate, he asked, “You mean, you’re being ordained on the Feast of the Annunciation of the Blessed Virgin Mary?” With a righteous rigor that is only palatable in one so young, I responded, “No, I’m being ordained on the Feast of the Annunciation of our Lord Jesus Christ to the Blessed Virgin Mary.” He smiled a thin smile. (Perhaps my righteous rigor wasn’t so palatable. After all, I had already lost the privilege of preaching in the parish on somewhat similar grounds; and even after my ordination all I was ever invited to do was take a chalice and chant the Gospel.)

So, I remember March 25 and the Feast of the Annunciation as the anniversary of my ordination as a deacon. The transferal of the date has been just a bit disorienting.

We do have a special devotion to the Blessed Mother in our house. This is particularly true of my Best Beloved, who has a shrine in her room and a collection of rosaries; but it’s true of me as well. While it’s not a common part of my private piety, I don’t have any trouble praying the “Hail Mary” with my Catholic patients; and I have the opportunity often enough to explain to non-Catholics the difference between devotion to the saints and asking their intercession, and true worship, which is due only to God.

And, after all, the Blessed Mother picked out our puppy. Those years ago when we were thinking of a puppy, and touring various opportunities for adoption (well, my Best Beloved was thinking of a puppy; I was thinking of wee hours trips to the back yard, without much enthusiasm, but with a fine devotion to my Best Beloved), my Best Beloved would tell me she would “just know” when we had found the right dog. In fact one Saturday afternoon she said, “This is it. This is her.” Sass was, and is, a sweet, somewhat submissive, little bitch of uncertain ancestry, and she has turned out to be a great success. When I asked my Best Beloved how she had chosen her, she replied, “Oh, the Blessed Mother spoke to me. She said, “There’s your dog. What are you waiting for?” Not that I was inclined to argue with my Best Beloved anyway; but, who was I to argue with the Blessed Mother? And after all: the dog has turned out to be a great success.

So, all in all the transferal of the Feast of the Annunciation has been something of a disruption of routine. I did observe it today, in the Daily Offices if not in the Eucharist. (I decided the transferal would take more time to explain than I had in a half-hour hospital service.) I did give thanks for my ordination, and for the gracious service of the Blessed Mother, well established in Scripture. And now I can give thanks that I may never see so significant a disruption of my routine in my lifetime; for it will be long and long before Easter comes anything like this early again.

Holy Mary, Mother of God, pray for this sinner, now and in the hour of my death. Amen.

Picked Up for Grand Rounds

One of my recent posts has been accepted for this week's Medical Grand Rounds, a blog carnival on all things health care that's now in its fourth year. This week responsibility for posting has been shared among three different host blogs. My post is linked at GruntDoc's. The second section is at Dr. Val's (and hers is clearly a reasonable voice). Finally, the third section is at David Williams' Health Business Blog.

Take some time to take in these interesting posts. The topics are wide-ranging, and the posts are very interesting (at least all those I've had a chance to look at so far). I'm pleased to be in such good company.