Thursday, August 30, 2007

Medicare Reimbursement: To Tell the Truth

If you were paying attention to the news last week, you heard comments about the new standards for Medicare reimbursement to hospitals for 2008, published by the Centers for Medicare/Medicaid Services (CMS). While there are a number of changes involved, the change getting the most attention has been a decision not to reimburse for care that results from “avoidable errors.” You can see some of the news reports here or here.

At first blush, this seems a very reasonable decision. Avoidable errors do result in injuries to patients, and additional costs in increased acuity, extended stays, and all the added expenses of personnel and materials that go with them. The notorious cases – the surgeon who amputates the left leg when it is the right that is diseased, or who leaves a sponge or instrument inside a patient when closing after the procedure – bear the added “expense” for us of loss of trust in physicians and hospitals, and corollary anxiety.

At the same time, there are some questions that I think need to be addressed, and that I haven’t seen in the news reports. Some of them may be answered in the proposed Final Rule, as published in the Federal Register (if you’re interested, you can access it here; but like many such publications it runs to more than 2100 pages). Some of them will almost certainly have to be worked out in hard adjudication. Here are those that occur to me.

Mistakes happen. How do we discern in principle what is an “avoidable mistake?” Some cases will be clear, but I expect most will not be.

When a mistake happens, who is accountable? Mistakes may be made by doctors, but this is the Final Rule on Hospital Reimbursement. How will the Rule balance culpability?

What if the patient is culpable? It is not uncommon for patient to withhold information from providers because in the patient’s opinion the information is “unrelated” or “unimportant.” It’s not uncommon for that withheld information to be in fact very important. If it results in additional costs, how will Medicare
hold the patient accountable?

Will this not simply shift costs from the back end to the front? More specifically, will this not result in additional tests in the beginning of a patient’s process so as to not miss anything? In times past there have been allegations of unnecessary and expensive testing by physicians and hospitals so as to avoid litigation. Now, perhaps, it will be to avoid losing reimbursement.

More basically, we have worked for some time in health care to develop a “non-punitive” environment - one in which professionals can admit mistakes because they don’t fear punishment, except in particularly egregious cases like those above. Mistakes are seen as problems of the system, and human beings are trusted to be doing their best, even if sometimes it isn’t enough. By working to develop better systems, so the theory goes, opportunities for human error are significantly reduced, and patient better served. By encouraging reporting, we identify the ways in which we need to improve the systems.

We’ve also been encouraging – indeed, by policy and procedure, requiring – professionals to admit when unexpected and unwanted consequences occur. It has numerous benefits over the old “admit nothing, lest ye be sued” attitude. Patients and families feel they are treated with more respect and sensitivity, and that their providers are more trustworthy. One corollary result is that physicians and providers are in fact sued less often, rather than more often; and that when sued the financial consequences are significantly less.

There are also greater and greater requirements for hospital quality and performance information to be available to the public. More and more information will be available for patients at Medicare and other web sites. The justification is that better informed patients will make better decisions about their care, resulting in better (and perhaps less expensive) care. Another part of the Final Rule specifies that hospitals that do submit quality data will be reimbursed at a (slightly) higher rate than those who don’t.

But how will this new Final Rule affect this? Will providers feel they need to withhold information about mistakes and unfortunate results lest Medicare refuse payment for patient needs? Will it feel riskier for providers at all levels to provide the information necessary to improve patient care? Will it feel riskier for providers to acknowledge mistakes that happen when it’s unclear what makes a mistake “avoidable?”

Perhaps CMS isn’t worried about this. As the 800-pound gorilla in the room, perhaps officials at CMS feel sufficiently powerful that physicians and hospitals and other providers will simply have to comply. At the same time, I think these are important questions, and I’m sure representatives for providers will raise them. I think we need to raise them as well.

Wednesday, August 29, 2007

More Prayer Book Reflections

It seems I've started something. Christopher over at Betwixt and Between was interested in my recent post on the Collect for Ordinations. And, as if his comments on that weren't interesting enough themselves, he went on to write this post. Then, his post stimulated this post by Derek over at haligweorc.

If the real questions are, "What can we claim as Anglican tradition," and "What do we mean when we call ourselves Anglicans?" - and I remain convinced they are - then discussions of the Episcopal Book of Common Prayer are important. We have long said that the tradition of the Book of Common Prayer is central to what it means to be Anglican. Indeed, many of us, myself included, maintain that we manage not to fall into confessionalism by our practice of incorporating our understanding of the Christian faith into our worship, and so into the Book of Common Prayer. For us as Episcopalians to argue that we are Anglican, in the face of those who want to deny us on morals charges, we need to make our positive defence based in our worship and in the fullness of our practice - and that means the Book of Common Prayer, and in this instance the Book of Common Prayer 1979.

It seems likely that the Anglican-Communion-as-we-have-known-it will be altered. Like any loss (and there will be loss), we will have to grieve. We will have to recognize that we won't get the "old normal" back, and so will have to engage the hard work of discovering the "new normal." For that task, we'll need affirmative arguments, positive statements - statements of who we are, not who we aren't. Appreciating how we have maintained the Anglican tradition in our Prayer Book, and recognizing how we might maintain it better, will be part of that; and to that end I think Christoper's and Derek's posts are worth reading.

Someone Else is Brainstorming

I haven't done any brainstorming for the bishops for a while; but that doesn't mean others haven't. Specifically, a few days ago The Anglican Scotist made a suggestion of his own. The post and the comments are worth your time (and, yes, one of the comments is mine; but it's his thought that's worth the consideration).

Saturday, August 25, 2007

I Feel Another Song Coming On

In light of the coming "deadline" in September, and all the rhetoric bouncing around the Anglican/Episcopal world, I was moved to recall the refrain of an old country song (Written by Don Rollins; made famous by George Jones, and covered by, among others, the Grateful Dead):

Now the race is on and here comes pride up the back stretch
Heartaches are going to the inside
My tears are holding back, trying not to fall
My heart's out of the running
True love's scratched for another's sake
The race is on and it looks like heartaches
And the winner loses all

Tuesday, August 21, 2007

A (Poor) Moral Argument About Universal Health Coverage

Well, I was bouncing around through the Net, when I ran across this post by Megan McArdle. She has written for The Economist, and her blog is at TheAtlantic.Com. She makes some statements about moral arguments for a national health plan, and specifically for a single-payer national insurance plan.

She poses this as a transfer of wealth from the young (as a class less likely to be sick, but also less wealthy) to the elderly (as a class more likely to be sick but also more wealthy). In her argument she undermines her own categories, acknowledging that the young and healthy will, unless they die young, eventually become old, and presumably less healthy. At the same time, she refuses to reach the obvious conclusion of that problem: that her arbitrary classes have more in common than they have that distinguishes them.

And since that is the case, arguing about wealth transfer is misleading. Indeed, it misses the fact that such wealth transfer is already taking place. Wealth is transferred from those who have insurance of whatever form (private or government funded) to those who don’t. Institutions cost shift, raising charges for those who can pay to cover the expenses of those who can’t. The same thing happens in any other industry, really: the local convenience store has a certain latitude in the budget to pay for losses due to shoplifting and accidental damage. In health care, the costs come from unreimbursed care provided to those without insurance. In health care, the wealth transfer takes the form of higher charges from health care providers, leading both to higher insurance premiums and higher co-pays.

She does acknowledge one moral argument for a single player health plan: “no one should die, or suffer unduly, because they don't have the money to pay for treatment.” Well and good; but she misses several other considerations.

First, while a single-payer plan is the most common model to be raised, it isn’t the only model. There are mixed models of government involvement with private insurers to provide universal coverage.

Second, her model is still based on paying to treat pathology rather than to prevent it. It has been amply demonstrated that the cost of paying to treat illness is significantly higher than the cost of primary care to prevent it.

And it is this last that highlights my greatest concern about many economic arguments against universal coverage for health care. Most of the arguments seem to have no sense of investment. They don’t consider long term savings in public health that prevents illness (including such concerns as the pandemics we are all anxious about these days), or that keeps the healthy working and productive. It seems to me to reflect some of the worst of our recent economic swings: it’s all about short-term profits instead of long-term value.

Read Ms. McArdle’s article. She is at least interested in moral discussion about universal health coverage. She’s interested in getting beyond the political expediencies of “Everyone should be taken care of,” or, “Yes, but not out of my wallet.” We need to bring such discussion to the public sphere. We just need to do it better.

Monday, August 20, 2007

On the Making of Bishops

I recently completed a chapter – really, more like an encyclopedia article - for a new book. It is being compiled by a colleague of mine, a chaplain in another hospital in the area, to provide information for specifically for physicians on the spiritual traditions of patients, and how those traditions address issues of health care. I wrote, as you might expect, about the Episcopal Church.

In addition to the information, the editor requested of each author a graphic for the article, and some brief statement representative of the tradition taken from Scripture or tradition. The graphic was easy. After consultation with my bishop, I submitted the Episcopal shield.

The statement was harder. The editor, himself a faithful Baptist, assumed for us writers that one or another passage of Scripture would be submitted. I thought of several, but none seemed quite right. It wasn’t because Scripture isn’t important in the Episcopal Church. Contrary to some current strident voices, it certainly is. But it seemed to me that no one passage of Scripture was more meaningfully “Episcopal” than any other. After all, there isn’t some distinctively “Episcopal” Bible. We read all of it, even if we wrestle with some parts more than others (and who doesn’t?). And, we share all of it with other Christians of the Western Church and, by and large, with the Eastern Churches. No single passage stood out for me as more “Episcopal” than “Catholic” or “Orthodox” or simply “Christian.”

Something from the Book of Common Prayer, then: that’s where any Episcopalian would go next. I looked through the 1979 Book (it is, after all, the Prayer Book we use, and in which I was ordained), including the “Preface to the First Book of Common Prayer,” and the section of Historical Documents, and through the Rites of Baptism and the Holy Eucharist (both Rites, and all six Eucharistic prayers). Finally, one prayer stood out for me. It is an ancient prayer, taken from the Gelasian Sacramentary (per Hatchett), but it has not been used in earlier Episcopal or Anglican Prayer Books.

O God of unchangeable power and eternal light: Look favorably on your whole Church, that wonderful and sacred mystery; by the effectual working of your providence, carry out in tranquillity the plan of salvation; let the whole world see and know that things which were cast down are being raised up, and things which had grown old are being made new, and that all things are being brought to their perfection by him through whom all things were made, your Son Jesus Christ our Lord; who lives and reigns with you, in the unity of the Holy Spirit, one God, for ever and ever. Amen.

Now, I will admit that this collect is a personal favorite of mine. At the same time, I was struck once again by how important this collect is in the life of the Episcopal Church. It is the last of the Solemn Collects in the liturgy for Good Friday. It is also the Collect after the ninth lesson in the Great Vigil of Easter. For each of these important rites of the Church, the collect is, as it were, a summary of what we believe God is doing. In the death and resurrection of Christ, we believe God is indeed restoring - or perhaps, re-creating – all of creation, so as to bring creation to perfection.

With that in mind, I was also struck by the third place in which this collect is used. This collect is the summation of the Litany for Ordinations in the Episcopal Church – all ordinations. Whether for bishop, priest, or deacon, this collect is read in every ordination in the Episcopal Church.

Now, this is a change from previous prayer books. The 1928 American book had this collect at the end of the litany:

ALMIGHTY God, giver of all good things, who by thy Holy Spirit hast appointed divers Orders of Ministers in thy Church; Mercifully behold this thy servant, now called to the Work and Ministry of a Bishop; and so replenish him with the truth of thy Doctrine, and adorn him with innocency of life, that, both by word and deed, he may faithfully serve thee in this Office, to the glory of thy Name, and the edifying and well-governing of thy Church; through the merits of our Saviour Jesus Christ, who liveth and reigneth with thee and the same Holy Spirit, world without end. Amen

This collect dates to the 1550 Ordinal of the Church of England, published then in the 1552 Book of Common Prayer, where it is used, again at the end of the litany, for consecration of bishops and priests, and in adapted form for deacons. It was used this way in the 1928 Book.

Now, I have suggested that one of the things that current Anglican arguments are about is bishops. Granted, I think over all it’s about what it means to be Anglican; and within that, then, how we interpret Scripture and how we do or do not accept human sexual lives. But, a critical event was the election of a bishop, and many of the subsequent actions and reactions have been either statements of, actions of, or ordinations of bishops. We all speak about ordination of bishops for “the whole Church,” even if we argue about what we mean when we say that.

It that’s the case, it seems these collects, once again in position to summarize the Litany for Ordinations, do describe a different understanding of what ordination is about, and not just the ordination of bishops, but all ordinations. The 1550 collect is, if you will, about one person, and that one person’s place in the structure and discipline of the Church. It is about one servant, the vocation to which he is called, his fitness for it, and his functions in it.

The 1979 collect has a much wider focus. In the 1979 rite ordination is not solely about one individual or one individual vocation. Rather, it places ordination in the context of God’s process of re-creating the world. The ordinand is not called simply to “serve in this office” of bishop (or priest or deacon), but to participate in raising up what had been cast down, and making new what had grown old, and so participating in God’s work of “bringing all things to their perfection” The fact that this collect is also in some sense the summary collect for both the Good Friday liturgy and the Easter Vigil only seems to confirm this view. And, of course, this is not just the work of the ordinand, but of the “whole church, that wonderful and sacred mystery.” And so in that sense ordination is hardly about the ordinand at all, but rather about the participation of the whole Church in God’s work of salvation.

In raising the question of what we mean when we speak of “Anglican tradition,” or when we call ourselves “Anglican,” I raised the question of whether we should follow classical Anglican content or classical Anglican method. This seems one clear illustration. Using the 1550 collect seems to me classical Anglican content, and its retention through English and American prayer books seems in that vein. On the other hand, the editors of the 1979 book followed, I think, classical Anglican method: seeking in ancient traditions of the Church resources appropriate for the Episcopal Church in our generation, just as Hooker and Jewel looked to the ancient scholars of the Christian faith for resources for a reformed catholic Church in England.

In these controversies, when the statements of bishops as individuals, as groups, and as “first among equals” have so much currency, and are attributed so much authority, I am struck by the differences in these collects used roughly in parallel in the different ordination rites. Looking at them, and recognizing the differences between classical Anglican content and classical Anglican method, I can see both how we come to speak so often of God doing a new thing, and how other speak of us leaving the Anglican tradition (understood as Anglican content). At the same time, if we are to appreciate the “historic episcopate, locally adapted,” perhaps we can consider these understandings, not as mutually exclusive, but as complementary and mutually informative. I would hope we could. I think it’s something that we as Anglicans used to do.

Friday, August 17, 2007

Newest at Episcopal Cafe

My newest post is up at the Episcopal Cafe. It's something of a numerical review of health care ministries in the Episcopal Church, based on the numbers in The Episcopal Church Annual. Go over and take a look; and while you're there, look at the work of my colleagues there. There's a lot there to enjoy, and I'm honored to be in their company.

Wednesday, August 15, 2007

More Worthwhile Reading for Chaplains and Others

I have commended before articles published in the online journal Plainviews, and have a link to Plainviews in my sidebar. Today I want to highlight two articles in the current edition in the Advocacy section.

The first article is “Healthcare Through a Theological Lens,” by Chaplain Keith Goheen of Beebe Medical Center in Lewes, Deleware. Starting with his own experience of the movie, “Sicko,” Chaplain Goheen offers a concise, coherent theological reflection on the American healthcare system, and American political will. His article is well worth the brief time it will take you to read.

The second article is "The Borg of Bioethics," by Nancy Berlinger of the Hastings Center. She writes about the classic ethics text, The Principles of Biomedical Ethics, by Beauchamp and Childress. Principles is notable as the primary source for most of us in healthcare of the Georgetown Mantra. Berlinger writes of the way the four principles of the Mantra have come to overwhelm and supercede almost all other principles in healthcare ethics, a concern which I share. Again, the article is not long but well worth your attention.

(And for more of my own reflections, look in the Labels under Health Care and Episcopal Culture.)

Monday, August 13, 2007

On a Slow News Day....

I said to my wife this evening that this was clearly a slow day for news when I saw that the big hook for “MSNBC Live with Dan Abrams” was a special report on Scott Peterson, noted uxoricide. Granted, there was Karl Rove’s departure; but for a few of us resignation is not nearly so satisfying as arrest might have been. In any case, it was clearly a slow day.

By the same token, it seems to be a slow day in the Anglican world. The best bit: it seems that today Peter Jensen, Archbishop of Sydney, has banned that liberal lightening rod, John Shelby Spong from speaking in any of the Anglican Churches of Sydney.

Now, it is certainly within his purview to do that. I’m certain, too, that virtually anything said by Bishop Spong would be challenged by Archbishop Jensen, however factual, on the principle that Bishop Spong’s objectionable statements must solidly discredit any otherwise unobjectionable statements he might make.

At the same time, I haven’t seen in any news item that any Anglican Church in Sydney had in fact expressed any interest in having Bishop Spong speak. News reports have him attending a conference at a United Church, and speaking at a Unitarian Church; but no interest from Sydney Anglicans. And that, of course, is really not surprising, is it? He has been invited by Archbishop Phillip Aspinall to preach in Brisbane's cathedral; but surely that's no reflection on Sydney.

I have read several of Bishop Spong’s books. I have had the same experience with each of those I have read. He begins with is a thorough examination of a particular issue in Scripture, including both sides of the issue. Next there is the same sort of examination in the history of the Church. There is a look at contemporary scholarship on the Scriptural record, and a look at contemporary scholarship on Church History. Next there is a review, as appropriate to the issue, of current academic, social, and scientific scholarship, followed by a review of how all these are playing out in the life of the Church at the time he writes. With each book I have read, I have found the work to this point thorough, fair, and balanced (at the very least in stating a wide variety of points of view and taking seriously folks with whom he disagrees).

And then, with each book I have read, he starts to talk about policy. That’s where, in many cases, he and I have come to disagreement. His scholarship was really quite good, and quite fair. His thoughts about what to do next were, I thought, wrong. Perhaps that’s why I read a few books, and didn’t go on to read more.

In a way, I feel sorry for Archbishop Jensen (with whom I disagree on many issues). There’s almost no way Bishop Spong could have come to town without Archbishop Jensen being asked about it; and yet just about anything the Archbishop might have said would only result in more headlines for Bishop Spong. At the same time, why ban a man from Sydney churches, when none, apparently, was foolish enough to extend such an invitation? Granted, Archbishop Aspinall did invite Bishop Spong to speak in Brisbane; but surely that would change nothing in Sydney. Surely there was some way to leave the responsibility with Archbishop Aspinall to explain why he did invite Bishop Spong, rather than with Archbishop Jensen to explain why he did not.

Well, of course, this will pass. I expect my Australian cousins will soon learn to ignore Bishop Spong just as most Americans – even Episcopalians – even progressive Episcopalians – do. This will turn out before long to be pretty much a teapot-sized tempest; but, then, I guess it is a slow news day….

To Honor Florence Nightingale

Life-giving God, who alone have power over life and death, over health and sickness: Give power, wisdom, and gentleness to those who follow the example of your servant Florence Nightingale, that they, bearing with them your Presence, may not only heal but pain and fear; through Jesus Christ, the healer of body andf soul, who lives and reigns with you and the Holy Spirit, one God, for ever and ever. Amen.

This is the collect for the feast of Florence Nightingale. She is the founder of modern nursing. She was a member of the Church of England, who heard her service to the sick as a call from God. A biography highlighting the spiritual dynamics in her life is here. One highlighting the importance of her use of mathematics to study and document the needs of patients is here. The elegant biography of her in Lytton Strachey's The Eminent Victorians is available on line, starting here.

Her feast day is August 12, this year displaced by its fall on a Sunday (I’m not sure why Kiefer says differently, but August 12 is the date in the 2003 Lesser Feasts and Fasts). However, as a hospital chaplain I always observe the day. It is an opportunity to honor her, and to honor all the nurses who have followed her, providing safe, sanitary, professional care to all of us.

Friday, August 10, 2007

Medication Access in Desperate Times

Thirty years ago or so, while I was in college, an industrialist in Connecticut, owner of knitting mills in Tennessee and the Carolinas, was arrested. His crime? Storing five or six tons of apricot and peach pits. Now, while I understand that in the Middle East apricot and peach pits are used to make sweets, that was not his alleged motivation. His motivation was a wife sick with cancer. His crime was storing up those pits as the primary ingredient in an unapproved, alternative cancer treatment called laetrile. I had already heard of laetrile; it was a staple of stories of desperate people going to Mexico for treatments they could not receive in the United States. But, this case was of personal interest: while I did not know the industrialist or his wife, I did know members of the family; and I knew the desperation and grief were real.

That, I think, is part of why I’ve noticed recent controversy about whether patients with life-threatening diseases should have access to treatments that are being researched but have not been proven to be effective, at least to the satisfaction and approval of the Food and Drug Administration. Today the Federal Appellate Court for the District of Columbia today determined that there is no constitutional right of terminally ill patients to have access to drugs still in clinical trials. You can read news stories on that here or here.

For a wider discussion of the issues involved, check out this segment of NPR’s “Talk of the Nation,” from July 30th. The speakers frame the issues well, and provide specific examples. It offers an interesting reflection on today’s Appellate Court decision.

This is a classic discussion balancing individual rights against social needs - in the language of the Georgetown Mantra, autonomy vs. justice, with, admittedly, related concerns from Non-Maleficence and Beneficence. I think we can outline that discussion this way:

Autonomy: I'm dying. I've heard this drug might help me. So far, it looks like it's probably safe. Even if it isn't, I'm already dying, so I have little to lose. I can't get this as part of a study, not even for "compassionate use." My doctor is willing to give it. I'm willing to take the risks. I should have a right to receive this drug, even though it hasn't made it through clinical trials.

Non-Maleficence: As a professional, I am committed to "do no harm" to patients. At this point, the hard question is, what does less harm? If I help this patient get this drug outside of a protocol, I might contribute to the patient's wellbeing. On the other hand, I might contribute to pain and suffering, and might shorten life. I might contribute to false hope now, and despair later.

Beneficence: What is really in the patient's best interest? If this drug works, it may be in the patient's best interest. On the other hand, most drugs that begin clinical trials are never approved. Is it in the patient's best interest to be exposed to a drug that not only might not work, but probably won't work? Is it in the patient's best interest to pursue life at all costs? Or, is it in the patient's best interest to recognize that our knowledge and capacities have limits, and think about how to make the best of the patient's life as it is?

Justice: We have a process in the United States for assessing the efficacy and safety of drugs. While we sometimes complain that the process is too slow, we inevitably complain when a drug proves ineffective and/or unsafe. A critical part of that process is gathering trustworthy data. Trustworthy data comes from well designed and carefully followed study protocols. “Compassionate use” provisions take this into account by requiring that the physician supervising the patient’s care track some information, but don’t provide data as clear as the study protocol itself. Use of medications outside of some study provision would provide no data at all. It could actually delay the completion of a study, and so either release of a good drug or elimination of a bad one. It could put patients through suffering with no countervailing benefit. While an individual might be willing to take the risks of a drug that hasn’t been fully studied, such access could also create risks for others – folks who are ultimately best served by thorough study of drugs before approval – that we as a community cannot permit.

The NPR discussion touched on but did not explore an issue I think is important in the controversy: the ready access to information about diseases and drugs, both in news media and through the internet. Every little study, however preliminary, offering some promise of medical progress gets picked up from medical journals and published in the first section of the paper and in the middle of the evening news. Patient groups and advocacy groups share information on line about their experiences.

Unfortunately, much of that information is preliminary at best, and useless at worst. It’s a long way from promise of a drug in cell cultures or mouse models to determination of efficacy and safety for human beings. Correlation is not necessarily causation; and the fact that it looks like something works doesn’t mean we actually know how it works. This reflects on another ethical category, a secondary category from the four principles of the Mantra: Faithfulness and Truth-telling. A desperate patient may say he or she is willing to accept the risks; but how well does the person actually know the risks? How accurate is the patient’s information, and how preliminary? A patient may assert he or she has “nothing to lose;” but how carefully has the patient been advised about alternatives? How carefully has the patient considered what is involved in making the best of the time he or she has, recognizing that we have not conquered death and do not expect to before the Kingdom comes?

I have served on a hospital’s Internal Review Board for Human Subject Research (IRB). I have participated in addressing requests for “compassionate use.” I have participated in reviewing research protocols specifically written for patients in the latest stages of life-threatening diseases. I have raised the concern that the drug’s known unwanted effects were bad, only to be assured by physicians that the disease by this point was worse. At the same time, these cases always involved drugs for which there was already some documentation of results in human patients, and reasonable expectation that these drugs would meet standards for approval. To consider access to drugs that haven’t gotten that far in the process, that won’t have that level of supervision, even for the sickest patients should cause hard ethical reflection.

I expect that the advocates for this access will ask for review by the Supreme Court. They are our final arbiters of questions of constitutional rights. Many of us will be watching and waiting to see whether the Supreme Court will take the case, and if so, how the Court will decide. Many will watch and wait, fully realizing that some will not live to see the resolution. And, while we watch and wait, we are still called to care for them as best we can.

Wednesday, August 08, 2007

There's Got to be a Joke in Here Somewhere....

Some of you will have seen the news that the Rt. Rev. Clarence Pope, retired Second Bishop of the Diocese of Fort Worth, has left the Episcopal Church to enter the communion of the Roman Catholic Church - for a second time. The usual suspects have noted this, and you can find a good review of the history at Desert's Child (and thanks to Episcopal Cafe for this).

So, I'm trying to figure out how this parallels the Avignon Papacy. More to the point, is Fort Worth the contemporary Avignon? Both the first and second bishops of that Diocese have left the Episcopal Church, and the third is considered likely. This has involved interference by foreign powers (political in Avignon; ecclesial these days). Both became visible centers of wider controversies. Both involve one Pope submitting to another (sorry, siblings, but I can't resist the pun).

Someone better informed on the histories of both might find more parallels, or simply laugh this away. But, isn't it fun to play with?

Saturday, August 04, 2007

Proper 13C: Random Reflections

I’m preparing for tomorrow’s sermon. For the past two weeks, something has come to me early on Saturday, something I posted here and here; and in both cases these reflections ended up, basically, as my sermons. Tonight I’m on my more common schedule: my sermon will come together in my head, by God’s grace, in the shower.

However, tonight I do have some random reflections.

The Gospel is the story of the successful farmer, who plans to tend to the results of a bountiful harvest by replacing his old barns with new ones, and then to rest easy for the rest of his life. When his “soul is required,” Christ speaks of being “rich toward God,” rather than rich in possessions.

What this brought to mind was the story of Laurence, Deacon of Rome, whose feast day will fall this Friday. When Pope Sixtus II was taken and executed in persecution under Valerian, Laurence as the bishop’s treasurer was spared on the condition that he turn the treasure of the Church over to the Prefect. When he said it would take three days, he was granted the time. As reported, he spent the three days disbursing the finances of the Church, putting it safely out of the Prefect’s reach. He then gathered the poor, the widows, and orphans in the Church, and presented them to the Prefect. “These,” he said, “are the treasure of the Church.” (This, reportedly, resulted in a particularly painful execution.) Perhaps this says something about what it means to be “rich toward God.” Perhaps, too, this bears some reflection in light of the statement in Colossians that “your life is hidden with Christ in God. When Christ who is your life is revealed, then you also will be revealed with him in glory.” Surely, Laurence saw Christ hidden in those served by the Church.

For whom are we working? The Preacher in Ecclesiastes seems to suggest there is little or not point, and certainly no joy, in all our work. Now, I’ve had days like that; but the Preacher surely needs some Prozac!

But, Jesus raises the same question about the wealthy farmer. For whom is he working? He speaks of his bounty as something that will free him from want. He does not speak of family and children, and how they will benefit. He does not speak his community and the good he might do. For whom is he working? Clearly, he is working for himself; but he does not have the future he dreams of to enjoy the fruits of his labor.

For whom do we work? To some extent, we do work for ourselves. Many of us are aware of working for others – for our families and children, for the good of the community, to make our contributions to a project or a team that is important to us. What would it mean instead for us to work for Christ, or at least to be “rich toward Christ?” I can’t help but think it must have something to do with working to build up the treasure of the Church – the treasure that Laurence saw. I can’t help but think it means looking for Christ hidden in them, as their lives, like ours, are hidden in Him. I can’t help but think it means looking for Christ in all regardless, recognizing that “there is no longer Greek and Jew, circumcised and uncircumcised, barbarian, Scythian, slave and free; but Christ is all and in all!” To be rich toward Christ must, I think, with building up and caring for the Church’s real treasures, whoever, and wherever they may be. Which certainly focuses the question: for whom do we work?

Wednesday, August 01, 2007

Donation Difficulties: the Case in San Luis Obispo

Those of us involved in supporting families when patients are dying, and sometimes through decisions regarding donation of organs and/or tissues of patients who have died, will be following the news closely. In San Luis Obispo, California, a transplant surgeon has been charged with dependent adult abuse, administering a harmful substance, and unlawful prescribing of sedatives. You can read news of the case here.

I have been involved in working with families considering donation for twenty years. I am trained by the local organ procurement organization to approach families about donation of tissues after a patient has died cardiac death (as distinct from brain death). I orient new nurses in my hospital to procedures at the time of death, and to working with the organ procurement organization. Therefore, I certainly have opinions of the facts as presented.

I will admit that my first question was whether this was another situation like that of Anna Pou, Lori Budo, and Cheri Landry in New Orleans. Were the facts ambiguous and arguable? Might this be a case of incrementally increasing pain medications for the right reasons – to relieve pain – that unfortunately ended when the patient died? It would certainly be possible for that to happen, and to be misunderstood by the grieving family, or regulators, or both.

However, the specific allegations of this case certainly rule out that possibility. Whether the physician is convicted, there are some definite concerns here regarding events.

Perhaps it would be best to begin with the process of seeking consent for organ and tissue donation. In all cases, the first step is assessment of the patient for severe brain injury. Broadly, we can identify three categories from the assessment: 1) the patient is brain dead, the brain so damaged that without the support of a mechanical ventilator (a “breathing machine”) all functions controlled by the nervous system would already have stopped; 2) the patient is so severely brain damaged that in best medical judgment the patient will not survive, but some basic functions like breathing could continue for a long time; or 3) the patient’s brain damage is less severe, and in best medical experience there is some possibility of recovery. Patients in category 1 may be eligible to donate solid organs, such as heart, liver, lungs, etc – our most common image of organ donation. Patients in category 2 may be eligible to “donate after cardiac death;” that is, it may be possible to recover kidneys if done quickly after breathing and heart function have been stopped long enough to verify death, usually five minutes. Patients in category 3 are not eligible to donate organs at all. (Any patient, whether on a ventilator or suffering brain damage or not, may be eligible after cardiac death – after the heart has stopped –to donate tissues – skin, long bone, heart valves, certain blood vessels, etc.)

In all cases of organ donation, whether in category 1 or 2, there is a point where there must be an independent judgment about the patient’s death. In category 1 that point is the diagnosis of brain death itself. Proper practice requires that the assessment of the extent of brain injury, the possibility of recovery, and the diagnosis that the patient is brain dead must be made without consideration of the patient’s eligibility to donate. Commonly, the diagnosis is made by a neurologist or neurosurgeon, or by a physician with expertise in intensive care, or by more than one such physician. The diagnosis is not properly made by a surgeon involved in transplant because of concern about conflicts of interest. Again, in proper practice that diagnosis is confirmed by appropriate medical tests, and the family is informed. Only after the family is informed that the patient is dead due to brain death is it appropriate to approach the family about the possibility of donation, unless family members bring it up themselves. (This last is also true of tissue donation: only after the patient has died and the family has had some period to accept this would it be appropriate to approach the family about donating tissues.)

In category 2, there is no diagnosis of brain death. Instead, there is a complete assessment of the brain injury and of the patient’s likelihood of recovery. The family is then informed by the physician that the possibility of the patient’s recovery is very poor. Families then face decisions of how aggressive to be in continuing support, and of what the patient would want regarding his or her own care. Some families – these days, perhaps most families – will decide that it is appropriate to stop medical intervention and allow natural death. For a patient who might be eligible for donation after cardiac death, this is the decision that must be fully independent. The family’s decision about continuing or withdrawing life support must be independent of any consideration of possibilities of donation. Again, only after they have been informed and have made their decision to withdraw care, and shared that decision with medical staff is it appropriate to approach the family about the possibility of donation, unless family members have raised the issue themselves.

To some extent, specific facts still need to be determined in court. In addition to the criminal case, there is a civil suit brought by the patient's mother against the physician, and also against the hospital, the system that owns the hospital, and the regional organ procurement organization. Many have begun to wonder what the consequences of these legal actions will be for efforts at organ and tissue donation both regionally and across the nation.

Of particular interest to me is that this has been investigated by the Center for Medicare and Medicaid Services (CMS). Institutions that receive funds through Medicare and/or Medicaid are required to follow federal regulations regarding organ and tissue donation, and compliance with those regulations is overseen by CMS. In addition, regional organ procurement organizations are subject to review by CMS and by the Health Resources and Services Administration (HRSA). An institution that isn't compliant can lose all Medicare and Medicaid reimbursement - for almost all institutions, a significant loss indeed. Usually, when there's a concern about compliant, it's because the institution hasn't been consistent enough in working with the organ procurement organization to be sure all patients who die are assessed for eligibility to donate, and that families of all eligible patients are approached to request donation. In this case, the concern would seem to be from the other pole: that some person or persons in this case were too proactive, and did not care for the patient and family appropriately. Direct involvement by CMS focuses high stakes for the institutions involved, and not just for one doctor.

At any given time in recent years, there have been between 75,000 and 80,000 persons on waiting lists who might benefit from organ donation. In recent years there have been between 20,000 and 25,000 organs donated. Today, according to the United Network for Organ Sharing (UNOS), an umbrella organization for regional organ procurement organizations, there are more than 98,000 currently on waiting lists, while through April of this year more than less than 10,000 transplants have occurred from less than 5,000 donors. Those discrepancies have for some time had the attention of Congress, and Congress has watched intently the work of CMS and UNOS in encouraging institutions and individuals to support donation. With all that attention, institutions are certainly concerned to comply with all regulations, and to cooperate with CMS and organ procurement organizations in identifying patients eligible to donate, and in properly approaching their families. If in individual or institution have been inappropriate in caring for a patient or in caring for a family in this process, the consequences could ripple through the nation's donation and transplant system. Many of us will be watching this case, knowing it could directly or indirectly affect what we do.