Sunday, May 24, 2009

Good Ethics Listening for Chaplains (and Others)

I have already pointed to the Center for Practical Bioethics as a good resource on matters of biomedical ethics.  There is a good deal of information on their web site, and some good ideas and discussion at the blog, Practical Bioethics.


Today I want to point to another resource they offer: The Bioethics Channel.  The Bioethics Channel offers a series of podcasts with interviews on a variety of bioethics issues.  Most are brief – fifteen minutes or less – and offer thoughts and opinions from experts both within and beyond the Center.


As a chaplain, I was interested in the recent podcast, “Religion and Medicine: Compatible?”  Two physician ethicists, Drs. Farr Curlin and John Lantos, gave their thoughts about why physicians should be sensitive to the interactions of spiritual and medical concerns among their patients, and how they might learn about them.  Their concern is not to obviate or displace chaplains or other religious professionals.  Instead, they appreciate how important spiritual issues and beliefs can be for patients, and how those beliefs might impact a patient’s understanding of and compliance with health care.  Thus, their interest is in how awareness of and sensitivity to spiritual concerns of their patients might improve doctor-patient relationships and, by supporting a more effective partnership, patient satisfaction and outcomes.


So, take a look at the Bioethics Channel, and see what you find there of interest.  It’s an opportunity for some continuing education and intellectual stimulation that is relevant to chaplains and others interested in health care ethics. 

Friday, May 22, 2009

Supporting the Hard Conversation: Paying for POLST

Yes, I've been away for a while; good times! Now, back to work....

A colleague of mine has brought to my attention House Resolution 1898, “Life Sustaining Treatment Preferences Act of 2009,” introduced by Congressman Earl Blumenauer (Democrat of Oregon). The intent of the resolution is to require Medicare to reimburse for a patient’s time with a professional when the purpose is to document patient preferences about treatment at the end of life.

The language of the title and of the bill reflects the movement to develop Physician Orders for Life-Sustaining Treatment (POLST). The point of the movement is to develop forms for a physician and patient to use in recording a patient’s preferences, not simply as a statement of intent, but as an actual set of physician orders. Moreover, the intent is that area physicians and area healthcare institutions (especially hospitals, emergency medical services, Emergency Departments, and long term care facilities) will agree to recognize and carry out those orders, whether or not the specific physician has privileges in that specific institution. Most physician orders are on an individual facility’s forms, and stay in the patient’s records. In the case of POLST, the form stays with the patient, and the patient or the patient’s agent can produce it when a patient is dying, trusting that the doctor’s orders for the patient’s treatment will be followed. The hope is that POLST orders can be implemented more quickly and with less difficulty in interpretation than current Healthcare Treatment Directives.

That raises issues for both institutions and physicians of proper credentialing and privileges. In a metropolitan area of any size, few doctors try to obtain privileges in every institution. There are usually too many institutions, and too little time; and so physicians will focus their practices in one or a few institutions. Rural physicians will rarely have privileges in the metropolitan referral hospitals to which patients in extremis might be transferred. There are issues of standards and liabilities to be addressed. At the same time, those issues aren’t insurmountable, and programs have risen across the country to develop such tools.

What is more difficult, however, is arranging for a good consultation in which a physician or other professional has time to sit down, hear a patient out, explain to a patient the options and issues for care at the end of life, and come to mutual understanding for the orders. Neither public (Medicare, Medicaid, etc) nor private insurers reimburse for that use of a physician’s or other professional’s time. And yet it can take - indeed, it should take – longer than most physician visits. If the patient is to really understand the options, and the professional is to really understand the patient (at least enough to complete the order set), they need time together.

That is the issue that Representative Blumenauer’s bill is intended to address. It would amend relevant Medicare law to add “consultations regarding an order for life sustaining treatment” as an intervention for which Medicare could reimburse.

In adding these consultations it adds a new subsection in the law to describe characteristics of such consultations in some detail. Especially important are the definitions that amended law would provide. It begins with a definition of the consultations themselves:

The term ‘consultation regarding an order for life sustaining treatment’ means, with respect to a qualified individual, consultations between the individual and the individual’s physician (as defined in subsection (r)(1)) (or other health care professional described in paragraph (2)(A)) and, to the extent applicable, registered nurses, nurse practitioners, physicians’ assistants, and social workers, regarding the establishment, implementation, and changes in an order regarding life sustaining treatment (as defined in paragraph (2)) for that individual. Such a consultation may include a consultation regarding--

  • ‘(A) the reasons why the development of such an order is beneficial to the individual and the individual’s family and the reasons why such an order should be updated periodically as the health of the individual changes;

    ‘(B) the information needed for an individual or legal surrogate to make informed decisions regarding the completion of such an order; and

    ‘(C) the identification of resources that an individual may use to determine the requirements of the State in which such individual resides so that the treatment wishes of that individual will be carried out if the individual is unable to communicate those wishes, including requirements regarding the designation of a surrogate decisionmaker (also known as a health care proxy).

The Secretary may limit consultations regarding an order regarding life sustaining treatment to consultations furnished in States, localities, or other geographic areas in which such orders have been widely adopted.

Also important

‘(2) The terms ‘order regarding life sustaining treatment’ means, with respect to an individual, an actionable medical order relating to the treatment of that individual that--

  • ‘(A) is signed and dated by a physician (as defined in subsection (r)(1)) or another health care professional (as specified by the Secretary and who is acting within the scope of the professional’s authority under State law in signing such an order) and is in a form that permits it to stay with the patient and be followed by health care professionals and providers across the continuum of care, including home care, hospice, long-term care, community and assisted living residences, skilled nursing facilities, inpatient rehabilitation facilities, hospitals, and emergency medical services;

    ‘(B) effectively communicates the individual’s preferences regarding life sustaining treatment, including an indication of the treatment and care desired by the individual;

    ‘(C) is uniquely identifiable and standardized within a given locality, region, or State (as identified by the Secretary);

    ‘(D) is portable across care settings; and

    ‘(E) may incorporate any advance directive (as defined in section 1866(f)(3)) if executed by the individual.

All of this is well and good. Also good are provisions for grants to establish and support programs for development of POLST-type documents. However, there is a provision that does concern me:

‘(3) The term ‘qualified individual’ means an individual who a physician… (or other health care professional…) determines has a chronic, progressive illness and, as a consequence of such illness, is as likely as not to die within 1 year. (Emphasis mine)

That restriction to those who a physician feels will probably die within a year becomes a significant restriction on POLST programs. After all, age per se is not considered “a chronic, progressive illness;” and yet a patient in his or her 90’s might well not be a good candidate for CPR. In my own setting we have elderly patients who arrive in ER with acute (and not chronic) concerns who request a DNR order, or point out that a Health Care Directive declines CPR.

It is certainly the case that staff see patients for whom they fear doing CPR will do more harm than good. Frail bones break under chest compressions. Inserting a breathing tube or using electric shock have their place, but are also matters of controlled violence. For the patient who’s had a significant stroke – which is, remember, an acute and not a chronic condition – staff don’t want to apply controlled violence when the medical evidence is that it will offer no benefit. Should Medicare not support a POLST conversation for a patient with that concern?And how comfortable with physicians be in determining likelihood of death within one year? One of the continuing issues in hospice care is difficulty physicians have making such a determination for a six-month time frame. All too often, by the time a physician is prepared to acknowledge and share with a patient that together they’ve reached the limit of what therapeutic medicine has to offer, the patient doesn’t have six months or even six weeks, but six days. One might think that one year offers more opportunity than six months; but it might just as well make “likelihood of death” that much harder to determine. Should Medicare not support a POLST conversation for a patient with that concern?

Finally, that’s complicated by the question of what constitutes “a chronic, progressive illness.” With good care patients with such chronic diseases as congestive heart failure, high blood pressure, or diabetes might live for years. However, individual patients may well not do as well; and any of those conditions might lead to related acute events that might well be life threatening. Should Medicare not support a POLST conversation for those patients?

This is a good effort, and one that should, I think, be supported. Reimbursing professionals and institutions for time spent with patients to determine their wishes and to insure that those wishes are followed is in keeping with the ethics lived out in health care today. It shows significant support for maintaining a good doctor-patient relationship, especially in addressing difficult decisions. However, the restriction of that reimbursement to the cases specified is a significant problem. It will leave out so many patients for whom such conversations are not only desirable but also medically reasonable that it will undermine one of the purposes of not only POLST efforts, but of Advance Directives generally: that all patients will have the opportunity to express their concerns and values, and expect that those concerns and values will guide the health care that they will receive.

So, folks, get to your computer or your fax machine. Let your member of Congress know how you feel about this effort; and if you support the effort, address the concern about the restrictions. We as a people have an opportunity to do good for many patients through Medicare reimbursement. I think we ought to do what we can to do good for more people, and not for fewer.

Tuesday, May 12, 2009

Grand Rounds Again

I've had another article accepted to the health care blog carnival, Grand Rounds. The new edition is up at Health Blogs Observatory, and my recent post on problems with a research article on religious coping was accepted.

This is National Hospital Week, and follows National Nursing Week, and to this Grand Rounds starts with a tribute to Florence Nightingale. For my Episcopal readers (and others interested in church issues), remember that Florence Nightingale is remembered in the Episcopal Calendar of Lesser Feasts and Fasts (August 12). You can find here a concise biography, including how she lived out her faith in her work.

So, head over to Grand Rounds and see what folks in health care are writing about. The articles are interesting and the scope is broad.

Wednesday, May 06, 2009

Anglican Network for Health: Can the Net Be Strong Enough?

At the current meeting of the Anglican Consultative Council (ACC) in Kingston, Jamaica, a great deal of attention is being paid to international Anglican networks, including the new Anglican Network for Health. The Rev. Paul Holley, the Representative of the Anglican Communion to the UN Offices in Geneva, Switzerland, and who was with us at the January meeting in Houston, was interviewed about the new Anglican Health Network. In the interview he speaks of his sense of the current and future work of the Network. He makes reference to the Houston meeting, as well as some of the results. You can find a podcast of the interview here (not quite eleven minutes). When you have a few minutes, it’s worth a listen.

In my most recent post at Episcopal Café, I expressed my concerns about changes in the Communion:

And my greatest qualm is that we have already lost forever the Anglican Communion that I knew, and that the Episcopal Church will soon follow. I don’t mean that the Church has departed from the Christian faith or the Anglican tradition. I don’t believe either of those assertions. It is, rather, that the shape and manner of the Communion has changed, and of the Episcopal Church will change.

I have to admit that I don’t have much hope. The Fellowship of Confessing Anglicans (FOCA: the GAFCON group) will want little to do with us, Covenant or no. Indeed, one of their favorite theologians has suggested that they should sign on to the Covenant as soon as possible, in hope that will persuade the Episcopal Church not to sign!

At the same time, I have expressed a concern in the past (here and here and here, at least) about Archbishop Williams’ commitment to a new, more centralized, "new-Rome-but-for-the-Papacy," ecclesiology. His comments so far at the ACC meeting only reinforce my opinion about what he thinks necessary. I fear that, FOCA or no, General Convention would have trouble signing on to that vision, either. For many of us that would be to embrace the influence of foreign prelates that we thought we had rejected in the English Reformation. The “brain trust” for this effort is to be the Inter-Anglican Standing Committee for Unity, Faith and Order, or IASCUFO. It occurred to me that IASCUFO could be an anagram for U-FIASCO – that is, attempts at “unity” by fiat will in the end be a fiasco. So, I don’t have much hope about this Communion of relationships holding, Instruments or no Instruments, with or without a Covenant.

And it is precisely ministry possibilities like an Anglican Network for Health that would be lost. My Best Beloved, who is much less interested in all of this than I am, asked me yesterday what mattered about it. My answer was that what would be lost, or at least seriously rearranged, would be the opportunities for ministry. The fact is we do have a lot of resources in the Episcopal Church, resources that we really want to share. In the past we’ve tried to share them by working with local Anglican groups around the world. Already some in Africa have refused to work with us, unwilling to take what they see as “tainted” money – tainted in part by what they see as our sinfulness, and in part by a “cultural imperialism” that we ourselves question and challenge, but that they see (largely accurately, I think) as a major threat to their own contemporary cultures. It’s harder for us to share our resources when the local contacts we have known will no longer have anything to do with us.

But perhaps the Draft Covenant and discussions around it offer a model for continuing, if not a useful tool per se. The Covenant speaks churches of the Anglican Communion and churches who sign the Covenant as, potentially, separate groups. Perhaps when other avenues fail, inter-Anglican networks could continue, supported by the two or three successor groupings of folks in the Anglican tradition. Being focused on ministries and not so much on ecclesiologies or ecclesiastical politics, perhaps networks like the Anglican Health Network can continue, allowing people to work together without having to agree on all, or even most things. Perhaps in the future, that could be a model for a different way of covenanting, one that could bring reconciliation among folks in the Anglican tradition.

One can only hope….

Tuesday, May 05, 2009

Once Again at Grand Rounds

Periodically I point to the ongoing web carnival, Grand Rounds. This week's edition (vol. 5, no. 33) is now up on the blog at Ausmed, and my recent post on DNR and AND orders has been accepted. Click over and take a look at a selection of blog posts and articles on issues in medicine and health care.

Monday, May 04, 2009

Once Again at Episcopal Cafe

My newest post is up at Episcopal Cafe. It's about loss - but not the sort of loss I usually write about as a chaplain. I hope you enjoy it. I hope you enjoy it enough to comment over your name, and let us know what you think.

Take some time while you're there to look at other parts of the Cafe. We'd like for you to read, and we'd like to hear from you. You'll need to set up a Typepad account, if you don't already have one; but it's quick and, like most such online accounts, free. So, please, leave a comment at the Cafe, and let us know what you think.

Saturday, May 02, 2009

General Convention 2009: Health Issues 4

Perhaps the most important, and probably the most controversial issue addressed in the Report to General Convention of the Standing Commission on Health is actually only briefly referenced in the Report. The topic is a Denominational Health Plan.

At the 2006 General Convention, Resolution A147, titled, “Study the Costs and Issues of Healthcare Benefits for All Clergy,” was passed in both Houses:

Resolved, That the 75th General Convention endorse the Church Pension Group’s proposal to conduct a church-wide study of the costs and issues surrounding the provision of healthcare benefits to all clergy and lay employees serving churches, dioceses and other church institutions and to report their findings to the 76th General Convention; and be it further

Resolved, That all dioceses, parishes and other church institutions are urged to cooperate with the conduct of this study by responding to requests for data regarding employee census and healthcare costs; and be it further

Resolved, That this study will include an analysis of the potential for a mandated denominational healthcare benefits program and other viable alternatives, culminating in a recommended solution and an actionable implementation plan.

The potential benefits of a mandated denominational health plan are potentially quite considerable. The first is simply making the actuarial risk pool much wider, and so spreading the risk. Since insurance rates are based on the average risk for any member measured against the total risks of all member, the more members in a group the better the average risk, and so the lower the cost of insurance. Historically, while the Church Medical Trust was willing to handle the negotiations, the costs were based on each diocese alone. That has made for some significant differences between dioceses with many clergy and those with few.

Mandating participation in the plan, and including lay employees, would also increase the pool. Historically, a diocese, or even an individual congregation could opt out of the plan, if Council or Vestry thought they could get a more economical deal. And since the plan to date has only included clergy, adding lay employees would certainly add members.

Let’s look at what the Church Pension Fund has proposed. The specifics are proposed in Resolution A177. The resolution, along with background and supporting information, is found in the Report to General Convention of the Church Pension Fund (it’s a long report, with a lot of valuable information; but keep scrolling down until you get to the discussion of the health plan).

The resolution is in three sections. The second section is a canonical change to implement the plan, while the third has to do with funding. The details of the proposed plan itself are in the first section:

Resolved, the House of _______ concurring, That this church establish The Denominational Health Plan of this church for all domestic dioceses, parishes, missions, and other ecclesiastical organizations or bodies subject to the authority of this church, for clergy and lay employees who are scheduled to work a minimum of 1,500 hours annually, in accordance with the following principles:

1. The Denominational Health Plan shall be designed and administered by the Trustees and officers of The Church Pension Fund, following best industry practices for comparable plans;

2. The Denominational Health Plan shall provide that, subject to the rules of the plan administrator, each diocese has the right to make decisions as to plan design options offered by the plan administrator, minimum cost-sharing guidelines for parity between clergy and lay employees, domestic partner benefits in accordance with General Convention Resolution 1997-C024 and the participation of schools, day care facilities and other diocesan institutions (that is, other than the diocese itself and its parishes and missions) in The Denominational Health Plan;

3. The Denominational Health Plan shall provide benefits that are comparable in coverage to those benefits currently provided by the domestic dioceses and parishes of this church;

4. The Denominational Health Plan shall provide equal access to health care benefits for eligible clergy and eligible lay employees;

5. The Denominational Health Plan shall provide benefits through The Episcopal Church Medical Trust, which shall be the sole plan sponsor for such benefits and continue to be operated on a financially sound basis;

6. The Denominational Health Plan shall have a church-wide advisory committee that is representative of the broader church and appointed by The Church Pension Fund, and such church-wide advisory committee shall receive an annual report about the status of The Denominational Health Plan;

7. For purposes of this Resolution, the term "domestic" shall mean ecclesiastical organizations and bodies located in the United States, including the Dioceses of Puerto Rico and Virgin Islands;

8. The Church Pension Fund shall continue to work with the Dioceses of Colombia, Convocation of American Churches in Europe, Dominican Republic, Ecuador Central, Ecuador Litoral, Haiti, Honduras, Micronesia, Taiwan and Venezuela to make recommendations with respect to the provision and funding of healthcare benefits of such dioceses under The Denominational Health Plan; and

9. The implementation of The Denominational Health Plan shall be completed as soon as practicable, but in no event later than by the end of 2012;…

Let me point out what I consider the most significant paragraph of this section, and, indeed, the most significant phrase in that paragraph:

2. The Denominational Health Plan shall provide that, subject to the rules of the plan administrator, each diocese has the right to make decisions as to plan design options offered by the plan administrator, minimum cost-sharing guidelines for parity between clergy and lay employees, domestic partner benefits in accordance with General Convention Resolution 1997-C024 and the participation of schools, day care facilities and other diocesan institutions (that is, other than the diocese itself and its parishes and missions) in The Denominational Health Plan; (emphasis mine)

So, there won’t be a single denominational health plan, in the sense that every eligible person in every diocese will be participating in the identical plan and paying the identical rate. There will be a single plan in the sense of being a single plan administrator and plan sponsor – the Church Medical Trust of the Church Pension Fund - but that’s not really a “single plan.” Moreover, look at all the things that an individual diocese can make choices about: “plan design options; cost-sharing guidelines; domestic partner benefits; and the participation of schools, day care facilities and other diocesan institutions.” That begins to look like there could be an awful lot of variation from diocese to diocese.

That doesn’t mean there aren’t simplifications and cost savings to be had. These are addressed in the Report itself, but some stand out. First, it would still bring all eligible clergy and lay employees into one large pool, or at least a small number of pools larger than we use now (according to the report at least one as small as 15 households!). It would further balance the risks in the pool by keeping younger, healthier participants in the pool with us graying members, instead of allowing individual congregations with younger folks to simply opt out, and skew the average age.

It will also reduce the number of plans, In conversation with an employee of the Church Medical Trust, our diocesan deputation was told that when first looked at there appeared to be more than 200 separate plans purchased in the Church. However, when characteristics were compared it turned out there were more like seven plans – but purchased from many different companies at many different prices. By focusing on the characteristics of the plans, the Church Medical Trust can negotiate with national companies and get national, or at least regional prices – and so better than an individual diocese might get.

Still, this will indeed be controversial. First, in the current optional plan there are certainly some dioceses doing quite well. They may find it hard to sacrifice for the benefit of dioceses doing more struggling. Small congregations will want to know as much as possible about how this will affect costs. Paying for heath insurance for clergy has become one of the most difficult costs for some congregations, and for dioceses that have a high percentage of such congregations. And of course there will be those who simply dislike the thought that the Church would mandate the plan (or anything else, for that matter).

And it probably won’t reduce what we’re paying now. The opportunity for savings – and it’s a big opportunity – is in reducing how fast our costs grow. That’s hardly insignificant. The Report estimates a savings over the first six years of the plan of $134 million. Still, that’s not immediate relief, but future savings.

This is an important plan for the Episcopal Church, and for the health of clergy and lay employees and their families. It is likely to be the most ambitious plan undertaken in this Convention, regarding health or anything else. I would encourage all Episcopalians to attend to this. Read the Report and the Resolution. Talk to your parish treasurer, and make sure he or she is also involved. Then, make sure to let your bishop and deputies know about questions and concerns. This will affect our life together in ways we will be much more aware of than most of us are of the Anglican Communion. It may not have the theological import or panache that other issues and resolutions have; but this Report and this Resolution will shape how the Church does business for a long time to come. We need to give it the attention that it deserves.

Friday, May 01, 2009

The Church and the Flu

Right now there are a great many concerns about the new flu.  We can call it the H1N1 flu, or the swine flu; but whatever we call it, it’s got people concerned.  In the metropolitan area where I work there have been two “probable” cases reported (confirmation from the Centers for Disease Control takes time).  That hardly seems overwhelming; but when I stopped by the drug store today, the shelves were almost emptied of hand sanitizer.

I’ve been looking at resources, and have even shared some with local clergy in my area.  They include the following sites that my own institution has been sharing:


 The resources MedlinePlus in Spanish may be especially helpful for some folks.

Episcopal Café, a web site of the Episcopal Diocese of Washington (D.C.) has a page with useful links, some of which address specifically how churches are addressing communion.  You can find that here.

Another comprehensive site, addressing a host of questions, is on the site of Episcopal Relief and Development (ER-D)  Their information includes material from CDC, and, as well as some materials for developed for Canadian Churches during the SARS epidemic.

Our siblings in the Evangelical Lutheran Church in America (ELCA) have also posted resources.  You can link to their information from here.

Remember that the most important steps to take are things we already know:

  • Wash hands early and often, and use appropriate sanitizers.
  •  If you feel sick, stay home as an act of grace to others.
  •  If you have a family member sick, keep that person home for the same reason.
  •  Use discretion especially if you’ve recently been in Mexico, or have been with someone known to have this flu.
  •  Follow guidelines from the CDC and the State Department about travel to Mexico.
  • Get your information from trustworthy sources: the CDC, local public health, or your health care provider. 

This is, as many have said, a time for concern, but not for alarm.  To some extent that’s because we’re not powerless, even in the face of illness, even in the face of pandemic disease.  We have good sources of information, and we have some basic practices for self-care, the most important of which are, literally, in our hands.  And, of course, we trust that we always have God as our helper.