Southern University
student Shanquil Thomas made a political statement
on campus Wednesday.
After walking into a
huge, green recreational vehicle parked in front of the student union, Thomas
sat at a laptop computer and signed a petition supporting President Barack
Obama’s health-care reform plan.
“I think this is
great that we can do this as college students because we’re the next
generation and this is going to affect us,” Thomas said.
Thomas was one of a
dozen or more Southern University students who attended a rally Wednesday
touting Obama’s plan for public health insurance that would compete with
private insurance companies.
There is a political
clash in Washington, D.C., and across the country between
Republicans and some Democrats who disagree with the president over the
feasibility of a public option government health-care plan that Obama has
proposed to insure the uninsured and give other Americans a choice between
public and private insurance.
The RV stopped at
Southern University as part of the American Federation of State, County and
Municipal Employees’ “Highway to Health Care” tour.
The tour started Aug.
10 in Missoula, Mont., and is slated to make 19 stops in
10 states over a three-week period, said Blaine Rummel,
a spokesman for the tour.
Rummel said the RV stopped
in Shreveport on Tuesday and was scheduled to
leave Southern at 1 p.m. Wednesday to visit three cities in Indiana.
“We want to show that
there is large support for the president’s public health-care plan outside of
the large metropolitan cities,” Rummel said.
Rummel said the American
Federation of States, County, and Municipal Employees supports nothing less
than a government public option.
During the rally at
Southern, American Federation of Labor and Congress of Industrial
Organizations Louisiana President Louis Reine told
the crowd that 50 percent of the bankruptcies in the nation are caused by
medical bills that cannot be paid.
“The cost of health
care lowers your wages. It’s time for a change,” Reine
told the students.
State Rep. Regina
Barrow, D-Baton Rouge, told the audience that people need to be part of the
process and tell their leaders in Washington, D.C., where they stand.
“This is about
safeguarding the future of our children’s children,” Barrow said.
Although he arrived
after the rally started and didn’t say anything publicly, Baton Rouge businessman Bill O’Quin attended the event and seemed to be the lone voice
against Obama’s health plan.
“I think we need health-care
reform but I believe in free enterprise. The government creates nothing. They
just collect taxes,” said O’Quin, a retired life
insurance company executive and owner of a publishing company.
“The debt and
government spending is out of proportion and it’s just unsustainable,” he
said.
O’Quin said he doesn’t have
the easy answer to health-care reform but he said government could start by
weeding out the fraud and waste of current government health programs such as
Medicaid and Medicare.
“A public option will
bankrupt our country and bargain away our children’s freedom,” O’Quin wrote in a handout he issued at the rally.
http://www.2theadvocate.com/news/53759392.html?showAll=y&c=y
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State employees and
volunteers plan to visit churches, community centers, day-care centers and
governmental buildings in the Baton
Rouge area today and Friday in an attempt to enroll
more children in a federally funded health insurance program.
The “enrollment
blitz” aims to sign up as many as 3,000 more eligible children with medical
insurance coverage, leaders of the effort said in a meeting in Baker on
Wednesday.
Louisiana Children’s
Health Insurance Program, known as LaCHIP, covers
eligible children until age 19 with a no-cost insurance plan.
LaCHIP is available to
children in households with monthly incomes ranging from $1,805 for one
person to $6,169 for a family of eight, or $624 more for each additional
person in the household.
For children from
families with slightly higher incomes, the state also offers the LaCHIP Affordable Plan, which covers children in
households earning an annual income of up to 250 percent of the federal
poverty rate, or about $55,000 per year for a family of four.
Kyle Viator of the
state Department of Health and Hospitals said Wednesday that a 2007 survey
shows that about 5 percent of children eligible for the programs are not
enrolled.
The blitz aims to
reduce that percentage.
Viator said the
primary reason that many children are not benefiting from the programs is a
lack of knowledge of the income guidelines.
“They think they
don’t qualify, or they think they can’t afford it,” he said.
Viator said many
people are not aware that the incomes of grandparents or step-parents living
in the homes are not counted when eligibility is determined.
“LaCHIP
has helped me and my family,” Latrice Morgan said
at the Baker event.
A working mother, Morgan
is able to obtain insurance for herself through her employer, but she said
she depends on LaCHIP to cover her children, both
of whom suffer from asthma.
DHH will hold an open
house from 9 a.m. to 1 p.m. Saturday at its regional LaCHIP
outreach office, 2521 Wooddale
Blvd., to assist families in enrolling children.
Information on the
program also is available by calling (877) 252-2447 or through the Web site,
http://www.lachip.org.
http://www.2theadvocate.com/news/53758887.html?showAll=y&c=y
[Video]
More than 3,000
uninsured kids in our area could soon get coverage through the Louisiana
Children's Health Insurance Program. The program gives low-cost or no-cost
health insurance to eligible kids in the state. News 2's Christine Lewis gets
answers on who is benefiting and what's being done to get even more kids
enrolled in the program.
http://www.2theadvocate.com/news/53736552.html
[BACK TO TOP]
My comments concern a
fund-raising flier I recently received from U.S. Rep. Dr. Bill Cassidy,
R-Baton Rouge.
I have known Bill for
many years; in fact, his hepatitis clinic was across the hall from my
arthritis clinic at Earl
K. Long
Medical Center
for several years. I like, admire and respect him as a person, physician and
as a citizen who puts himself on the line to serve the public (and be open to
criticism from those who disagree with his stand on issues).
His letter starts off
reasonably enough — “I think we all agree that health care reform is needed,”
but immediately goes downhill from there, to “but it should be market reforms
which strengthen the physician-patient relationship.”
We do not “all” agree
that health-care reform is needed. During their eight years in power, no
Republican president or Congress has ever advocated comprehensive health-care
reform. Next, and throughout the letter, he refers to the “patient-physician
relationship,” which he does not define or discuss, as being threatened by
the Democrats’ health plan.
After 40-plus years
of medical practice — in general practice before Medicare was enacted and in
practicing internal medicine and rheumatology after Medicare — I believe I
understand the patient-physician relationship, and especially the impact that
“government medicine” has had on it.
The clinics that Dr.
Cassidy and I staffed are all attended by patients who have no insurance,
many of whom were sent by their previous physicians because they lost their
insurance (along with their patient-physician relationship). That makes it
crystal clear that to give these patients a choice, they need insurance.
Medicare, which has
never interfered with the patient-physician relationship, has, on the
contrary, immeasurably improved the patient-physician relationship for the
elderly. Nevertheless, most physicians vociferously opposed “government medicine”
prior to Medicare, predicting irreparable damage to the patient-physician
relationship, and are now recycling their “bureaucrat between you and your
doctor” fright wig for today’s audience, hoping that past predictions have
been forgotten.
The remainder of Dr.
Cassidy’s letter is standard Republican boiler plate, including unexplained
and/or meaningless catchphrases such as “patient centered approach,” “market
reform” and “antitrust issues.” I find it insulting to my professional
colleagues to suggest that they don’t practice “patient centered” medicine.
His best suggestion is liability reform, which is shunned by the Democrats.
None of these
Band-Aids suggest recognition of the enormity of the health-care problem or
the obvious conclusion that only the government has enough clout and
resources to deal with it. In view of Dr. Cassidy’s ideological approach to
the problem, I believe he can contribute more to health care by returning to Baton Rouge and
resuming his outstanding medical practice.
Herbert Dyer
retired physician
Baton Rouge
http://www.2theadvocate.com/opinion/53754507.html#
[BACK TO TOP]
Houma Courier | 08.19.09
In recent weeks, the
race for the local Senate seat has taken an ugly turn toward the negative.
In the days leading
up to the primary, all three candidates kept the focus on positive
expressions of their own strengths rather than denigrating their opponents.
But since the race
narrowed to Brent Callais, R-Cut Off, and Norby Chabert, D-Houma, there has been an unsettling
trend toward attacks.
It began the night of
the Aug. 1 election, when Chabert charged that Callais
supports closing Chabert Medical
Center, Houma's
charity hospital.
Callais, in fact, has
expressed support for privatizing some services to make the hospital less of
a burden on taxpayers. That is a long way from closing it, and Chabert should
be careful not to inflame public passions about what is essentially a
disagreement over how the hospital is run, not whether it remains open.
For his part, Callais got into the mudslinging last week when his
campaign sent out a mailer trying to tie Chabert to President Barack Obama's
health-care overhaul plan.
Chabert has said he
supported Obama's candidacy, but that hardly means he supports everything the
president proposes.
We were much more
comfortable when the candidates were focusing on their own strong points
rather than heaping scorn on the supposed shortcomings of each other.
Some of the blame
belongs to the candidates, of course, who should have better things to talk
about — particularly this far along in such an important campaign.
But some of the blame
belongs to the voters of District 20, only 20 percent of whom bothered to
vote in the Aug. 1 primary.
With such poor
turnout, the candidates are probably desperate to create some enthusiasm,
even if it is of the negative variety.
If a sizeable portion
of the electorate could be counted on to go out and do its civic duty by
voting, the candidates would be free to focus on issues of their own without
worrying about whether the campaign is gaining enough interest.
That is not an
excuse, of course. Each candidate is responsible for how the campaigns are
conducted. Until recently, they each had a lot of reason to be proud of their
conduct.
And even now, Callais and Chabert can take pride in the fact that they
have participated in so many debates and forums. They have truly done all
they could to inform the public about the issues facing the Senate district
and how they will approach those challenges.
Now the challenge
belongs to the public. Can we take what we know about these two men and come
to a decision about who should be this area's next senator?
While their excellent
participation in public forums make the task easier, their recent focus on
negativity has harmed the cause.
We encourage each to
get back on the positive track and tell us why we should support him. That's
what we all want to hear.
Editorials represent
the opinions of the newspaper, not of any individual.
http://www.houmatoday.com/article/20090819/OPINION/908199918?Title=Let-s-get-race-back-onto-the-positive
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Will Callais’ approach lead to win?
Houma Courier | 08.19.09
When a sports team
runs a play that succeeds again and again, it's up to the opposition to find
something that counters it. With some help from Democrats, Republicans are
showing they can do it and may provide lessons for campaigning in the next
couple of years.
For years, the
Democrat playbook has been to present an image to conservative constituencies
that comprise a majority of a district that their candidates are conservative
enough to win their votes, yet to do everything possible to obscure the fact
they are more than willing to vote for liberal policies demanded by their
party leaders. Perhaps the most accomplished practitioner of this strategy in
Louisiana
is the area's own Rep. Charlie Melancon,
D-Napoleonville, who in 2008 managed to run unopposed in a district that gave
only about 35 percent of its vote to his co-partisan Barack Obama.
The rise of national Democrats to heights not seen in three decades,
largely dependent upon lapdogs such as Melancon, at
the same time sow their own seeds of destruction of that success and
of politicians of Melancon's ilk. Because they have
a comfortable majority, the very liberal White House and congressional
Democrat leadership pursue policies that are simply too liberal for these
lapdogs to be able to disassociate themselves from their masters. However,
Republicans can benefit only if they take advantage of this opening.
At least one seems to
be. Republican former Lafourche Parish Councilman Brent Callais
has sent a campaign ad highlighting opponent Democrat lobbyist Norby Chabert's congruence with
Obama — and by implication his agenda — in the special election for state
Senate to be contested Aug. 29. Chabert has responded with the standard
lapdog playbook recommendation — claim this "distorts" his views
while simultaneously attacking Callais for making
true statements.
Chabert's weaseling on the
situation raises questions about his ability to govern. Chabert himself actually
began the distortion days earlier when he accused, on the basis of Callais expressing a desire to "moderately
support" privatizing Leonard J.
Chabert Medical Center (named after his late father, a long-standing
local political boss who once held this seat), that this equated to Callais wanting to close the facility.
Chabert cannot think
critically if he cannot understand that if a need is there, privatization of
the facility will not close it and this should provide more efficient use of
state resources. And if the demand is not there, then why waste taxpayers'
dollars on something not needed? Privatization does not mean closing, and to
think so shows Chabert either wants to use the issue to score political
points or lacks the intellect to be an effective state senator.
Another demonstration
of this weakness comes in his response to Callais'
ad that reminds the public that Chabert voted for Obama. Chabert claims too
much is being made of the vote which he said, in part, came from Obama's
opponent Sen. John McCain's vote against a water resources project that
Chabert asserts was unwise. This means one of two things. One, Chabert is
akin to a single-issue voter who cannot make judgments about what is best as
a whole for the people. The other is that he simply needs an excuse because
he agrees more than disagrees with Obama's agenda. So either his district
would get a senator unable to see the bigger picture, or one who is
mendacious.
Thus, when Callais also asserts that Chabert "cannot be
trusted," there is real evidence to back this up, in terms of the
former's trying to explain away his affinity for Obama and willingness to
distort Callais' statements. Yet Chabert pouts that
this mailing is a "negative" attack that he said Callais said the latter would not do. This also is a
common Democrat lap dog tactic, that when their inconsistencies are pointed
out, they accuse opponents of being distorting and negative. But the flier
only points out that "Norby Chabert supports
Barack Obama. Brent Callais opposes Barack Obama
and his government-run health care," both simple statements of fact,
neither disputable. Yet Chabert calls Callais'
notification "negative" and somehow untrue — again, leading one to
wonder whether somebody who thinks like this is qualified to serve in public
office.
Therefore, the
election Saturday after next could demonstrate a Republican strategy with
sharp reverberations for future state contests. A Callais
win using these tactics, in a district historically represented by Democrats
and whose electorate gave the majority of their vote to Democrats in the
primary, will show that a relentless exposure of the inconsistent
words-to-behavior aspect of Democrats in conservative districts is the key to
winning.
Jeffrey Sadow is an associate professor of political science at
Louisiana State University-Shreveport. These are his own
views solely. You can read his blog at www.jeffsadow.blogspot.com.
http://www.houmatoday.com/article/20090819/ARTICLES/908199916?Title=Will-Callais-approach-lead-to-win-
[BACK TO TOP]
New Targets For Treatment Of Invasive Breast Cancer Discovered
ScienceDaily (Aug. 19, 2009) —
Research led by Suresh Alahari, PhD, Associate
Professor of Biochemistry and Molecular Biology at LSU Health Sciences Center
New Orleans, has shown for the first time that a tiny piece of RNA appears to
play a major role in the development of invasive breast cancer and identified
a gene that appears to inhibit invasive breast cancer. The research is
published in the August 21, 2009 issue of the Journal of Biological Chemistry.
The LSUHSC
researchers are the first to demonstrate that miR-27b, a novel microRNA, not only inactivates the ST14 gene which they
found suppresses the growth of breast tumor cells, but also that miR-27b
stimulates the breast cancer to invade other cells.
MicroRNAs are a new class of
small, single-stranded RNA molecules which play an important regulatory role
in cell biology. They bind to target genes and decrease their function. MicroRNAs may act as oncogenes
(a gene that contributes to cancer development) or tumor suppressors.
In this study working
with a line of human breast cancer cells, Dr. Alahari's
team found that aggressively invasive breast tumor cells contain a large
quantity of miR-27b molecules, while normal cells do not. Further analysis
revealed that miR-27b increases during cancer progression, in direct
proportion to the decrease in function of the ST14 gene. They found that
miR-27b promotes cell growth and cell invasion, suggesting that miR-27b acts
as a breast cancer oncogene. They also found that
ST14 inhibits both cell growth and cell invasion, suggesting that ST14 is a
breast cancer tumor suppressor gene and that it may also serve as a marker
for the early detection of breast cancer.
According to the
American Cancer Society, an estimated 192,370 new cases of invasive breast
cancer are expected to occur among women in the US during 2009; about 1,910 new
cases are expected in men. Excluding cancers of the skin, breast cancer is
the most frequently diagnosed cancer in women. An estimated 40,610 breast
cancer deaths (40,170 women, 440 men) are expected in 2009. Breast cancer
ranks second as a cause of cancer death in women (after lung cancer).
"We are in the
process of confirming these results and these studies will reveal whether
ST14 can reduce breast tumor growth in animals," notes Dr. Alahari, who is also a member of the LSUHSC Stanley S.
Scott Cancer Center. "Blocking the miR-27b/ST14 interaction or rescuing
ST14 function may be an effective therapeutic approach to advance breast
cancer treatment."
This study was
supported by funding from the National Institutes of Health, the Susan G. Komen Breast Cancer Foundation, the Louisiana Board of
Regents, and the Louisiana Cancer Research Consortium.
http://www.sciencedaily.com/releases/2009/08/090819153929.htm
[BACK TO TOP]
While
some Democrats maintain that bipartisan health care reform work
still has potential, others seem to be hedging their bets. The Christian Science Monitor reports that "In
all likelihood, (White House Chief of Staff Rahm
Emanuel and press secretary Robert Gibbs) are engaging in creative ambiguity,
designed to send signals to multiple audiences – friend and foe – and keep
options open as long as possible." And, as Gibbs himself
said, it is still August. "Crunch time for passing reform by the
end of the year is still months away. The longer the White House is able to
keep its options open, the greater its chances of settling on a firm position
that can pass both houses of Congress."
"Meanwhile, facts on the ground indicate that bipartisanship is not
completely dead." Senate Finance Committee Chairman Max Baucus,
D-Mont., said Wednesday that "bipartisan progress continues."
He also said the bipartisan group of six committee negotiators
would meet today by telephone (Feldmann,
8/19).
The Wall Street Journal reports that Democratic
leadership and the White House see little chance of bipartisan support and
are considering passing the most expensive parts of the legislation separate
from larger reform, and solely with Democratic votes: "The idea is the
latest effort by Democrats to escape the morass caused by delays in Congress,
as well as voter discontent crystallized in angry town-hall meetings. Polls
suggest the overhaul plans are losing public support, giving Republicans less
incentive to go along. … In recent days, Democratic leaders have concluded
they can pack more of their health overhaul plans under this procedure....
They might even be able to include a public insurance plan to compete with
private insurers, a key demand of the party's liberal wing, but that remains
uncertain" (Weisman and Bendavid, 8/20).
But bipartisan hope remains, The Hill reports: "'Bipartisan progress continues,'
Baucus said. 'The Finance Committee is on track to
reach a bipartisan agreement on comprehensive health care reform that can
pass the Senate. ... I am confident we will continue our steady progress
toward health care reform that will lower costs and provide quality,
affordable coverage to all Americans'" (Rushing, 8/19).
Sen. Charles Grassley, the ranking Republican on the committee, said
Wednesday "that the outpouring of anger at town hall meetings this month
has fundamentally altered the nature of the debate and convinced him that
lawmakers should consider drastically scaling back the scope of the
effort," The Washington Post reports. Grassley also called on
President Obama to publicly state that he'd sign a bill without a public plan
in it and that lawmakers should focus on getting 80 votes (Montgomery and
Bacon, 8/20).
Democratic leadership is still talking as if a bipartisan bill is possible
going forward, however, The Hill reports in a second story: "A senior aide
to Senate Majority Leader Harry Reid (D-Nev.) said
Wednesday that Democratic leaders would prefer to advance a bipartisan bill
through the Senate, instead of forcing it through using special budgetary
rules" (Bolton, 8/19).
"Privately, Democrats are preparing a one-party push, which they feel is
all but inevitable," The Associated Press reports. "On Wednesday, Jim
Manley, spokesman for (Reid) warned Republicans that (budget) reconciliation
is a real option. The White House and Senate Democratic leaders still prefer
a bipartisan bill, he said, but 'patience is not unlimited and we are
determined to get something done this year by any legislative means
necessary'" (Babington, 8/20).
CBS News: "Worried that the White House is caving
under pressure from the right, some liberal democrats are now pushing for a
'go it alone' strategy on health care reform that does not include
Republicans at all. 'Over and over again the Republicans have said no,' said
Rep. Donna Edwards, D-Md. 'I don't think that they
want reform'" (Cordes, 8/19).
Still Republican and insurance industry attacks may eventually force
Democrats to scale back some of their reform provisions, Kaiser Health News reports: "Indeed, a senior Senate
Democratic aide acknowledged earlier this week that Democrats likely will
have to 'scale back' the package this fall if the ongoing bipartisan
negotiations involving six Finance Committee members fall apart. 'If we don't
get something by mid-September, there will be a great deal of interest in
reconsidering whether we need to go down a different path,' the aide said in
an interview. 'There are legions of ways you could go'" (Pianin and Carey, 8/20).
http://www.kaiserhealthnews.org/Daily-Reports/2009/August/20/Together-or-Separate.aspx
[BACK TO TOP]
What Makes Spain's Health Care System The Best?
by Jerome Socolovsky
Listen
to the Story
Morning Edition
[4 min 32 sec]
Spain's single-payer
health care system is ranked seventh best in the world by the World Health
Organization. The system offers universal coverage as a
constitutionally-guaranteed right and no out-of-pocket expenses — aside from
prescription drugs. Patients do complain, however, about the long wait to see
specialists and undergo certain procedures.
Transcript:
STEVE INSKEEP, host:
Americans debating
health care can do comparison shopping with other nations. We heard this week
about Britain's system,
and this morning we go to Spain.
Its health care system is being ranked as one of the best in the world by the
World Health Organization. As Jerome Socolovsky
reports, most taxpayers there don't seem to mind paying for it.
(Soundbite
of crowd chatter)
JEROME SOCOLOVSKY: La Paz University
Hospital in Northern
Madrid is not known for its creature comforts. But most patients
say they're not bothered by the hard plastic chairs or the absence of
soothing music in the waiting rooms. La Paz
might be one of the oldest and biggest hospitals in Spain, but
it's considered one of the best.
Unidentified Woman:
(Spanish spoken)
Unidentified Man:
(Spanish spoken)
SOCOLOVSKY: Sali Avayeda(ph) has come for a follow-up appointment. She had a
kidney transplant five months ago.
Ms. SALI AVAYEDA:
(Spanish spoken)
SOCOLOVSKY: I feel
like a new person, she tells her doctor. Before the operation, Avayeda said she hardly ever set foot in a public health
facility. She was one of the minority, the 10
percent of people in this country who pay extra to be treated at
privately-run clinics. But when symptoms of kidney disease developed a few years
ago, Avayeda headed straight to this public
hospital.
Ms. AVAYEDA: (Spanish
spoken)
SOCOLOVSKY: The
doctors are excellent. The nurses are very nice, and the service has been
really good, she says.
(Soundbite
of door opening)
SOCOLOVSKY: Out in
the waiting room, another kidney recipient, 32-year-old Jorge Ordiya(ph),
is not quite as enthusiastic.
Mr. JORGE ORDIYA:
(Spanish spoken)
SOCOLOVSKY: The care
is good, technically speaking, but the personal service has its ups and downs,
he says. The most common complaint of patients is the long wait to see
specialists and undergo certain procedures. On the other hand, a study
published last year in the U.S.
journal Health Affairs found that in Spain,
there are a third fewer deaths caused by delayed access to health care than
in the United States.
Spain's constitution,
drawn up in 1978 following the Franco dictatorship, not only guarantees the
right to universal health care, it also requires the state to provide it. The
World Health Organization's ranking system puts Spain's health care system
seventh in the world, well ahead of America, even though it spends much less
on health care.
Dr. Jimenez says the
system covers virtually every medical need.
Dr. JIMENEZ (La Paz University Hospital):
(Spanish spoken)
SOCOLOVSKY: I don't
know of anyone who's had to go to another country for treatment that doesn't
exist in Spain,
he says. There are thousands of primary care clinics, even in small villages.
Patients have a choice of doctors they can see as often as they like, and
there are no co-payments and no claims forms. Even undocumented immigrants
are treated.
In Spain, no one
worries about their health coverage. If someone loses a job, is short of
money or needs long-term care, the system will look after them. For those
Americans who are used to private doctors offering a plethora of tests and
the latest technologies, the Spanish system might seem a little basic, but no
one is turned away.
Life expectancy in Spain is one of Europe's highest, and many of
family practitioner Heronimo Fernandez Torente's(ph)
patients in the northwestern city of Lugo
are over 80 years old. He says there's no question of rationing.
Dr. HERONIMO
FERNANDEZ TORENTE (Family Practitioner): (Spanish spoken)
SOCOLOVSKY: People
come complaining of osteoarthritis or that they are 90 years old and their
cholesterol is a bit too high, and you have to refer them for treatment, he
says, because the system guarantees it.
Torente's also vice president
of the main Spanish doctor's association, the OMC. He complains that
physicians here are underpaid and overworked. Still, he defends Spain's
medical service and insists it has nothing to do with socialism.
Dr. TORENTE: (Spanish
spoken)
SOCOLOVSKY: It's the
humanization of medicine, he says. As a citizen, it's my obligation to make
sure that everyone has basic health coverage. But while health care costs are
rising fast, Spanish politicians don't dare limit coverage. On the contrary,
one of the most sure-fire vote getters for both left and right is the promise
to build new hospitals using taxpayers' money.
For NPR News, I'm
Jerome Socolovsky in Madrid.
(Soundbite
of music)
INSKEEP: This is NPR
News.
http://www.npr.org/templates/story/story.php?storyId=112014770
[BACK TO TOP]
By Brian Nelson
I have survived over
40 years of ill health. Even so I have learned to live a life of chronic patienthood where I am not dominated by illness. I have
managed to focus on goals that have nothing to do with illness. Living life
for me is learning to surf above the uneven terrain of my health.
My health history is
so involved I have created a Google document to keep track of it. I’ve had
three kidney transplants, a pancreas transplant, 27 years of Type 1 diabetes,
and four-plus years of metastasizing cancer. I’ve broken my leg, elbow,
wrist, both feet, hands, skull and ribs (yes, I might be accident prone from
time to time). Plus, I’ve coped with all the secondary illnesses that waltz
along with these problems, including osteoporosis, gastroparesis,
cataracts, gallbladder failure, impacted bowel and chronic bleeding.
Today, my most
obvious issue, a side effect of treatment for head and neck cancer, is
chronic facial swelling, also known as moon face. The removal
of several lymph nodes from my neck and subsequent radiation treatments have
rendered my lymphatic system unable to drain fluids from my head. I get up
each morning and remind myself that I’m going to be swollen, tired and
nauseous. So if I get something done, like epoxy the hatches of the kayak I’m
building, it’s a great day. Or if I get through all my (liquid) food, it’s a
great day. Or if one of our cats comes up to say hello, rubs itself on my leg
and settles down for a nap near me … yep: great day!
The changes in my
appearance as a result of my cancer treatment can be difficult for other
people to understand. Last week, the cable service technician arrived at our
door. He wasn’t the most charming of people. When Diane, my wife, opened the
front door, he barked: “You don’t have dogs?” She reassured him we didn’t and
he entered, only to be confronted by me, a stooped, swollen-headed man who
breathed through a hole in his neck and was dressed like a samurai on
holiday.
To further his
unease, I started talking to him – apologizing for my terrible diction and
unintelligible voice (an unfortunate and unintended result of my cancer).
When he responded, “Why doesn’t she interpret?” I naturally started to don my
“kill the technician” armor, preparing for a loud but unintelligible assault
on the jerk.
Diane realized that I
was about to sink our chances of ever again receiving the BBC America channel
and hastily cautioned me that “now wasn’t the time.” I disagreed, and by head
nods and hand gestures we commenced to argue.
Luckily I lost the
argument. Diane talked with the tech, listening to his fear of contagion and
fear of my spitting on him, and correcting him about my medical condition and
my ability to spit. The contrite tech then confessed that two of his close
relatives had died from cancer and apologized to both of us. I accepted his
apology instead of lopping off his head, and he redoubled his efforts at
perfecting our service, going above and beyond.
How does one deal
with someone whose appearance has changed from the dashingly handsome (O.K.,
I’m taking some poetic license) to totally disfigured and, one might say,
grotesque? We’ve been trained by movies and TV to worship perfection. After
all, the bad guy is always either bald, short, limps, is missing an eye,
scarred or has some other abnormality to distinguish him from us, the perfect
audience. My close friend recently told me he was “shocked, I tell you,
shocked,” by my appearance when he saw me again after six months. I’m shocked
sometimes too.
It’s as much a
learning curve for me as for others. I am not sure how people will take me:
whether I will make them uncomfortable, whether they will be able to overlook
the changes and look for the person who still inhabits this misshapen head. I
have to talk myself into going out now. A little pep talk reassures me that,
whatever others may think, I must not quit trying. My difficult speech has
similarly influenced my choices – I tend not to answer the phone and am now a
listener in group settings, only lobbing in a few bon mots
every so often, and then re-lobbing them until people understand. My timing
is truly unique. To combat the verbal steamrollering of members of my family,
I raise my hand before speaking. Quite humiliating, sort of, but very
effective.
What do I want people
to do? I want everyone to feel comfortable around my appearance. Don’t worry
that you have to address my illness in a compassionate way, or at all. Just
say what you want when you want. I’ll let you know if you offend, or if I
need something. What I enjoy most is watching others enjoy themselves.
My friend Steve said
to me, “Well, you’ve got that portly Asian look down now.” That was nice,
funny and quite off the cuff. It made me feel that I could relax and not
worry that the conversation was going to slide into the Grand
Canyon of medical awkwardness.
My neighbor’s
3-year-old daughter treats me just like everyone else, someone to flirt with!
So if you see a slightly hobbled, melon-headed man wearing a hat, walking
toward you with a stick, just say, “Hi, it’s a great day, isn’t it?” And I’ll
say, “Yep, it’s a great day,” and feel it too.
Brian Nelson, 50, is
a former actor, insurance salesman, theater director
and computer consultant and says he only wears kilts at weddings. He lives in
Brooklyn with his wife Diane and four cats,
Whitman, Yeats, Poe and Emily. He recently began blogging about his life and
health at http://briananelson.blogspot.com/
http://well.blogs.nytimes.com/2009/08/20/when-cancer-changes-your-appearance/?scp=1&sq=When%20Cancer%20Changes%20Your%20Appearance&st=cse
[BACK TO TOP]
By ANEMONA
HARTOCOLLIS
Deborah Migliore was pushed into a small conference room in a
wheelchair, looking kittenish in red and white pajamas and big gold hoop
earrings. Her weight was down to about 90 pounds, from 116, her face gaunt,
her sad eyes droopier than ever.
Dr. Sean O’Mahony had been called in to tell her the bad news: she
was sicker than she realized, and the prognosis did not look good.
“What’s the cancer I
have?” Mrs. Migliore, a 51-year-old former cocktail
waitress, asked jauntily. “I have no idea.”
“Carcinoid,”
Dr. O’Mahony replied.
“I don’t want to lose
my hair,” she said, laughing nervously.
“Currently, there are
no established cures,” the doctor said. “Think very carefully about what
treatments you do and don’t want to have as these issues arise.”
It was what doctors
in the end-of-life business call “firing a warning shot,” but Mrs. Migliore did not seem to hear the bullet whizzing past.
“It’s more or less, I
want to be alive again,” she interjected. “Going here, going there. My
husband, I want to be able to do things for him.”
Part psychoanalyst,
part detective, Dr. O’Mahony had to listen to the
cues and decide what to do next.
Most doctors do not
excel at delivering bad news, decades of studies show, if only because it
goes against their training to save lives, not end them. But Dr. O’Mahony, who works at Montefiore
Medical Center in the Bronx, belongs to a class of doctors, known as
palliative care specialists, who have made death their life’s work. They
study how to deliver bad news, and they do it again and again. They know
secrets like who, as a rule, takes it better. They know who is more likely to
suffer silently, and when is the best time to suggest a do-not-resuscitate
order.
Palliative care has
become a recognized subspecialty, with fellowships, hospital departments and
medical school courses aimed at managing patients’ last months. It has also
become a focus of attacks on plans to overhaul the nation’s medical system,
with false but persistent rumors that the government will set up “death
panels” to decide who deserves treatment. Many physicians dismiss these
complaints as an absurd caricature of what palliative medicine is all about.
Still, as an aging
population wrangles with how to gracefully face the certainty of death, the
moral and economic questions presented by palliative care are unavoidable:
How much do we want, and need, to know about the inevitable? Is the
withholding of heroic treatment a blessing, a rationing of medical care or a
step toward euthanasia?
A third of Medicare spending
goes to patients with chronic illness in their last two years of life; the
elderly, who receive much of this care, are a huge political constituency.
Does calling on one more team of specialists at the end of a long and final
hospital stay reduce this spending, or add another cost to already bloated
medical bills?
Dr. O’Mahony and other palliative care specialists often talk
about wanting to curb the excesses of the medical machine, about their
disillusionment over seeing patients whose bodies and spirits had been broken
by the treatment they had hoped would cure them. But their intention, in a
year observing their intimate daily interactions with patients, was not to
limit people’s choices or speed them toward death.
Rather, Dr. O’Mahony and his colleagues were more subtle, cunning and
caring than their own words sometimes suggested.
An Escort for the
Dying
They are tour guides
on the road to death, the equivalent of the ferryman in Greek myth who
accompanied people across the river Styx to
the underworld. They argue that a frank acknowledgment of the inevitability
of death allows patients to concentrate on improving the quality of their
lives, rather than lengthening them, to put their affairs in order and to say
goodbye before it is too late.
Dr. O’Mahony, 41, went to medical school in his native Dublin, straight out of
high school. He intended to go into oncology. But during training at a
prominent cancer hospital in New
York, he changed his mind as he saw patients return
to the hospital to die miserable deaths, hooked to tubes, machines and
chemotherapy bags until the end.
“In Ireland, and
I think most other places, it would be very much frowned upon,” he said.
Sandy-haired, a wiry
marathon runner, Dr. O’Mahony is the sixth of eight
children; his father is a university professor devoted to preserving Gaelic
as a second language, and his mother a painter. When he was 3, his brother,
who had cerebral palsy, died at age 4. His awareness of his parents’
helplessness, burnished through years of family conversations, helped steer
him to palliative care, he said.
Dr. O’Mahony entered the field a decade ago, shaped by an
almost messianic movement that began as a rebuke to traditional medicine but
has become more and more integrated into routine hospital practice.
As medical director
of Montefiore’s palliative care service, he helps
train fellows, supervises research projects and manages the pain, often with
powerful drugs like fentanyl, methadone and
morphine, of patients with a range of illnesses, like cancer and AIDS.
He consults on
questions with ethical, moral and sometimes religious overtones, like whether
to remove life support. He acts as a troubleshooter with recalcitrant
patients, like an elderly man who was sneaking cigarettes (they negotiated a
schedule of when he could get out of bed to smoke), and advises the
terminally ill and their families.
Dr. O’Mahony favors crisp button-down shirts, but no white
coat. His bedside manner ranges from gentle amusement to studied neutrality;
he eerily resembles the unemotive Steve McQueen of
“Bullit.”
His coolness is his
armor. “I do not feel obligated to be sort of eternally involved with the
experience of death,” Dr. O’Mahony said. “It’s not
healthy to be there all the time.”
But the danger is
that “death gets to be banal,” he said.
“Do you know that
poem by Dylan Thomas?” Dr. O’Mahony asked with a
faint smile. “After the first death, there is no other.”
But How to Tell Her
He had seen many
deaths before he met Debbie Migliore. She left her
home in the Bronx at 19 to pursue the one
talent she knew she had, looking good in a bikini.
Old photographs show
her flaunting a saucy smile and a mane of black hair. “I used to be a topless
dancer, excuse the expression,” she said. She worked at clubs in Manhattan and upstate,
and was married twice before meeting Joe.
It was a marriage of
opposites. Joe had always been socially awkward and studious, a nerd, he said
with a touch of defiance. He went to New York University
part time, got a culinary degree and worked as a chef in a casino. Finally,
he got a job with the New York City
parks department as a horticulturist. Working with plants suited him, because
he worked more or less alone.
He had embraced his
solitude so completely that when he met Debbie he had been thinking of
becoming a priest.
They met 12 years ago
through a personal ad she had put in The New York Post, and married almost
instantly. Joe’s mother had spotted the ad, which said, roughly, “Likes to
dance.”
Debbie’s big regret
was never having children, after a hysterectomy in her 30s; Joe would have
liked a large family but accepted that it was too late.
Her health started to
fail soon after they married. Over the last decade, she suffered two strokes
and developed an autoimmune disorder. Three or four years ago, doctors found
a tumor in her lung, which was attributed to a neuroendocrine
cancer known as a carcinoid tumor. She was treated
through surgery and radiation. Apart from a dry cough, her husband said, “she
was wonderful.”
In March, she broke
her arm while turning a mattress. While repairing the arm, doctors found more
cancer, and Dr. O’Mahony was called in to talk
about her uncertain future.
They met at
Morningside House, the Bronx nursing home
where she was recovering from surgery, joined by Mr. Migliore,
social workers, nurses and a physical therapist. For about an hour, Dr. O’Mahony asked open-ended questions, looking for clues as
to how much she knew and how much she wanted to know.
“What are your
biggest concerns?” was his opening move.
“First of all, the
food is terrible,” Mrs. Migliore said. She was
trying to fatten up with spaghetti — the thought of other food disgusted her,
which is often a sign of deteriorating health. But the pasta was cold, she
said.
One leg would not
support her weight. Her back hurt; she would like a massage. “I get annoyed
when things are not my way,” she said. “And I cry too much.”
“Well, it’s hard for
most of us not to have control over things,” Dr. O’Mahony
said.
“Aside from the
food,” he pressed, “what are the things that concern you?”
“I want to get
better,” Mrs. Migliore said.
“What’s your
understanding of the status of the tumor?” Dr. O’Mahony
asked.
“The doctor that took
it out, he was just amazed,” she said. “He says, ‘Oh, Debbie, I did a good
job.’ I said, ‘Yes, you did.’ ”
Dr. O’Mahony tried to remind her that she still had cancer.
“One of the frustrating things about this illness is the way it can pop up in
different parts of the body,” he said.
Mr. Migliore joined in, asking whether there was a way to
slow the growth of the cancer.
“The treatments that
are available for it can provide some local control, and they can slow the
progression of the illness,” Dr. O’Mahony replied.
“But there is no way
of knowing it, right?” Mrs. Migliore asked,
astutely, apparently registering the equivocation in the doctor’s tone.
Then Dr. O’Mahony fired his warning shot: “There are no
established cures.” And Mrs. Migliore fired back
with her wish to be “alive again.”
Picking up on her
cue, Dr. O’Mahony asked, “What gives you strength?”
She liked to shop, she said. Perking up, she chided her husband for
forgetting to bring the Victoria’s
Secret catalog.
“You sit home and
watch ‘I Love Lucy,’ ” Mr. Migliore said. “Do you
think ‘I Love Lucy’ cares if you wear a $400 outfit or a $22.95?”
The meeting ended on
a lighthearted note, and Dr. O’Mahony never
returned to the prognosis that the nursing home staff thought Mrs. Migliore would want to know.
Beyond Mrs. Migliore’s hearing, he said: “People giving very concrete
estimates of survival can in essence cause as much harm as good. I think she
was signaling to us quite a lot that it was important to her to be able to go
home, to walk, to be able to promote her self-image, to shop for clothes.”
He predicted that her
disease would progress, perhaps rapidly, through a series of crippling
events.
But he said he had
learned from mistakes early in his career that it was not always helpful to
presume to have answers, to mark a spot on the calendar. He said he would
rather focus on things he really could help with, like making sure Mrs. Migliore was getting enough pain medication.
But before leaving,
he made sure that she had a health care proxy — her husband — who would make
decisions for her if she became incapacitated. He knew it would be harder to
get one later.
Palliative care
doctors are taught to lead by example. Dr. O’Mahony’s
proxy is his companion, an oncologist himself.
But Dr. O’Mahony does not press hard for a written advance
directive, sometimes called a living will, in which patients can specify
treatments — like cardiopulmonary resuscitation, breathing machines,
dialysis, transplantation, blood transfusion, antibiotics, and food and water
delivered through a tube — that they would or would not want if they were
unable to speak for themselves. “The mere fact of putting words on paper may
be very distressing,” he said.
Perfecting the
Technique
Delivering a grim
prognosis used to be something that doctors figured out how to do on their own, or did not do at all.
Now “Breaking Bad
News” is a standard part of the curriculum at many medical schools, including
the Albert Einstein College of Medicine, the school affiliated with Montefiore.
In an experimental
role-playing exercise, fourth-year medical students were given 10 minutes to
tell an actress, Susan Telcher, that her mammogram
indicated a high likelihood of breast cancer. During one session, led by Dr.
Charles Schwartz, a wisecracking internist and psychiatrist armed with a
stopwatch and a Coke, not every student proved to be a natural.
The students, most in
their late 20s, often had a hard time getting beyond medical jargon. One of
them, who planned to become a pediatrician, failed to read the handout on the
patient, with disastrous results. She spent most of her 10 minutes sneaking
peeks at the clinical notes, trying to divine the problem, while the actress
blithely chattered on about how well she had been feeling.
A student named Paul
(most asked to have their last names withheld for fear of harming their
careers) told Ms. Telcher that her mammogram had
revealed a “finding.”
“You’ve got to get
that cancer word out there early and often,” Dr. Schwartz admonished.
Students often excuse
a poor performance by saying they would have behaved differently in real
life. But “the data is, they do what they do,” said Dr. Schwartz, who
conducts the training with Dr. Sharon Parish, an associate professor of
clinical medicine at Einstein.
In his experience,
physicians who themselves have signed advance directives are more comfortable
talking to their patients about dying.
But Dr. Nicholas
Christakis, an internist and social scientist at Harvard who has studied
end-of-life care, has found that doctors are generally bad at making
prognoses. The better they know a patient, the worse they are at
prognosticating, possibly, Dr. Christakis has theorized, because they view
death as a personal failure. Most predictions are overly optimistic, he has
found, and the sicker the patient, the more likely the doctor is to
overestimate the length of survival.
In one study by Dr.
Christakis, doctors who privately believed that patients had 75 days to live
told them they had 90; the actual median survival period was 26 days.
“Go to the bathroom
mirror, look yourself in the mirror and say, ‘You’re dying,’ ” Dr. Christakis
said. “It’s not easy.”
Lessons Learned
Along the way, Dr. O’Mahony has picked up the wisdom of the trade. He has
learned that older people tend to take bad news better than younger people.
That
patients
with advanced cancer generally go into a sharp decline three months before
death, but those with dementia, heart disease or diabetes may have a bad
month and then get better, making their prognosis trickier.
That people who do
not have family or friends, or are alienated from them, are more likely to
want to hasten death than those with more social support.
That
patients
who are agreeable by nature may not admit that they are in pain.
That people who blame
their self-destructive behavior for their illness are less likely to ask for
help, and that hard-charging professionals sometimes would rather not manage
their own illness.
That people can know
in their darker moments that the prognosis is grim, yet at other moments
imagine they will go back to being their old selves.
And Dr. O’Mahony knows that the family is sometimes best at
delivering bad news, as in the case of Eddie Ascanio.
Mr. Ascanio, a 52-year-old limousine garage attendant,
arrived in Montefiore’s emergency room last spring,
in the last stages of head and neck cancer.
The palliative care
staff immediately called a meeting of Mr. Ascanio’s
family members to determine whether they realized he was near death.
Mr. Ascanio was too angry about being in the hospital to
attend the meeting. His sister, Helen Wilson, who had taken on the role of
family anchor while her husband, a plumber, served time for bank robbery,
told the doctors she had brought her brother to Montefiore
because she was unhappy with his treatment at another hospital.
“Listen, I need to
know what’s going on with my brother; he’s losing massive weight, not
eating,” she said she had begged the previous doctor. “Something is not
right.”
Two doctors on Dr. O’Mahony’s team listened quietly, and she seemed relieved
just to be able to talk things through. When one of the doctors asked if she
wanted to take her brother home to die, she said, “That probably will make him
very happy. We’ll set him up in my daughter’s bedroom.”
Her nephew, Tony,
balked. “Is that to say there isn’t even a 1 percent chance of recovery?” he
said.
Mrs. Wilson answered
before the doctors could. “The cancer’s spread too far, Tony,” she said. Mr. Ascanio died four days later, in his niece’s bedroom,
surrounded by stuffed animals and his family.
Lagging on Hospice
Care
While palliative care
is available to give patients a chance to die without being tormented by
excessive medical care, statistics suggest that in New York, the world center of academic
medicine, aggressive treatment is still the rule.
At Montefiore, only 12 percent of dying patients from 2001
to 2005 entered hospice care, for an average of 4.9 days, during their last
six months of life, according to the latest data from the Dartmouth Atlas of
Health Care.
At Mount Sinai, it
was 14 percent of patients for 4.6 days; at NewYork-Presbyterian,
15 percent for 5.2 days; and at New York
University Medical
Center, 20 percent for 6.7 days,
according to the Dartmouth
data.
Nationally, nearly 32
percent of dying patients had hospice care during the same period, for an
average of 11.6 days.
In New
York, hospice is “brink-of-death care,” said Dr. Ira Byock, the director of palliative medicine at Dartmouth-Hitchcock Medical
Center in Lebanon, N.H.,
and the author of “Dying Well.”
While treatments that
try to extend lives produce more fees for doctors and hospitals, they may be
given for reasons besides money. “Many clinicians don’t want to send the
message that they’re giving up on their patients,” said Dr. David Goodman, a
co-author of the Dartmouth Atlas. “They see palliative care as diminishing
hope.”
Dr. O’Mahony suggested that family finances also played a
part in decisions on hospice care, because Medicare typically covers only a
few hours a day of such care at home.
The health care bill
being discussed in the House would ensure Medicare reimbursement for
consultations about end-of-life treatment between patients and their doctors,
nurse practitioners or physician assistants every five years, or more often
in the case of a life-threatening change.
The bill would help
validate the work of palliative care doctors, who often work on salary and
whose services are often subsidized by the rest of the hospital because they
do not generate much revenue.
But the provision has
fueled criticism. Former Gov. Sarah Palin of Alaska has raised the
specter of “death panels” that would rule on whether to treat defenseless
patients like her son Trig, who has Down syndrome. While there is nothing in
the House bill to suggest that such panels would exist, the end-of-life
language became so radioactive that several members of the Senate Finance
Committee said they would not include it in their version of the bill.
The Congressional
Budget Office estimated that the proposal would cost $2.7 billion over 10
years.
There was no estimate
of savings at the other end, from patients forgoing expensive tests and
treatment. A few studies have found that hospital care for patients who get
palliative care consultations costs thousands of dollars less than care for
those who do not. But some of these studies have been conducted by advocates,
and they have looked at hospital costs after the fact, rather than using
randomized controlled trials, the gold standard in medical research.
The author of one
study, Dr. Edmond Bendaly, an oncologist in Marion, Ind.,
said cost studies had been hampered by the ethical and practical difficulties
of signing up dying patients for trials that might provide disparate care.
But he said the research so far showed a “strong signal” of savings from
palliative care.
Dr. O’Mahony and his colleagues are well aware of the ethical
debates over the boundaries between proper conduct and euthanasia. “We’re not
vested in having patients refuse treatment,” Dr. O’Mahony
said. “We are there to support patients and their families.”
Families sometimes
worry that by refusing treatment for a patient — especially food and water,
which are so closely associated with comfort and love — they are approaching
euthanasia.
Deep sedation, to the
point of unconsciousness, may also be used to relieve intractable suffering,
and it “has caused almost as much distress and debate in the palliative
care-hospice world as euthanasia has,” said Dr. David Casarett,
a palliative care doctor at the University of Pennsylvania, who is leading a
national evaluation of end-of-life care at Veterans Affairs hospitals.
“Is it used to end a
life, or up until the end of life?” Dr. Casarett
said, summarizing the debate. Among those who use it, he said, the consensus
is that “we would never sedate with the goal of hastening death.”
Palliative care doctors
talk about the difference between prolonging life and prolonging death.
“So it’s not
euthanasia,” said Dr. Desiree Pardi, who went into
palliative care after learning that she had breast cancer, and is now the
director of the service at the Weill Cornell Medical College of NewYork-Presbyterian Hospital. “It’s just sort of letting
them die completely naturally. It’s hard to explain to a lay person, because
we know we need food and liquid to live. But we don’t need them to die. We’re
just feeding whatever is killing them.”
In the political wars
over end-of-life care, advocacy groups for the disabled are often as adamant
as religious groups in challenging measures that could be seen as hastening
death. “Health care providers encounter people at a time of crisis; they see
the worst happening,” said Diane Coleman, the founder of an advocacy group
for the disabled, Not Dead Yet. “They don’t see them get through it and say,
‘Even with my functional losses, I’m still having a good time.’ ”
A Resistance Among
Doctors
Palliative care still
goes against the core beliefs of many doctors.
In a teaching session
one day last winter, Dr. Lauren Shaiova criticized
a group of idealistic young residents for sending a 42-year-old patient with
end-stage liver disease and a lifetime of drinking to a nearby hospital for a
liver transplant.
Dr. Shaiova is a friend of Dr. O’Mahony’s
— he marched in her wedding procession — and is chief of palliative care at Metropolitan Hospital,
a city-run hospital serving the poor and working class of East
Harlem.
She is also Dr. O’Mahony’s counterpoint, demonstrative and impulsive
where he is cautious and unemotional. Married to a hospice doctor, with three
young children adopted from Russia,
Dr. Shaiova, 50, would be a rebel and something of
a nonconformist in most settings. She plays a harmonium for chemotherapy
patients and chants a Buddhist prayer before staff meetings. She says that
her husband once confided to her, as they were lying in bed one night, that
he was not afraid to die. Her Russian grandmother in Brighton Beach
has made a do-not-resuscitate order, and so has she.
Dr. Shaiova’s older brother, Michael, a car mechanic, was
shot in the head on a street in Chicago,
their hometown. She heard the news from emergency room doctors who called to
ask about “harvesting” his organs.
“Harvest?” Dr. Shaiova recalled thinking. “I’m growing beans? Nobody was
willing to say he was brain-dead.”
Now, facing the
abashed residents in their white coats, she reviewed the history of the
patient, who was living in a single-room-occupancy hotel: He was agitated and
confused, and had alcoholic brain damage. He could no longer walk. To qualify
for a transplant, he had to be alcohol-free for six months.
“We had done a day’s
work on him — got the D.N.R., treated his pain, arranged for hospice,” she
said. The receiving hospital, she believed, was part of the conspiracy of
denial, only too happy to get the payment for accepting the patient, who
ended up dying before he could be evaluated.
But, several
residents objected, the man kept asking for a liver transplant. It seemed
unprofessional, even inhumane, to refuse.
“They say when a
person is drunk or out of it, he tells the truth,” one resident said. “His
options should not stop.”
“Was it really a
viable option for him?” Dr. Shaiova demanded.
“Maybe we should take
it as a last wish,” the senior resident said, from the back of the room.
Dr. Shaiova said they should have realized the patient would
never survive. “Doctors are the worst predictors,” she said after the
session.
Asked how she deals
with the death of her patients, Dr. Shaiova said,
“I play the harmonium.”
Her Final Days
In early June, Dr. O’Mahony went to Ireland on vacation. He was
looking forward to seeing his mother, Kathrina, 74.
She had received a diagnosis of breast cancer in 1995. The cancer returned in
2006, and she was told it was not possible to remove all of
the tumor.
She had recently
painted over the image of her body on a PET-CT scan, used to confirm the
presence of a local recurrence of cancer. “I got her the scan,” Dr. O’Mahony said gleefully.
While Dr. O’Mahony was away, Mrs. Migliore
received radiation to try to shrink a tumor that the doctors said could wrap
around her spine and paralyze her. She would return from the treatments —
administered every day for 29 days, her husband said — in a stupor. “Most of
these doctors are convinced they’re doing the right thing,” he said. “It’s
just that I don’t want to have a walking wife who’s in zombieland,
you know?”
He was taking things
a day at a time, and taking sedatives. “I’m on 350 milligrams of Zoloft every
day, so I feel pretty good,” he said.
When Dr. O’Mahony returned, he learned that Mrs. Migliore had been admitted to Montefiore
a few days earlier, as cancer infiltrated her bone marrow and she became
dehydrated. He scheduled a bedside conference his first day back.
Mrs. Migliore could no longer walk, or even sit up on her own.
She was checked in to Room 954A North. Her window had a panoramic view of the
Bronx, with Calvary
Hospital, which cares
for terminal cancer patients, in the foreground, its red-brick bulk marked by
three crosses.
Dr. O’Mahony and Mr. Migliore stood
side by side at the foot of the bed. Mrs. Migliore
looked incorporeal, so slight she melted into the bedsheets.
“So we’re just here
to see how you’re doing today,” Dr. O’Mahony began.
“Well, I want to go
home; that’s all I want to do,” Mrs. Migliore said.
“I do not want to stay here.”
“O.K,” her husband
answered, sniffling.
“So when are you
taking me home?” Mrs. Migliore said.
“Well, we just need
to get you a little bit stronger, O.K.?” Mr. Migliore
said. “That’s what we’re here to discuss. We’re here to tell you what’s going
on.”
“How are you doing?”
Mrs. Migliore asked her husband, her voice
softening.
“I’m doing O.K.,” he
said.
Growing agitated,
Mrs. Migliore said that a woman at the nursing home
had tried to marry her. She said that she objected that she was already
married, and that she was locked into a room in what seemed to be a funeral
home. She said she had thrown china plates out the window in a vain bid to be
rescued. It sounded like an elaborate parable about the bride of death, and
her husband could not convince her that it was all in her head.
Turning to a visitor,
she kept asking, “Are you pregnant?” as if she wished she herself could be.
Dr. O’Mahony adjourned the conversation to a conference room,
leaving Mrs. Migliore alone.
Mr. Migliore immediately asked how much time his wife had
left.
“I can’t give a
definite response in terms of the number of days or weeks,” Dr. O’Mahony said.
Mr. Migliore said another doctor at the hospital had
estimated four to six months.
Dr. O’Mahony gave his standard warning: It is hard to go from
prognostic estimates based on large populations to individual cases.
Nonetheless, he conceded that she was getting much worse.
Mr. Migliore said he did not think he could take care of her
at home and proposed she go to Calvary. “How
do we convince her this is the right decision?” he
asked.
“During these times
when her thinking is impaired, you are her voice,” Dr. O’Mahony
replied.
Two days later, Mrs. Migliore was across the street at Calvary.
Her husband tacked photos of their wedding to the bulletin board. Within a
few days, her speech had deteriorated to “baby talk,” as her husband put it,
and she was eating little more than Italian ices.
She turned 52 on June
30, and her husband managed to feed her a spoonful of birthday cake. He was
thrilled when she said it tasted like excrement. For that moment, she sounded
like herself.
Much of the time, she
was heavily sedated to stop her from screaming. She was given morphine for
pain and haloperidol, an antipsychotic, for delirium, which can be a side
effect of advanced cancer and opiate drugs. “She seems terrified,” Mr. Migliore said.
He said the staff had
asked if they should disconnect the tube feeding her sugar and water. “Then
what, she starves to death?” Mr. Migliore said. “I
can’t. I can’t, even though I’m the proxy.” A fatal injection, if that were
possible, seemed more merciful to him. “The way things are going now at this
point,” he said, “I’m hoping God takes her tonight. Living like this is
barbaric.”
He got his wish three
days later. “She never asked me, ‘Am I going to die?’ ” he said, so he never
had to do what he feared most: give her an answer.
Mrs. Migliore died on July 3, after eight days at Calvary, less than four months after Dr. O’Mahony fired his warning shot. He had several
conversations with her before she died, a luxury that other types of doctors
might not have. But he never told her directly that she was going to die.
Asked why, Dr. O’Mahony said that Mrs. Migliore
had appointed her husband as her surrogate, and that she had responded to
open-ended questions with a focus on the details of her everyday life, rather
than a desire to foresee the future. He saw that as a road map for his
approach to her prognosis.
“Patients sometimes
will be very explicit about wanting that information very, very clearly
delivered,” he said. “Whereas other people don’t.”
Dr. O’Mahony has not spoken to Mr. Migliore
since his wife died, and he does not expect to. Once the ferryman has
delivered his patients across the river, he rarely looks back.
http://nytimes.twi.bz/yc
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