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From Catholic Healthcare West to Dignity Health Care
A harbinger of things to come? One of the largest Catholic health care systems in the country has relinquished its formal Catholic identity. I've talked to many people who think that the bishops can "make" a hospital be Catholic -or close them. But that's not the legal reality, at least in most cases. What will happen, in most cases, is some type of disaffiliation--the hospital will continue, in some form, although not an official "Catholic" facility. It doesn't affect tax exempt status, which most hospitals get through their not-for-profit charitable nature, not through their religious nature.
About the Author
Cathleen Kaveny is the Darald and Juliet Libby Professor in the Theology Department and Law School at Boston College.
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"...has relinquished its formal Catholic identity."So often relinquishing an institution's "formal Catholic identity" depends upon the instutution's religious community (in the canonical sense) or religious order that founded and sponsors the institution (and, in relation to that, whether their institution receives its tax status as a religious corporation, an educational institution or as a public trust). Obviously (for various reasons, possibly dwindling number of nuns among the reasons) the six religious orders that ran Catholic Healthcare West felt it was time to cut "formal" ties with the Catholic Church. For one thing, in the future, such fomerly Catholic hospitals won't have to worry about their Catholic status being revoked by a bishop (as St. Joseph's Hospital and Medical Center in Phoenix had last year).
Dignity.Excellent choice of names. As my age cohort (War Babies) and the one right behind us (Baby Boomers) get old, we worry about the loss of dignity which comes with having living wills and end-of-life directions ignored.If a hospital insists that a dying patient be forcibly fed and forcibly hydrated, against her/his will (in both senses of the word), why would that patient go into that hospital?
Just the first among many - and when do catholic universities start to go in this direction. Really, look at the Phoenix situation last year - what other recourse do they have in the face of certain bishops or even the USCCB?Their "catholic" mission will continue (with a little "c"); as you state, their legal/tax status will not change. But, they are freed from the current episcopal institutional narrative that gets in the way of their primary, gospel mission.
Dignity! Dignity?? Have they realized the problems that that name has with the uber-ecclesiastics? http://en.wikipedia.org/wiki/DignityUSAOh, the meringue will indeed hit the mixmaster over this one.
Jimmy Mac - I had the same thought. There is also an association of funeral homes called Dignity - perhaps not the connotation a hospital system desires :-)http://www.dignitymemorial.com/dm20/en_US/main/dm/index.page
So if it is no longer formally associated with the Catholic Church ... what is it?For a not-for-profit, its concerns - competition, market share, operating margin - seem pretty darn for-profit.
Humanae Vitae, the gift that keeps on giving.
Well, sure. Hospitals were Catholic because they were run and staffed by nuns. The nuns are gone; the Catholicism is gone.It will be a great loss for human beings, who were cared for with intelligence, respect, and kindness. The best thing about the Church in America was the nuns. That selflessness has gone from our world, replaced with bickering over social programs. Patients will just have to fend for themselves, as they sink in the system, either loudly, demanding their rights, or quietly, overwhelmed and exhausted. There will be no one there to care for them as human beings, children of God.
Good.I have no desire to go to a Catholic hospital, and avoid it where possible. Maybe having to battle with a bishop over his authority to dictate what medical care I must have or not have is something to avoid, period.Gerelyn has it right: If a hospital insists that a dying patient be forcibly fed and forcibly hydrated, against her/his will (in both senses of the word), why would that patient go into that hospital?I was asked to make the decision if my mother would have a burdensome procedure done to feed her artificially. She was not in any condition to undergo anything, after decades of congestive heart failure. It would have been simply cruel. I could see the doctor was greatly relieved I declined. She mercifully died four hours later. I have zero confidence that a Catholic hospital subject to the tender mercies of any bishop would have allowed my decision to stand.
Jim, hospitals are large institutions -- it's hard to plan and manage for the future. Having to respond constantly to the varying requests of BOTH Church and public authorities for compromises and future assurances and audits and special units with separate rent and separate personnel and funding just to make a transaction work means that the hospital is spending a lot of resources and brainpower threading needles in one tiny area of its operations that do not promote the provision of services to the larger community. You can sing all day about how sinful contraception is, but when you haven't convinced 90% of the relevant population sitting alongside you in the pews, you have a problem of authority. Making Catholic institutions the whipping boy in the debate because you can doesn't solve the problem and it is increasingly clear that many will exit if they can.
Barbara is right, too. I also think there is a moral issue here. In my view, Catholic health care would be virtually dead now if it weren't for sister McBride in Phoenix. If that mother had been allowed to die, I think the regulators would have descended on it. Many non-Catholics --and many Catholics believe that Bishops Olmsted is not a good decision-maker (and that was confirmed by later events)==getting him out of the loop was a good thing, not a bad thing.
Saw in today's paper that Christus St. Vincent in Santa Fe refused an abortion to a raped 12 year old girl.During Right to Life week here and while parental notification battles are fought at the legislature here, are we effectively preeaching the Gospel of Life to the total community?
Having spent some time in a Catholic hospital, I find the illusion that the institution can remain "Catholic" because an order of Catholic religious sisters once founded the hospital is, well, quaint at best.Hospitals, even on the smaller size, of the for-profit or non-profit variety, are big moneymaking operations - huge economic engines for the local economy in terms of jobs, services, and infrastructure. After the federal and state government, the Catholic hospital I referred to is located in a suburb in a large metropolitan area had the single largest payroll of any private corporation in the county. Every two weeks, this hospital's payroll dumped $millions into the local economy. More births occurred at this hospital than anywhere else in the state. We're talking $millions.This is not to say that the religious sisters who originally sponsored the hospital didn't try their best to maintain the Catholic identity of the institution through seemingly endless "mission effectiveness seminars" conducted for medical staff and employees. These religious women, who originally became involved in health care ministry when they responded to calls from Abraham Lincoln to nurse the wounded and dying during the Civil War, now had become corporate moguls in big business. It just that Jesus was right when he said that "no man can serve two masters" (Matthew 6:24). The poor religious women who founded these hospitals have become overwhelmed by the corporate imperatives that govern free market enterprise. There's no shame to this state of affairs - it's just the way our world works.In fact, it was one of the sisters of this congregation of religious women, whom I worked with, who eventually, as president of the sisters' own healthcare system, engineered the corporate takeover of the congregation's hospitals by a national non-profit corporation. The sisters apparently, facing diminishing numbers in their ranks, tried as well as they could but could no longer keep the hospitals' economic beast caged.But all that is only a backdrop to what has happened in Phoenix: As Cathleen Kaveny rightly points out, everyone especially the people of Phoenix who look to St. Joseph Medical Center for their health care needs are better off that Bishop Olmsted is now "out of the loop" when it comes to the medical decisions at St. Joe's.Only a very ambitious celibate hierarch could believe that it is a greater moral good for a mother to die due to complications from an unviable pregnancy and leave her other four children orphans for the rest of their lives. Ignorant politicians like Olmsted have no business being anywhere near the life and death healthcare decisions people have to make every day.Sr. Margaret McBride, like thousands of religious women before her, was an angel of healing for suffering women and their children. Thank you, Margaret.
David S. --Like you, I have a very high opinion of most nuns. But have you talked to any recently? Except for those belonging to very conservative orders, they are among the most liberal members of the American Church. And, yes, they were and are the backbone of the Church. But the hierarch and cnservative Catholics raised such a stink about that that they were recently subjected to "a visitation". But the joke was on their persecutors == the visitors found them in good shape theologicay :-)
I just want to add this: Barbar's point IMO is critical -it's about service(read also witness) and not being tied up in the varied demands in a small area.Footnote: a friend who I consider quite pro life said Olmstead is "crazy." I hearily concur.As Pogo said, "We have met the enemy...."
Wow! I cannot believe the poor understanding of Catholic teaching reflected in many of these comments. Gerelyn's and Carolyn's understanding is completely backward. The church teaches that you cannot withhold food, but it certainly does not require forcibly feeding a patient. No extraordinary means are required.And Bobs comment about the raped 12 year old fails on 2 grounds. First, the more helpless person here is the unborn child and second, that 2 wrongs (rape followed by abortion) do not make a right. Do not get me wrong, he describes a terrible situation and my heart goes out to the 12 year old. But abortion is not the answer.
@ Bruce LaFranchi: What you say are things that only could come from someone who doesn't have a uterus and is clueless when it comes to empathy for suffering humans. Hence, your referencing "Catholic teaching?"I hope this never happens to you [it is repulsive to even contemplate it], but let us know if you change your thinking IF your 12 year old daughter or granddaughter would ever be raped and become pregnant.And furthermore, no one, especially a woman with a unviable, complicated, medically dangerous, potentially lethal pregnancy would ever consider an abortion "the answer."Abortion is always a bad medical outcome. However, in life, many times the "bad" is more than likely better than the "worst." Unfortunately, we live in a reality where women must sometimes choose between a host of bad outcomes.For all the women out there who are faced with what must seem an impossibly bad choice, I always found solace remembering my sainted sixth-grade teacher, Sister Mary Adelaide, often quoting St. Paul: "For I am convinced that neither death nor life, neither angels nor demons, neither the present nor the future, nor any powers, neither height nor depth, nor anything else in all creation, will be able to separate us from the love of God that is in Christ Jesus our Lord."
Gerelyn,Nice story but off-target. The teaching is '... A feeding tube is not required, however, if it wouldnt prolong life, would be excessively burdensome for the patient, or would cause significant physical discomfort....'Not '... her nephew insisted the local bishops directive on use of feeding tubes required the Catholic hospital to install one. ...'
Jim,Thanks for your empathetic wishes and poignant observations about my body structure. As I said,'...he describes a terrible situation and my heart goes out to the 12 year old...' and I should have included her family as well.Unfortunately, basic biology teaches us that the fetus is a new human being. That human deserves its life regardless of how it started. That human did not choose to be conceived in that way anymore than the 12 year old chose to be raped. But both those things have happened. So now we have to make a choice, and I believe the lesser of the two evils is carrying the unborn child to term even though i know that will have a deleterious impact on the 12 year old and her life will be forever scarred by the experience. Btw, abortion is not a 'bad medical outcome'. A bad medical outcome is we operated but couldnt save the patient. An abortion is a good medical outcome, when thats the procedure you desired.
The Holy Father emphasized that water and food, even when administered artificially, are "a natural means of preserving life, not a medical procedure. Therefore, their use must be considered ordinary and appropriate and as such, morally obligatory."http://www.indcatholicnews.com/news.php?viewStory=8315
"The nuns are gone; the Catholicism is gone."Do you actually believe that? Therefore there are no Catholic schools unless nuns run them. Therefore there are no Catholic nursing homes unless there are no nuns running them.What a narrow definition of what it is to be a Catholic anything.Therefore, there is no Catholic church because there are no nuns running it. (I can buy that one!)
Oops - s/b: "there are no Catholic nursing homes unless there are nuns running them."
A sad loss to the whole Catholic community, the many people of other faiths who relied upon 'Catholic' healthcare, and a definite disservice to the memory of the many sisters and religious workers who built and cared for so many individual community hospitals. The charitable and attentive care that always was in the forefront seems to be subjected now to bottom line economics. Dignity is a nice word, but Catholic means so much more.
Bruce and Gerelyn --It is my understanding that Pius XII did not require that food and water be given if someone were definitely dying, while JP II did. Another example of popes disagreeing.In fact, I don't think I have ever even heard of a Catholic hospital in this archdiocese force feeding a dying person. Maybe I'm wrong, but things like that do tend to become known where true. But from what is being said here, pparently there have been dioceses with very conservative bishops who have insisted on that policy. It would be interesting to study just how many dioceses required it, if any.
Bruce,Gerelyn's reference to the story is exactly on target. I prefer not to be in the position of arguing with the hospital over straining the gnats of interpretation of various policies when I or a relative's fate is at stake. Bottom line: the patient's directive was ignored. All the theory in the world is fine; it's how situations on the ground are affected in the moment. There are too many instances where horrors develop, despite countervailing smooth words.Please take time to read more of the 145,000 citations in Gerelyn's google search."Experts say no other large health systems in the U.S. have nutrition and hydration policies like those governing Catholic facilities. Catholic officials have said the directive is consistent with previous doctrine. But the revised language eliminates what many Catholic ethicists viewed as flexibility in its application to patients in a persistent vegetative state. The previous policy said there should be a presumption in favor of use of feeding tubes, rather than an obligation. Morever, according to Catholic officials and outside experts, the directive may well apply to a wider range of patients, those that it describes as having chronic and presumably irreversible conditions," though the organization representing Catholic health facilities downplays the impact. Experts say this affected group could include those with massive strokes, advanced Alzheimers disease, traumatic brain injury and Lou Gehrigs Disease....Dr. Lachlan Forrow, a Harvard University medical ethicist and palliative care specialist, expressed strong concern about the new policy, stressing its potentially broad scope. That gets to be a very, very large number of people, said Forrow, who heads a panel developing recommendations for the state of Massachusetts on end-of-life care." http://www.kaiserhealthnews.org/Stories/2010/February/24/Catholic-direct...
Thanks, Carolyn.Here's a discussion of the Tulsa event: http://www.americamagazine.org/blog/entry.cfm?blog_id=2&entry_id=2673 The last poster at that discussion says she thinks Catholic hospitals honor Do Not Resuscitate orders. I don't think people should take that for granted, either. E.g., doctors at Mercy hosptials are required to resuscitate. Agree that arguing with the hospital is not to be considered. The check-in person may assure an arriving patient that the hospital will respect her will and directives, but a nurse on the floor may have other ideas. The people who actually come in contact with the patient vary from hour to hour. What one says, the next may deny or ignore. Etc. Why add the possibility that end-of-life directives will be overridden to the already difficult situation?
Gerelyn and Carolyn,I think below are the relevant paragraphs. Reading 145,000 more citations does not add anything to the argument. Because the nephew, who was her health proxy objected, all hospitals, regardless of their affiliation, would have faced the same problem. Once the patient cant make a decision, the proxy controls regardless of previous paperwork. And I believe thats primarily because there is no certainty in these situations. No one can predict the future or what the outcome of various procedures or lack of action will produce. Its entirely a judgement call.But the patients nephew, her designated proxy, demanded that a tube be inserted, citing a September 2008 letter written by Tulsa Bishop Edward J. Slattery, who ordered Catholic health facilities in his diocese to provide artificial nutrition and hydration in such situations. Slattery relied on a 2007 statement by the Vaticans Congregation for the Doctrine of the Faith asserting a moral obligation to do so.Yet Oklahoma law requires honoring a patients advance directive or else transferring the patient to a provider that will honor it. Initially, the attending doctors and St. John officials sought to transfer the woman to a nursing home where her request to forego a PEG tube would be honored. But her nephew vetoed that. Given that the nephews position was in line with the bishops, the hospital then tried to transfer the patient to a nursing home where a feeding tube would be installed. Sister Carol Keehan, executive director of the Catholic Health Association representing hospitals and other facilities, said the bishops point is you dont have the right to just stop feeding them because their life is a burden. But the new policy, in her view, would come into play infrequently, mainly in cases involving a persistent vegetative state. For that reason, said the CHA senior director for ethics, Ron Hamel, "There probably was not much publicizing" of the revised directive by Catholic facilities.There are more than 600 Catholic hospitals and hundreds of nursing homes and other facilities; the hospitals alone admit nearly six million patients a year. Keehan doesn't see much potential for conflict between patients and families end-of-life wishes and the new directive. Advance directives are held in great respect in Catholic hospitals, she said in a recent interview. Some might like to say theres a terrible problem, but there isnt.
Jimmy Mac 01/24/2012 - 3:12 pm subscriberThe nuns are gone; the Catholicism is gone.Do you actually believe that? Therefore there are no Catholic schools unless nuns run them. Therefore there are no Catholic nursing homes unless there are no nuns running them.What a narrow definition of what it is to be a Catholic anything.Therefore, there is no Catholic church because there are no nuns running it. (I can buy that one!)Jimmy Mac 01/24/2012 - 3:18 pm subscriberOops s/b: there are no Catholic nursing homes unless there are nuns running them.
Yep. The best face of Catholicism was the nuns in the schools, hospitals, and nursing homes. That kindness and charity is gone, replaced with a legalistic mentality and an almost angry drive for social justice, narrowly and jealously defined. An institution, like a person, is what it does.Ann, yes I know nuns - and like and respect them greatly. Of course, they're "liberal" - there are no large religious communities left - they can hope for help for the people about whom they care particularly only from the government. Very sad, I think.
Bruce,In that case, be absolutely sure who your proxy is, and specify successor proxies in case of incapacity or death of the original designee. It's the question of who gets to interpret what constitutes Catholic teaching in your particular case, and at a time of great stress. DNR's may be ignored; it may not always be possible to survive a transfer to another facility, and just having to haggle with a bishop like Slattery of his surrogates is a terrible burden. Who needs it? or hazards the chance?It's situations like this I want to avoid (source undetermined from someone posting here before; my file incomplete):"A woman died in 1992, aged 90. She was a resident of a Little Sisters of the Poor home. She had suffered a number of small strokes. She had expressed end-of-life directions quite clearly, including NO feeding tube.She had another small stroke and was taken to a Catholic hospital. They stabilized her, etc., and said she could be returned to the Little Sisters home. But they said she would have to have a feeding tube inserted. They told her daughter this. The daughter said NO feeding tube. They hospital staff told the daughter that without the feeding tube, the Little Sisters of the Poor would not take her mother back. They convinced the daughter of that. The daughter went back into her mothers room and explained that she had to have a feeding tube. She then went back out into the hall to call her family members and tell them the latest development. When she got off the phone and went back into the room, her mother was dead.Her daughter believes she died of fear/frustration/horror at being helpless in the hands of strangers determined to force feed her. As it turned out, of course, the Little Sisters had said nothing like that. It was simply the hospital staff who were determined to do what they wanted to do, regardless of the patients wishes. It didnt occur to the daughter to call the Little Sisters of the Poor and ask them if that was really their rule for their residents. She trusted the Catholic hospital staff."Ann O also spoke previously of having to battle a doctor who was as rigid as Slattery. I find such anecdotal evidence cautionary.
I also think it is false that non-Catholic health care is not respectful of or caring for patients and their families. I have had occasion to go as an accompanying family member to Beth Israel-Deaconness in Boston. I cannot speak highly enough of the nursing staff, or of the way they handled the concerns of anxious family members.
(Carolyn, I wrote that comment about my mother. Next month with be the 20th anniversary of her death. Thank you for saving it.)---- Advance directives are held in great respect in Catholic hospitals, vs. the use of feeding tubes "must be considered ordinary and appropriate and as such, morally obligatory. Who wins that argument, the nun or the pope?
David Smith is at it again: "the angry drive for social justice." Where did that semantic come from?The days of having many nuns in place to provide education, nursing, etc. is gone.The nuns of today have been "visited," a good legal canonical term, and their limited number carries on many wonderful things. They try to deal with present and furture realities, not nostalgia.From where I sit, there's far too much "it's about us" coming from USCCB and many others in Catholic corners trying to hang on to a credibility that's continually being lost - because 'it's about us."That credibility can only begin to be regained when the first priority is about others -service. David's right about one thing - legalism has replaced that so , to paraphrase Shakespeare, "the first thing we should do is kill all the (canon) lawyers."
I agree with Cathleen and Carolyn's comment on caution. At present, my wife and I are dealing with one case of lethal disease, although without the urgency of the instances mentioned above. We and the doctors involved have a choice of Catholic or non-Catholic hospital, both nearby and considered generally good. Statistics of care options are known to the doctors and us but apply only to a group. They do not tell what will happen with the individual. The possibility that some medically incompetent and irresponsible bishop like Olmsted is lurking in the background with influence over serious medical activity in one of these hospitals is a frightening prospect. The reactions to his thinking and action that we heard from 200 other bishops give little reason for comfort. The notion of telephoning around to investigate moral specifics of involved parties is theoretically useful but impractical with the complex of people and organizations involved. We trust the ethical and medical competence of the specific professionals with whom we are dealing and can do no better.
Gerelyn --I am so sorry about what happened to your mother. Poor lady. It wasn't right.That argument about "ordinary means" never ceases to amaze me. The principle that ordinary means should be used to care for the sick is beyond reproach. Anything less would be cruel. It's the definition of "ordinary" that is the problem. Given that the official theologians are so enamored of the concept of "natural" (as well they might be), it seems to me than "non-ordinary means" should be defined as "means not found in or not produced by nature". Water and food found in and produced by nature (e.g., water and fruit) would then be ordinary, while anything like hardware (the tubes and machines) are non-natural in the sense of the above definition, and, therefore, they would not be required. Ordinary stuff is what is found all around us. Tubes and specialized machines aren't.But even the offering of food and water can e iffy. When my mother was dying (at age 85 and somewhat senile), she refused to eat. Was she to be forced? There was no thought of that except by the rigid doctor. I should add that when her doctor insisted that tubes be used my father and I went to consult with the priest who taught medical ethics at our seminary here. (He is highly regarded -- even non-Catholics take his courses). He said of course she didn't have to have what she was refusing. It is very surprising to me how many people here have had bad experiences at Catholic hospitals. I think the laity in repressive dioceses should somehow make this an issue with the bishops == and the Vatican, of course. I suspect the Vatican is the problem, given its idolatry of JP II.
David S: "The best face of Catholicism was the nuns in the schools, hospitals, and nursing homes" is not the same as The nuns are gone; the Catholicism is gone.I am not for one minute denigrating the value and service of the thousands of nuns who had a great deal to do with making this church what it was. But if the existence of Catholicism is based on the existence or non-existence of any particular group (including clerics of all stripes, levels and magnitude) then it is doomed.I always thought that Catholicism survives because of its uniqueness of Eucharist, mission and ministry. Those essentials will exsit long after groups, stripes, levels and magnitudes come and go.
Thank you, Ann. The daughter in the story was my sister. I was the person she was calling. Our mother died without the last sacraments. ----------This is an interview with Jane Brody, NYT columnist. I've clipped some of her columns and included them in my end-of-life directives. http://well.blogs.nytimes.com/2009/03/20/planning-for-death-when-youre-h...
Gerelyn,I am deeply saddened to hear that was your mother. Thank you for your generosity in sharing the unconscionable experience. Such travesties of care deserve wide dissemination, so that families may be warned. This is very helpful as I update my directives. In fact, I was planning to attach some of your materials.Jane Brody's book is on my list. Again, thank you.
"I also think it is false that non-Catholic health care is not respectful of or caring for patients and their families."Cathleen, I agree.It makes me wonder just what it is about Catholic hospitals that are distinctive. It's difficult not to think about the question in terms of branding and marketing. And the trends that are driving Catholic health care systems to broaden their membership seem to be more about economics and finance than the moral/doctrinal hot button topics that we tend to kick around here.
Thank you, Carolyn. I'm going to order Jane Brody's book, too. ---------Agree, Jim, that it's about money. I'm sure everyone is aware of the financial success/clout/etc. of orders like the Sisters of Mercy. http://tinyurl.com/7gf4t94 ----------Link to a summary of an article from Neurology Today:http://journals.lww.com/neurotodayonline/Fulltext/2010/06170/Should_Feed... Notice the many conditional (weasel) words and phrases. Expecting patients and their relatives to engage in disputations with nurses and doctors, when none of the participants are theologians but some of them are in extremis, is cruel and crazy.
The unavoidable reality in many senses: No margin, no mission.
A post-announcement article from Kaiser Health News, similar to the one Cathleen started with, is at http://www.mercurynews.com/breaking-news/ci_19800103 . Its closing comment from the director of a project which aims to protect reproductive services in religious-secular mergers is notable: "What we are seeing on the Catholic [hospital] side is a willingness to let the secular partner develop a way to keep the services intact."
I looked at the USCCB Ethical Directives (see excerpts below). They seem to be imprecise enough that you could get very different interpretations of what they require depending on who you ask for advice. If you get an interpretation that seems unreasonable to you I would consult other knowledgeable people to see if they all agree. The closing paragraph indicates that these directives are recommended by the USCCB for implementation by the diocesan bishop, so their application is left to each bishop to decide."We have a duty to preserve our life and to use it for the glory of God, but the duty to preserve life is not absolute, for we may reject life-prolonging procedures that are insufficiently beneficial or excessively burdensome. Suicide and euthanasia are never morally acceptable options....The use of life- sustaining technology is judged in light of the Christian meaning of life, suffering, and death. In this way two extremes are avoided: on the one hand, an insistence on useless or burdensome technology even when a patient may legitimately wish to forgo it and, on the other hand, the withdrawal of technology with the intention of causing death.The Churchs teaching authority has addressed the moral issues concerning medically assisted nutrition and hydration. We are guided on this issue by Catholic teaching against euthanasia, which is an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated. While medically assisted nutrition and hydration are not morally obligatory in certain cases, these forms of basic care should in principle be provided to all patients who need them, including patients diagnosed as being in a persistent vegetative state (PVS), because even the most severely debilitated and helpless patient retains the full dignity of a human person and must receive ordinary and proportionate care.56. A person has a moral obligation to use ordinary or proportionate means of preserving his or her life. Proportionate means are those that in the judgment of the patient offer a reasonable hope of benefit and do not entail an excessive burden or impose excessive expense on the family or the community.57. A person may forgo extraordinary or disproportionate means of preserving life. Disproportionate means are those that in the patients judgment do not offer a reasonable hope of benefit or entail an excessive burden, or impose excessive expense on the family or the community.58. In principle, there is an obligation to provide patients with food and water, including medically assisted nutrition and hydration for those who cannot take food orally. This obligation extends to patients in chronic and presumably irreversible conditions (e.g., the persistent vegetative state) who can reasonably be expected to live indefinitely if given such care. Medically assisted nutrition and hydration become morally optional when they cannot reasonably be expected to prolong life or when they would be excessively burdensome for the patient or [would] cause significant physical discomfort, for example resulting from complications in the use of the means employed. For instance, as a patient draws close to inevitable death from an underlying progressive and fatal condition, certain measures to provide nutrition and hydration may become excessively burdensome and therefore not obligatory in light of their very limited ability to prolong life or provide comfort.59. The free and informed judgment made by a competent adult patient concerning the use or withdrawal of life-sustaining procedures should always be respected and normally complied with, unless it is contrary to Catholic moral teaching.60. Euthanasia is an action or omission that of itself or by intention causes death in order to alleviate suffering. Catholic health care institutions may never condone or participate in euthanasia or assisted suicide in any way. Dying patients who request euthanasia should receive loving care, psychological and spiritual support, and appropriate remedies for pain and other symptoms so that they can live with dignity until the time of natural death....This fifth edition of the Ethical and Religious Directives for Catholic Health Care Services was developed by the Committee on Doctrine of the United States Conference of Catholic Bishops (USCCB) and approved as the national code by the full body of the USCCB at its November 2009 General Meeting. This edition of the Directives, which replaces all previous editions, is recommended for implementation by the diocesan bishop and is authorized for publication by the undersigned."http://www.ncbcenter.org/document.doc?id=147
John Hayes --Yes, these directions are not clear at all, and one of them is plain silly when you look at it closely. Consider: " the withdrawal of technology with the intention of causing death. . ." Withdrawal of help doesn't *cause* death -- it lets it happen. I'm not defending euthanasia, but let's be very careful not to say someone killed someone else because he or she did NOT do something. This silliness is repeated in "euthanasia, which is an action or an omission which of itself or by intention causes death. . ." I can intend to kill my neighbor all I want but he won't die of it. Yes, my intention is evil, but I didn't kill him. Such loose talk muddies the ethical waters.In fact, given the bishops' own exceptions, in some cases one may ethically withdraw help and not thereby "kill" the sick person at all. Then consider: "even the most severely debilitated and helpless patient retains the full dignity of a human person and must receive ordinary and proportionate care." It has been argued that we die in stages. Aquinas argues that just as there is a sequence of forms in a fetus develops into a human person, analogously when a person dies slowly, the human form (the soul) is lost first, then the animal one, then the vegetative on. (Amazing what you can get out of Thomas if you ignore what he says.) in fact, you can be brain dead and still breathe. The higher functions are lost, while the lower ones persist, and in some cases it is the electrical system of the heart which keeps the body going. Yes, the heart has an electrical system of its own which can function without the brain.\
Tonight, I found that the Archdiocese of Boston publishes an "approved" Health Care Proxy form, giving the instructions you want carried out by your proxy:I direct that my Agent make Health Care decisions for me which are consistent with authentic Roman Catholic ethical, moral and religious principles and based upon my profound respect for life and my belief in eternal life. I direct my Attending Physician(s) and the Facility where I am a patient, provide me with proper medical treatment and care including, but not limited to:(a) appropriate pain relieving medicine in an amount to alleviate or suppress my pain, but not calculated specifically to cause or hasten my death;(b) food and water to sustain my life, including when provided by artificial means, and including when I am diagnosed as having a chronic and presumably irreversible disabling condition(sometimes described as a persistent vegetative state)and I am reasonably expected to live if given food and water; however, my Health Care Agent may consent to discontinuing food and water when they no longer provide reasonable hope of prolonging my life or relieving my suffering, or they may be discontinued when their provision or the means of providing them causes me significant discomfort or imposes other excessive burdens on me or my family(c) standard comfort care appropriate for any patient suffering from illness, injury or disease; and(d) [if I am pregnant] treatment or care necessary to benefit my unborn child, even if such treatment or care shortens or prolongs my life when I am diagnosed as having a terminal condition(e) _______________________________ (Please list other wishes here)__________


text:
You down with OOP? - Yeah you know me!
Teacher: Garrett Smith Held Wed and Friday, 7-9pm, Sunday 9:30 AM
Twitter: @xkit (follow & mention).
LinkedIn: Garrett Smith (endorsements welcome)
dhtmlkitchen at gmail.com
Overview: JavaScript Language Fundamentals and design patterns for web programming.
Resources Web Development Resources
Browsers provide debuggers that can be launched from a breakpoint, the application's menu, or the debugger keyword in the script.
Parameter Object
Passing around lists of parameters? Typechecking arguments? Stop doing that. Here's how to make your code clearer and less error-prone.
Type Conversion
ClassName Swap
Event Delegation and the Cascade.
Functions are callable objects with an internal [[Scope]] property. Learn how to call functions and pass functions to other functions, where they can be later called.
Array Methods added to EcmaScript 5
Sort, map, filter, and more.
Prerequisite: Functions.
The prototype chain is used for reading property resolution.
User-defined functions can be used to construct new objects. Objects have, on their prototype chain, the constructor's prototype.
Prerequisite: Functions.
Scope Chain and Identifier Resolution
This class covers closures.
Prerequisite: Functions.
Custom Events
Fire custom events from your own user-defined objects.
Prerequisite: Functions.
Prerequisite: Scope Chain and Identifier Resolution.
Singleton with information hiding in function scope.
Prerequisite: Functions.
Prerequisite: Scope Chain and Identifier Resolution.
Interface-Based Design
Prerequisite: Custom Events.
Two interfaces with a similar signature. The Devil's in the details -- encapsulate them!
Event Notification System
An abstract system for event notification.
Prerequisite: Functions.
Prerequisite: Scope Chain and Identifier Resolution.
DOM Events Adapter
An system for DOM event notification, designed to handle delegation and specific event models.
Prerequisite: Functions.
Prerequisite: Scope Chain and Identifier Resolution.
The Factory pattern, the Decorator pattern, newApply, and the holy grail: Abstract Factory.
Prerequisite: Functions.
Prerequisite: Parameter Object
Prerequisite: Scope Chain and Identifier Resolution.

subset: commoncrawl


text:
Insurance Coverage for Clinical Trial Costs: Beyond the Recent New Jersey Agreement
Please use for reference only.
Kristine Conner and Carolyn Vachani MSN, RN, OCN
Last Modified: November 1, 2001
New Jersey's ten largest health insurers, all members of the New Jersey Association of Health Plans (NJAHP), recently agreed to cover routine care costs for patients enrolled in Phase I and II cancer clinical trials, extending an earlier agreement to cover Phase III trials. This makes New Jersey the first state in which insurers have voluntarily agreed to provide such coverage. The agreement was achieved through the efforts of the New Jersey Working Group to Improve Clinical Outcomes in Cancer Patients, a voluntary statewide coalition consisting of health insurers, health care providers, pharmaceutical companies, cancer researchers, ethicists, legislators, and patients. Other participating organizations besides the NJAHP included the New Jersey Commission on Cancer Research, the Cancer Institute of New Jersey, and the American Cancer Society, Eastern Division, New Jersey.
Governor Christine Todd Whitman, who formed the Working Group last February, officially announced the agreement on December 16th. Her announcement came just one day after the Institute of Medicine issued a report entitled "Extending Medicare Reimbursement in Clinical Trials," which urged the Health Care Financing Administration-the federal agency that administers Medicare-to establish clear rules that would end widespread uncertainties about what should or should not be reimbursed.
Clinical trials often provide access to promising new cancer treatments and ways of reducing treatment side effects. In some cases, they offer the best or even the only option for treating patients and improving their quality of life. Furthermore, clinical trials are essential in making progress against cancer. However, many health insurance plans automatically define them as "experimental" or "investigational" procedures and exclude them from coverage-making it difficult, if not impossible, for many people to participate.
To understand the New Jersey agreement, it's important to understand the two types of costs associated with clinical trials: research costs and routine care costs. Research costs are those associated with conducting the trial, such as the experimental therapy or medication itself, data collection and management, physician and nurse time, and analysis of results. Typically, these are covered by the organization sponsoring the trial, whether that be a research institution, pharmaceutical company, or government agency such as the National Cancer Institute. Routine care costs; include doctor visits, hospital stays, and laboratory tests. Many health insurers refuse to cover these if they are associated with a clinical trial.
The ten New Jersey health insurers will now cover these costs for plan members who enroll in cancer clinical trials that are administered or approved by the National Institutes of Health (which includes the National Cancer Institute), the U.S. Food and Drug Administration, the Department of Defense, and the Department of Veterans Affairs. The insurers included in the agreement are Aetna U.S. Healthcare, AMERICAID Community Care, AmeriHealth HMO, Inc., CIGNA HealthCare of New Jersey, Inc., Horizon Blue Cross Blue Shield of New Jersey, Managed Healthcare Systems of New Jersey, Oxford Health Plans, Physicians Health Services, Prudential HealthCare, and United Healthcare of New Jersey. Together they provide health plan coverage or administration to 4.8 million state residents.
Several states, including Maryland and Virginia, already have laws mandating insurers to cover the costs of cancer clinical trials, or are considering bills to the same effect. The New Jersey agreement is especially noteworthy because it represents the first voluntary agreement by insurers. Furthermore, it resulted from a collaborative effort by an independent Working Group that represented the interests of insurers, consumers, and the medical community. Back in September, the group issued a report of its findings, which included the following:
Most major improvements in cancer treatment have been accomplished through controlled clinical trials despite the difficulty in recruiting patients due to a number of barriers, including financial concerns. If more patients participated, clinical trials would be completed in a more timely fashion and critical treatment questions would be answered, resulting in improved care for all patients.
Studies indicate that clinical trials do not cost much more than standard care and may in many instances cost less.
Patients faced with life-threatening illnesses should have the increased choice afforded by access to the promising new therapies offered in clinical trials.
The report also notes that many insurance companies will cover whatever is considered "standard" treatment, even if it is often ineffective (such as chemotherapy for recurrent lung cancer). "In contrast," the authors write, "if a new treatment becomes available which shows promising results in pre-clinical trials and has shown to be safe in early clinical trials, insurers frequently will not pay for the care associated with receiving this new promising treatment because it is only available through a clinical trial. This is true even though the costs of the new treatment may be similar or even less than standard therapy. Therefore, payors are commonly reimbursing for therapies that do not work, instead of paying for new therapies that may or may not work, but which have potential." It is this type of faulty logic that the agreement is designed to remedy.
Ann Marie Hill, Executive Director of the New Jersey Commission on Cancer Research, is optimistic about the potential impact of the new agreement. "The New Jersey program provides a model for other states to implement similar programs," she says. "Basically it means that insurers' exclusion of cancer trials as investigational treatments no longer exists."
While this is a step in the right direction, Hill urges patients and their families not to assume that any clinical trial they want to participate in will be covered.
"First of all, patients have to be insured by one of these plans in New Jersey," she says. "We're actually getting more calls from across the country than from people in New Jersey." Furthermore, if the trial is not associated with one of the four government agencies mentioned above, it is not included in the agreement. That is meant to protect patients, she adds, because these federal agencies subject researchers to strict scientific and ethical standards. However, other plan limitations may affect coverage as well.
"People in certain HMOs may still be limited to certain hospitals and providers under contract with that plan," she notes. And then there's the issue of coverage for out-of-state clinical trials. That too will depend on the particulars of the contract, she stresses. In other words, individuals will still have to spend some time and energy hammering out coverage specifics with their own insurance providers.
According to Cecelia Gray, Radiation Oncology Social Work Manager at the Abramson Cancer Center of the University of Pennsylvania, many patients face difficulties in getting coverage for clinical trials participation. Generally, Phase I and II trials present the biggest problems, because the usefulness of the treatment under evaluation is still relatively uncertain.
"Each insurance company deals with this differently," Gray says, "and they have different reasons for classifying some treatments as 'experimental' and others not." While she applauds the New Jersey agreement and other states' legislation regarding coverage for clinical trials, she also emphasizes the need for a system of checks. "There has to be some mechanism in place for checking on the insurance companies," she notes.
The Working Group is currently putting together a Web site that should ease the transition for insurers, physicians, and state residents. It will feature a database of clinical trials to which the agreement applies, information about the approval process, and general information about cancer. In the meantime, patients can work with their insurance plans to get more specific information, or call the New Jersey Commission on Cancer Research (609-633-6552), The Cancer Institute of New Jersey (732-235-6777), or The American Cancer Society, Eastern Division (732-297-8000).
The New Jersey Commission on Cancer Research estimates that forty hospitals in New Jersey offer some form of cancer clinical trials. Many are affiliated with national cooperative groups that enroll participants throughout the country, such as the National Surgical Adjuvant Breast & Bowel Project (NSABP), The Eastern Cooperative Oncology Group (ECOG), Radiation Therapy Oncology Group (RTOG), Cancer & Leukemia B Group (CALBG), Gynecological Oncology Group (GOG), and Southwest Oncology Group (SWOG). There are ten pediatric cancer centers in New Jersey that have affiliations with the Children's Oncology Group, a newly formed alliance of the Pediatric Oncology Group (POG) and the Children's Cancer Group (CCG).
The New Jersey Working Group to Improve Cancer Clinical Trials Questions and Answers about the Agreement to Provide Health Insurance Coverage for Cancer Clinical Trials
The Working Group compiled the following information to answer the most commonly asked questions about the agreement.
What is the status of the Consensus Agreement to cover cancer clinical trials?
As of December 16, 1999, members of the New Jersey Association of Health Plans, which represents the state's ten largest health insurers, have agreed to voluntarily cover the routine health care costs of any of their members enrolled in Phase I, II, and III approved cancer clinical trials. NJAHP members provide health plan coverage or administration to 4.8 million New Jerseyans and 98% of the state's HMO market.
What is an approved cancer clinical trial as defined under this agreement?
An approved cancer clinical trial is a trial authorized or approved by one of the following:
- The National Institutes of Health (NIH)
- The U.S. Food and Drug Administration (FDA)
- The U.S. Department of Defense (DOD)
- The U.S. Department of Veterans Affairs (VA)
What costs are covered by this agreement?
Routine medical costs will be borne by the health plans. All other costs (administrative, additional tests mandated by protocol, monitoring) will be paid for either by the investigating company, the institution at which the trial is being conducted, or some other sponsoring party.
How can one determine whether or not a trial is approved?
The Working Group is currently engaged in a project to establish a web site, which provide lists of approved trials included in the Consensus Agreement. Ultimately, it is hoped that funding can be obtained to maintain the web site and enhance its capabilities to allow easy access to such information for health care providers, health plan medical groups, and patients.
How will this affect coverage for other clinical trials not related to cancer?
This agreement covers cancer only. It should not be construed to offer coverage for noncancer-related clinical trials.
Why is this agreement only covering cancer and not other life-threatening diseases?
The infrastructure developed nationally for cancer clinical trials is the most established and comprehensive among all life-threatening diseases. The National Cancer Institute has an extensive network of designated cancer centers (including The Cancer Institute of New Jersey) that offer state-of-the-art research in all areas of cancer. National Cooperative Groups have research partnerships that extend to sites throughout the country including New Jersey and Community Clinical Oncology Programs exist to bring clinical studies to the community level (e.g., Hackensack Medical Center). There are more controls, monitoring, and oversight for cancer studies than any other disease. For these reasons, cancer represents an ideal vehicle for taking the first steps in establishing a fair system of cost reimbursement for clinical trials.
How will the cost of "routine patient costs" be determined?
Routine patient care costs will be determined by the health plan in accordance with the definition of these costs contained in the Consensus Agreement.
Does the agreement cover only the HMO business of a health plan or other lines of business as well?
Because the agreement is voluntary, each individual health plan will make the determination as to the lines of business the agreement will cover. Health plans may find it advantageous to make an across-the-board decision with respect to all fully insured or self-funded business in order to simplify benefit administration and network issues for the company.
Currently, the five NJAHP HMOs that participate in the Medicaid program will offer this coverage to beneficiaries. In addition, it is anticipated that the year 2000 Medicaid contract will include this service for Medicaid beneficiaries. However, Medicare is controlled by the federal government through HCFA (Health Care Financing Administration) and is not included at this time. The Working Group will serve as strong advocates to address this issue at the federal level and among self-insured entities.
How can a cancer patient find out more about this agreement?
A Web site is being developed that will let patients, physicians, and medical directors from health plans have access to information about approved clinical trials by disease, sponsor, and investigator sites. In addition, educational information and resources will be provided. Until the Web site is on line, a patient can call The New Jersey Commission on Cancer Research (609-633-6552), The Cancer Institute of New Jersey (732-235-6777), and The American Cancer Society, Eastern Division (732-297-8000) for more information.
Why is this agreement so important?
This is the nation's largest and most comprehensive voluntary agreement by ten of New Jersey's leading health insurers to provide coverage for the routine costs of cancer clinical trials. It will serve as a model for other states and may have national implications.
What if I do not have any insurance?
Medicaid beneficiaries may be covered by participating NJAHP HMOs under the agreement. Some hospitals in New Jersey will provide access to clinical trials for uninsured patients on a case-by-case basis. In addition, the Working Group is committed to work to increase access to cancer clinical trials through education, advocacy, and innovative interventions.
What if my doctor is not involved with clinical trials?
The New Jersey Commission on Cancer Research can provide information about hospitals in New Jersey where physicians offer access to clinical trials.
Will this increase the cost of insurance in New Jersey?
The Mayo Study released in May 1999 indicated little or no additional costs for routine care of cancer patients participating in clinical trials (Chute et al, No. 10, May 19, 1999). In addition, the Working Group will include a cost analysis of approved clinical trials as part of its database.
Are all cancers included in this agreement? Are prevention and supportive care trials also covered?
All cancers are included within the agreement. Prevention, treatment, and supportive care studies are included within the agreement as long as they fulfill the approval requirements.
How have other states handled this issue? What mandates have been adopted and how are they working?
Some states have relied upon legislation and regulation to deal with insurance coverage for the routine care of clinical trials. According to the National Conference of State Legislatures, Rhode Island has mandated coverage for Phase II & III trials. In 1998, Maryland mandated insurance coverage for Phase II & III of clinical research involving a life-threatening disease and Phase I coverage for cancer. In April 1999, Virginia mandated insurance coverage for Phase II and Phase III clinical trials. Other states, including New York, Pennsylvania, and Vermont, have bills pending that would mandate coverage. Studies indicate that mandates increase costs and result in adversarial relationships between health insurers and providers.
How many patients in NJ will be assisted by this agreement?
Under the agreement, it is estimated that between 150,000 and 175,000 of New Jersey's cancer patients will have increased choice and improved benefits. The American Cancer Society estimates that 40,000 people are diagnosed with cancer in New Jersey each year. Of this number, 25,000 will be covered under the agreement. The New Jersey Commission on Cancer Research has just updated its survey on clinical research in New Jersey and reports that 1,350 new patients were enrolled in clinical trials and 4,200 patients were continuing in follow-up or ongoing studies within New Jersey institutions in 1999. This represents approximately 3.3% of cancer patients in New Jersey. The Working Group hopes to expand participation to 15% of all cancer patients per year on nearly 6,000 patients in the next three years.
How many clinical trials will be included?
The Coalition of National Cancer Cooperative Groups estimates that 200 to 400 open trials are available to patients in New Jersey at any time. In addition, the Working Group estimates that The Cancer Institute of New Jersey has 70 NCI-approved trials open in New Jersey.
While the agreement includes the ten major health insurers in New Jersey, what about other insurers who are not members of the New Jersey Association of Health Plans?
All insurers offering coverage in New Jersey will be invited to participate in the Working Group.
If a patient is already participating in a clinical trial, will they still be covered?
All costs from the date of agreement will be covered. Costs prior to the agreement will not be retroactively covered.
Did any patients participate in Phase III clinical trials under the original agreement signed in February 1999?
One of the purposes of the Working Group is to track this type of information. At this time, there is not a system available to answer this question, but the Web site and database discussed above will allow us not only to know how many patients are on trial, but also evaluate costs and outcomes.
Facilitating Clinical Trial Coverage by Your Health Plan: Strategies from the National Cancer Institute
While some states are taking steps to expand insurance coverage for clinical trials, these decisions are usually left up to individual health plans. The National Cancer Institute suggests the following steps for dealing with coverage issues up front when deciding to enter a clinical trial.
Understand the costs associated with the trial. Ask your doctor or the trial's contact person about the costs that must be covered by you or your health plan. Are these costs significantly higher than those associated with standard care? Also, inquire about the experience of other patients in the trial. Have their plans paid for their care? Have there been any persistent problems with coverage? How often have the trial's administrators been successful in getting plans to cover patient care costs?
Understand your health plan. Be sure you know what's in your policy. Check it to see if there's a specific exclusion for "experimental treatment." Look closely at the policy to see how the plan defines such treatment and under what conditions it might be covered. If it is not clearly defined, call the plan's customer service line, consult their web site, and/or write to them. Ask for specific information about clinical trials coverage.
Work closely with your doctor. Talk to your doctor about the paperwork he or she submits to your insurer. Often the way the doctor describes the treatment affects the likelihood of coverage. You might ask your doctor or the hospital to send an information package to the insurer that includes studies supporting the procedure's safety, benefits, and acceptance by the medical community. This package might include:
- publications from peer-reviewed literature that demonstrate patient benefits;
- a letter that uses the insurance contract's own language to explain why the treatment, screening method, or preventive measure should be covered;
- letters from researchers that explain the clinical trial;
- support letters from patient advocacy groups.
Be sure to keep your own copy of any materials that the doctor sends to your health plan for future reference.
Give your health plan a deadline. Ask the hospital or cancer center to set a target date for the therapy. This will help to ensure that coverage decisions are made promptly.
If a claim is denied, read your policy to find out what steps you can follow to make an appeal. In What Cancer Survivors Need to Know about Health Insurance, the National Coalition for Cancer Survivorship suggests that you and your doctor demonstrate to the health plan that:
- the therapy is not just a research study, but also a valid procedure that benefits patients;
- your situation is similar to that of other patients who have responded well to this therapy;
- possible complications have been anticipated and can be handled effectively.
You also may wish to contact the Health Insurance Association of Amercia for more help.
Additional Information Resources
On OncoLink
- Financial issues for patients. Includes up-to-date insurance news, information about financial assistance, and an interactive billing forum.
Press Releases About the New Jersey Agreement
- NJAHP Says Clinical Cancer Trials Agreement Establishes Precedent for Cooperation New Jersey Association of Health Plans.
- Statement on private insurers' cancer clinical trials coverage plans American Cancer Society.
- New Jersey Insurers Agree to Pay for Clinical Trials National Cancer Institute.
- Governor Announces Precedent-Setting Agreement by Health Insurers to Cover Treatment of All Phases of Cancer Clinical Trials Office of Governor Christine Todd Whitman.
Other Useful Links
- Cancer Institute of New Jersey, New Brunswick, NJ (NCI-designated Cancer Center): patient information
- Cancer Institute of New Jersey, New Brunswick, NJ (NCI-designated Cancer Center): clinical trials information - features a listing of current clinical trials
- New Jersey Commission on Cancer Research
- Facing Forward: A Guide for Cancer Survivors - features a section on insurance issues, National Cancer Institute
- cancerTrials - the National Cancer Institute's clinical trials information resource.
- section on insurance issues


text:
Once upon a time, there was this podcast called Robochode. Then it died. Then it came back. I'm not very good at telling stories.
For people that weren't around the same time as Robochode (which is understandable since the last episode aired nearly 2 years ago), it was a couple of dtoiders shooting the shit about random things in science and technology. Binary Chode is exactly that. Half the cast of the original Robochode (ZP and Bloodspray) will be making their return. The rest of the cast will be filled out by an old man, a lady, and yours truly. At least two of us will be slinging back a couple of drinks.
We will be recording our first episode tomorrow at 9:00 Eastern Standard Time. The control freak in me did plan out a list of topics, but the lush in me is very prone to derailing and forgetting. Even though we have a list of things to talk about, we would love to get questions from you folks as well. If it's something vaguely sciencey, we'll probably try our best to answer it. You can either post questions in this thread, e-mail questions to binarychode AT gmail DOT com, or tweet us at @BinaryChode. And while you're at it, follow the Twitter account. In addition to taking your questions, we'll probably tweet random shit we find that you'll find interesting.
The first few episodes are going to be us getting our bearings, but we should at the very least have a link to directly listen to the podcast. We're going to figure out how to get iTunes/RSS capabilities eventually. Baby steps.
tl;dr Get hyped for this podcast.


text: Last week someone asked me if I could make a tutorial on "how to draw baby Road Runner", step by step. Of course I received the request, but I couldn't tackle it until I had my previous list done. So today I will be filling two requests on baby figures from the WB group. I had a lot of fun drawing Baby Road Runner because he was actually one of my favorite characters just three years ago. The tutorial isn't going to be that complex because I made sure to draw baby Road Runner in a pose that would be easy to replicate. The total drawing time took me about forty five minutes from start to finish, with an additional twenty minutes to color in. You will need a regular pencil and eraser when you get ready to tackle this tutorial on drawing baby Road Runner. I have a feeling that he will be liked, and tackled by a lot of members and visitors. Have fun people and don't forget to rate and comment.


text:
With each day that goes by delivery is becoming ever more likely. You may experience Braxton-Hicks' contractions, which help to soften the cervix and prepare for labor. The amniotic fluid that surrounds your baby ensures she'll hardly notice these mild tightenings.
Even at this late stage of pregnancy, it may still be hard to imagine your baby being born and living in your home. You and your partner may settle into life with your newborn with ease, and manage without any help, but it's still a good idea to have backup support just in case.
What you may not be prepared for is the fact that you're likely to be exhausted after weeks of poor sleep during pregnancy, and the rigors of labor itself. Add to this interrupted nights' sleep and the whole adjustment to being a new parent, and you may well find you'll need to call on people to help practically and emotionally.
It can help enormously to have a good support network set up in advance. Ideally, this will be close family and friends who you know you can rely on to drop in to help, but who will also know when you need to be left alone. Even an hour's help to prepare you a nutritious meal, or hold your baby while you get a much-needed rest or a shower, can give you some welcome respite.
Have the number on hand for your lactation consultant, so that you can ask for advice. Also get on the phone to moms-to-be whom you've met at prenatal classes; they more than anyone will be able to relate to how you're feeling.
Don't be too proud to accept help with housework and shopping. Knowing these tasks are taken care of will help you relax and focus on your baby.
Try to limit the number of guests you have in the early days, and make sure that they are warned that visits will be short. Although you will be desperate to show off your new baby, visits can be draining so it's better to wait until some routines are more established.
Large meals are likely to leave you feeling uncomfortably full, especially late in the third trimester. If you go long periods of time between meals, you may become light-headed and feel weak from hypoglycemia-low blood sugar. This is because the baby is constantly drawing glucose from your bloodstream.
Healthy snacking is the key to eating well and comfortably:
Excerpted from Pregnancy Day by Day.
Copyright © 2008 Dorling Kindersley Limited.
Buy this book now!
© 2000-2016 Sandbox Networks, Inc. All Rights Reserved.


text:
Musser is bringing innovation to both the stadium and the concert hall with the new M300K Performer marimba. Face the elements with the all-weather durability of Musser Kelon bars or upgrade to the concert performance sound of rosewood on the same instrument.
"The Musser M300K Performer Marimba is built to accommodate the musical performance for the field with a robust frame, as well as the inside concert hall," said Jim Catalano, Musser Business Manager. He continued, "The ability to have one frame that can hold Kelon Synthetic Bars or be interchangeable with Rosewood Bars is a great feature."
The M300K is a 4.3 octave marimba with a square tube steel frame that rolls over the toughest terrain on 8" hard rubber wheels. Standard features include: the Kelon bars with scratch resistant and durable silver vein powder coated resonators for full bodied tone, a front-mounted square tube accessory rack with two accessory clamps and gas strut-assisted height adjustment from 34" to 44", accommodating for the various heights in student performers. Rosewood bars are also available at an additional cost.
The new M300K Musser Performer Marimba carries the American made Musser sound to any performance venue with this all-weather, versatile 2-in-1 performance instrument every band will want to be playing on.
To view a short video of the M300K visit: http://youtu.be/KXp1PJ4uewc
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Conn-Selmer is the leading manufacturer and distributor of musical instruments for student, amateur and professional use under the brand portfolio of Vincent Bach, CG Conn, King, Holton, Selmer, Armstrong, Leblanc, Ludwig, Musser, Prelude, Galway, Glaesel, Soloist, William & Lewis, Scherl & Roth. With a focus on quality craftsmanship, innovation and superior musical performance, Conn-Selmer operates U.S.A. production facilities.
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Important Global Message
The Miami-Dade County Emergency Operations Center has been activated and is closely monitoring Erika. For any updates about County facilities and services, please visit: http://www.miamidade.gov/emergency
The County offers employees a competitive benefits package. Within this site you will find information on medical, dental, vision, term life insurance, group legal, disability income protection plans, deferred compensation, retirement, wellness, and discount programs. Benefits are administered by the Benefits Administration Unit of the Internal Services Department, Human Resources. Employees should contact their Department Personnel Representative (DPR) for questions regarding their benefits eligibility.
Employees can estimate the biweekly premium cost for the various optional life and disability options available to eligible County employees by using the Benefits Calculator
Eligible Miami-Dade County employees are guaranteed Group Medical, Dental, Vision coverage as long as they enroll during the initial benefits eligibility, during the annual benefits open enrollment or within 45 days of a status change or HIPAA qualifying event.
Life Insurance
The County provides with Basic Group term life insurance and also lets employees purchase additional insurance called Optional Life Insurance.
Supplemental Benefits
In addition to the health and life insurance plans, the employees may also participate in the employee-paid programs like Group Legal, STD\LTD, Flexible Spending accounts, County Death Benefits, etc
Leave of Absence
A leave of absence is an approved absence without pay for a maximum period of one year. This section addresses maintenance of group benefits while in a no-pay status. Questions regarding eligibility for leave of absence, including the process to request approval, must be directed to your departmental personnel representative.
The Consolidated Omnibus Budget Reconciliation Act (COBRA) is a federal law that requires most group health plans to provide a temporary continuation of group health coverage that otherwise might be terminated. COBRA requires continuation coverage to be offered to covered employees and their covered dependent(s) when group health coverage would otherwise be lost due to certain specific events.
The content on this page is to provide an overview of the retirement benefits available to Miami-Dade County employees when they retire.
Deferred Compensation
When you retire, you'll want to maintain the lifestyle you currently have. Social Security and the Florida Retirement System are not intended to replace all of your income at retirement. It is wise to start a savings plan now. The Deferred Compensation Plan is a tax deferred savings plan that can be used at retirement to supplement your Florida Retirement System and Social Security benefits.
Forms & Notices
The most frequently used benefit forms are listed on this page. Important informational and disclosure notices are also included.
Employee Support Services
The Miami-Dade Employee Support Services is a benefit designed to provide a confidential service to employees whose personal problems are affecting their ability to function on the job, at home, or in society.
You are now leaving the official website of Miami-Dade County government. Please be aware that when you exit this site, you are no longer protected by our privacy or security policies. Miami-Dade County is not responsible for the content provided on linked sites. The provision of links to these external sites does not constitute an endorsement.
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Nascar's Next Generation
A New Car and a Hyped Star Liven Up a Sagging Brand of Racing
Nascar is a sport in need of a tuneup. Attendance has been slipping; viewership has been falling. But Sunday at the Daytona 500, America's premier form of motor sports will be getting the overhaul it needs.
Daytona, the season's kickoff extravaganza, marks the race-day debut of Nascar's "Gen-6" Sprint Cup car, the series's most innovative overhaul since 2007. This machine aims to put the "stock" back into stock-car racing.
For years, Nascar featured cars that looked nearly exactly alike, to emphasize parity among teams and drivers. Not anymore. Fans will see cars recognizable as a Ford, a Chevy or a Toyota (the three manufacturers that run in the series). The cars feature body panels unique to each manufacturer, so they look more like showroom cars.
Facing a decline in fan interest, Nascar has sought to bring back brand identity, which helped fuel the series's rise in the 1950s and 60s.
So far, enthusiasm is high. "I haven't met anyone who hasn't said that [the new Gen-6 car] is not the best-looking car we've ever had," said Jamie McMurray, an Earnhardt Ganassi Racing driver who won Daytona in 2010.
Gen-6 was also built to upgrade competition. The engines are 358 cubic-inch V8s (the same size as last year's), but the cars are about 150 pounds lighter. "Every track we go to, I think we're going to have a chance to break the track record," McMurray said.
Here is a look in the rearview—the previous five generations of stock-car racing, and the new one (at right).
Generation 1 (1948-66)
The car: Nascar founder "Big" Bill France created the series to feature real showroom cars, strictly stock. "A lot of guys drove their cars to the racetrack to compete," said Robin Pemberton, a Nascar vice president who has worked on every generation of racer except the first. "That's how stock they were."
Era's dominant driver: Lee Petty (pictured)
Top speed at Daytona: 160.627 mph average, Richard Petty in a 1966 Plymouth
Generation 2 (1967-80)
The car: Teams were still using showroom car bodies in this era, but engineers were now building in some serious racing voodoo. "The car body looked pretty stock," said Albert "Buz" McKim, a historian with the Nascar Hall of Fame. "But there was a lot going on beneath."
Era's dominant driver: Richard Petty (pictured)
Top speed at Daytona: 177.602 mph average (the fastest to this day), Buddy Baker in a 1980 Oldsmobile
Generation 3 (1981-91)
The car: Due to the energy crisis in the Jimmy Carter years, Nascar followed Detroit's lead and downsized for the 1981 season. The cars' wheelbase was reduced to 110 inches. According to the rules, teams still had to buy body panels from manufacturers, but the movement from stock to pure race-bred machines continued.
Era's dominant driver: Dale Earnhardt
Top speed at Daytona: 176.263 mph average, Bill Elliott in a 1987 Ford (pictured in 1985)
Generation 4 (1992-2006)
The car: "This is when the cars really were getting bizarre," said McKim. "They looked a little like spaceships." Now highly modified racers, the cars no longer looked stock at all. The science of aerodynamics altered Nascar's look, and not everybody liked the results.
Era's dominant driver: Jeff Gordon (pictured)
Top speed at Daytona: 172.712 mph average, Dale Earnhardt in a 1998 Chevrolet
Generation 5 (2007-12)
The car: Following high-speed crashes that took the lives of Earnhardt in 2001 and Kenny Irwin Jr. in 2000, Nascar developed this version, dubbed the "Car of Tomorrow," primarily for safety reasons. All teams used the same car body and frame. With the exception of engines and decals, brand identity took a back seat.
Era's dominant driver: Jimmie Johnson (pictured)
Top speed at Daytona: 152.672 mph average, Ryan Newman in a 2008 Dodge


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How many images should be updated or rotated in on a slideshow carousel that features things like products or articles?
Most people seem to agree on the common sense of a maximum around 5 images, but agree that less is better where possible. Jakob Neilsen suggests 5 because:
I found a similar question for mobile sites, which unfortunately also did not have a definitive answer:
How many photos should be in a slideshow for mobile on page load?
As I expected, the answer given for this question also indicates that the maximum number of slides should be as many as an average user would view at one time. I would expect this number to be about 4-6, but I couldn't find a specific number anywhere. This would probably require user testing as the content of the slides would greatly affect this. For example, slides with more text and information should be shown for longer (and I have seen many sites that do this terribly) and there should probably be less slides as it involves more effort on the user's part to view each one. A carousel with single images can scroll more quickly and therefore should include more, as a user will reach the end sooner.
In my searching, I also found this great resource that may be helpful for you as you are designing your carousel:
I think I read you should automatically load no more than three images. Don Norman or Jakob Nielsen made the suggestion, but I can't find the report again on their websites.
Edit: Why is this being down voted? Let me clarify. I can't find the report again on their websites. I was having a bad user experience. The answer is 3.


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Top white-collar crime prosecutor to lead SEC
|Mary Joe White stands by as President Barack Obama announces in the State Dining Room of the White House in Washington, Thursday, Jan. 24, 2013, that he will nominate White to lead the Security and Exchange Commission (SEC), and re-nominate Richard Cordray to lead the Consumer Financial Protection Bureau, a role that he has held for the last year under a recess appointment. (AP Photo/Carolyn Kaster)
WASHINGTON -- President Barack Obama sent his strongest signal yet Thursday that he wants the government to get tougher with Wall Street, appointing a former prosecutor to head the Securities and Exchange Commission for the first time in the agency's 79-year history.
Mary Jo White, former U.S. attorney in Manhattan, has an extensive record of prosecuting white-collar crime, won convictions in the 1993 World Trade Center bombing and the 1998 terrorist attacks on two U.S. embassies in Africa, and put crime boss John Gotti away.
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2014 Alan Major Basketball Camps
Team Camp is Full. The 49ers are not accepting any more teams for their 2014 Team Camp.
Individual Shooting Clinic
Day camps will be held at the 49ers Charles Hayward Practice Gym.
Session One: July 11 & 12; Session Two: July 25 & 26 and Sesson Three: August 1 & 2
Cost: $60 for one session, $100 for two sessions and $140 for all three sessions.
Each day of each session: 8 am to 12 pm (Rising 2nd through rising 5th graders); 1 pm to 5 pm (Rising 6th through 12th graders).
Each session is limited to the first 40 applicants.
Campers grouped together via individual skill level (all skill levels welcomed)
Contact Mark Bialkoski at:704/687-1008 or 704/687-4939 for more information
Open to all Boys age 7 through 17
Clinic will be held in Halton Arena
June 29 - 10 am to 2 pm
Team camp is closed. Thanks for everyone that registered for this year's team camp. If you have any questions contact Mark Bialkoski at 704-687-1008.
June 27-28
No busing to and from different locations
Wide variety of competition from three surrounding states
Guarantee of 4 Varsity games per day
Click here for Team Camp on-line registration
Call Mark Bialkoski - 704/687-1008 for more information


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Road of Knives is a "battle blog" wherein Zak Smith, Shawn Cheng, and other artists take turns drawing monsters fighting each other.
from the website, Road of Knives
I'm looking for similar games or rulesets that involve drawing each others' characters. Ideally, I'd like to know if there are any games with more complicated rule systems.


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The 5 Creepiest Death Rituals From Around the World
#2. Aboriginal Body Exposure
What Is It?
Australian Aboriginal beliefs are very diverse, and as such, there are many traditional methods of dealing with corpses, such as burial, cremation, mummification and cannibalism, though the latter is hotly disputed. Probably because all the evidence has been eaten.
Exposure on raised platforms, however, was one of the more common rituals, particularly in the North. There are two main burial stages. The first is to leave the corpse on a raised platform and cover it with leaves and branches until the flesh has rotted away, a process which can take months.
Next they retrieve the bones from the platform and paint them with red ochre. The bones are then either placed in a cave until they become dust or are placed inside a hollowed out log. Or, in some cases they are carried around by relatives for up to a year, which we're guessing makes for some awkward first dates.
This is sometimes followed by a total destruction or abandonment of the deceased's property, and for a time no one is allowed to say the name of the deceased.
Dear God, Why?
Aboriginals do believe in the human soul, though they consider the soul to have two sections. The rituals are dealing with the fact that one of those parts (the ego) tends to come back and haunt the living, and as every horror movie has taught us, ghosts are dicks. The destruction of the deceased's home and refusal to acknowledge him is their way of telling the ghost to fuck off.
Now you'd think the part about carrying around the actual bones of the dead person would increase the chances of a haunting, but this is a culture that was never exposed to the movie Poltergeist and who thus does not know any better.
#1. Space Burial
What Is It?
Space burial is obviously a fairly modern death ritual, unless there was some ancient, burly fellow who could throw things really fucking high. But it is no less insane, especially seeing as it costs about the equivalent of a small Eastern European nation's GDP to perform.
Yes, You can purchase your own space burial, though the cost depends on just how far out into space you want to end up. You can have your ashes sent into low orbit for a while for as low as $695, but getting a spot on a deep space Gemini Module can run up to $60,000.
Above: A $60,000 plaque that says "You're Dead and in Space."
The first one of these was performed back in 1997, from an aircraft carrying a modified Pegasus rocket, which contained ashes of 22 people (including Timothy Leary and Gene Roddenberry). The rocket blasted into orbit 11 kilometers above the Canary Islands, of all places, whereupon it will remain aloft in the heavens for eternity.
Oh, wait, no. It re-entered the atmosphere in 2002 and was immediately burned to a crisp.
Dear God, Why?
This has been a symbolic gesture for deceased who had an interest or career in space (though an expensive symbolic gesture, especially considering you still have to have the body cremated ahead of time). But in Timothy Leary's case, he actually requested it, possibly out of a simple desire to make disposal of his remains as absolutely inconvenient for the world as possible.
Though we do have to give credit to Clyde Tombaugh (the man who for 70 years successfully hoodwinked the world into believing Pluto was a real planet) because his space burial will let him go down as having traveled further than any other human. A bit of his remains were stuck aboard the New Horizons spacecraft, launched by NASA in 2006 and headed for the "planet" Pluto.
Tombaugh is somewhere around Saturn by now, and will make it to Pluto in the summer of 2015. At that point the craft will likely be intercepted by an alien life form, who will likely interpret the inclusion of a dead person's ashes as a symbolic declaration of war.
For a look at some disorders that would make you wish for the sweet embrace of a space burial, check out The 6 Most Gruesome Disorders Anyone Can Get or find out about people who decided they didn't like death no matter its trappings in 7 People Who Cheated Death (Then Kicked It in the Balls). And don't miss our look at The Worst Drinking Game Ever (NSFW).


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Losing Fingernails After Chemotherapy
Last Modified: February 12, 2006
Dear OncoLink "Ask The Experts,"
My sister has just finished all her chemotherapy and radiation treatments for breast cancer. Her fingernails are turning dark and separating from the bed. Is there anything she can do to help this situation? Will any creams or other products help to strengthen the nails?
Carolyn Vachani RN, MSN, AOCN, OncoLink's Nurse Educator, responds:
Unfortunately, not much will help. The chemotherapykills the cells of the nails, so they are already dead and may fall off before new cells can grow back. Best advice is to keep them clean in order to prevent any infection. If the nail beds are sore, a band-aid on the tip of the finger may give some protection. If the skin is broken, be careful with perfumed creams, as these may irritate it. It is probably best to stick with baby creams/ointments - they will be most gentle to the exposed skin.
After Being Diagnosed, Life Can Change Overnightby Bob Riter
July 20, 2016
3 Great Reasons To Have Gratitude On Your Cancer Teamby Marlys Johnson
July 25, 2016


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See images from Himawari-8 in the new satellite viewer
This demonstration product is most suitable for people
with fast internet connection and high data allowance.
Low-definition satellite images
Satellite View Selection
04:30 UTC on Wednesday 27 July 2016 | Cloud/surface composite, Australia
Images from Japan Meteorological Agency satellite Himawari 8 via Bureau of Meteorology.
IDY28000 Australian Government Bureau of Meteorology Bureau National Operations Centre Satellite Notes for the 1800UTC Chart on 27 July 2016 Issued at 5:00 am EST Thursday on 28 July 2016 Patchy low cloud over southern parts of SA, through Victoria and southern NSW formed with the cooler airmass and clear skies overnight. A middle level cloud band over Tasmania is associated with a trough in the upper levels. Another upper level trough is responsible for the extensive cloud band extending over the southwest region of WA.


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Just started, so my question is very basic. I got Coopers Lager Kit, did everything by instructions, temperature has been stable at 22-24C but gravity doesn't go down. OG was 1.039, dropped to 1.020 on the 4th day and stays at that level for several days (today is 10th day of fermenting with very little bubbling). Tastes very bitter. What is wrong? Should I just bottle?
1.020 is quite a high final gravity. It sounds like your fermentation is stuck. I would swirl the fermenter to resuspend the yeast (without introducing any air) and see if fermentation resumes. If that fails, then I would buy more of the same yeast that you originally pitched, if it's dry yeast rehydrate it in 90-100F water (32-38C) for 15 minutes, then add it to the fermetner. If you used liquid yeast, make a starter, and when the starter is bubbling fiercely, add it to the fermenter.
If you didn't make a starter or didn't rehydrate dry yeast, high final gravities are frequently what you get.
Some kits are intended to have higher final gravities, but you got less than 50% apparent attenuation. You should expect at least 60% and probably more like 70%.
I would be more worried about the bitter taste, was it bitter or acid as in vinegar? As Korz already said it could be a stuck fermentation. I think the yeast packets in the beer kits are not under ideal conditions most of the time and stuck fermentations should not be very uncommon. Swirl or re-pitch in that case. But an infection could also leave your beer in that state, you should smell and taste it, just make sure to use sanitized equipment to taste it or you could end worse than what you started with :D.


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I have a 16 month old daughter and am concerned about her health. I like to know what pre-cautious measures should we take as parents in case she has fever, sore-throat and chest congestion. Please provide detail. Thanks
What pre-cautions are to be taken by parents in case of sore-throat, chest congestion and fever for toddlers?
Fevers are a normal response to either viral or bacterial infection, and are a good way of knowing your child's body is responding normally and attempting to fight off the infection. The downside to fever is that even a low-grade fever can make you just feel awful. Askdrsears.com has some great advice on how to handle fevers in young children. He says:
Exceptions to the above two rules are:
All of these four points are considered medical emergencies and your child should see a doctor immediately.
Otherwise, fever reducers such as ibuprofen and acetaminophen are good to keep on hand. If you don't want to give your child medication, you can try bringing down moderate fevers with tepid/lukewarm baths, or by simply rubbing your child's arms and legs with a cool, wet washcloth. This does NOT mean cold water. The Dr. Sears site answers practically every question you could ever have about fevers and fever management.
Sore throats are not usually an emergency. The real challenge is to make sure that you keep your child hydrated as they frequently won't want to eat/drink much if their throat hurts. Giving them popsicles/ice cream/frozen yogurt/etc. can encourage them to eat. Most sore throats are caused by viruses and will go away on their own, but if the sore throat is accompanied by fever and swollen neck glands then you may have a case of strep throat which needs to be treated with antibiotics.
Chest congestion can be tricky and can be a sign of everything from a cold to pertussis and pneumonia/influenza. Using a humidifier can help make breathing a little easier. Certain plants like eucalyptus, camphor, and lavender are ingredients in an over-the-counter salve found here in the US which has been shown to improve breathing and congestion in people who use it. If the congestion is getting to be especially tricky, taking your child into a bathroom, shutting the door, and turning on the shower as hot as possible will create a steam room (you should NOT be in the shower. You just want to create a sauna-like effect. We usually sit on a closed toilet with our son/daughter on our lap). Sometimes exposing your child to the cold will help the bronchioles to contract and make breathing a little less labored. If it's cold outside, you can take your child directly outside, or, if it's summertime, you can stand them in front of a freezer for a few minutes.
If you start to notice a sucking in around the rib cage when your child inhales, this could be a sign of a serious respiratory infection and your child should be seen by a doctor. It sounds strange and you worry that you won't recognize it when you see it, but without any training I knew it when I saw it on my daughter when she was 6 months old.
As always, go with your gut. You know your child. If she seems really ill and you feel like she needs to be seen by a doctor then don't hesitate. If you want more information about any of this stuff, the Ask Dr. Sears website is a really good reference. Just type your term into the search box. And as Valkyrie says, getting into the habit of good hygiene early is the best prevention!
Get in the habit of washing her hands after diapering/playing with pets/playing in the dirt/choose your own adventure. We sing 'Happy Birthday' so that the kids wash their hands for at least 30 seconds.


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via Personal Recipe 1765125:
Great video ;)
Any old excuse to get on their bikes and hoon around... I like it! :)
A new music clip.....
Should I introduce you the new judge of the CRISPhouse here? It is me (I studied very hard and finished with a diploma; the chef of the judgesschool is also me): I am deciding now this and that/ several things and then I set it in action. I am the judge (,I'm also the police) and the rules are also from me. When the other member(s) of the house don't want my rules or any rules, that is not my fault. The wrong actions/the actions I don't like are being/are going to be penalized. I am Tré.


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Trying create archive in Ubuntu 12.10 on FTP thought Nautilus right click Compress I got this message: Could not create the archive. You don't have permission to create an archive in this folder. In Ubuntu 12.04 it's ok.
When you're ready to create the archive, do this: press
After you've connected, go back to the Archive Manager and click the "new" button. Tell it to save the file to where you need it (in the FTP directory.)
If this method didn't work for you because you couldn't access the FTP directory from within the Archive Manager, then try this alternate approach:
The key to both of these is to run the program as Root, incase the problem was a system permission limitation on your end. If the FTP server is rejecting write access, then there's nothing you can really do.