{'fraction_non_alphanumeric': 0.025057825751734774, 'fraction_numerical': 0.00038550501156515033, 'mean_word_length': 4.479408658922915, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
A piece of my mind. One vote for death panels.

One Vote for Death Panels I WISH WE HAD DEATH PANELS. I don’t mean that I’m in favor of some appointed group of erudite experts gathering to decide who lives or dies in a process controlled by the government, but rather the death panels that were originally proposed. I’m in favor of periodic discussions about advance directives that Medicare would pay for as medical visits. As a geriatric psychiatrist, I have a fair amount of experience with this type of death panel. Approximately twothirds of the patients admitted to our geriatric psychiatry inpatient unit have dementia, with a wide array of behavioral disturbances. These problems in behavior made it difficult for these elderly patients to receive care at home. They would then seek care from our unit or, too often, would be admitted to nursing homes that would continue to have problems managing the behaviors and then refer these folks to us. As part of the care delivered, we would meet with the patient, and then with the family, to explain the type of dementia, the typical course that could be expected, as well as ideas about how the behavioral component of the disease manifests and how it can be managed. Finally, we talked about what the future would bring, usually giving the alreadyburdened patient and family an explanation of the inexorable downhill course of progressive dementia leading to death. We tried to explain the course of the illness to the family, opened the discussion about what care was available, and asked the patient and the family about what care they may want both now and in the days ahead. After this hour-long discussion, families typically said two things to us. First, they always thanked us for taking the time to share some education and discuss these issues. As they were showering me, the attending physician, with gratitude, our social worker would always shoot me an evil glance. She would comment after the meeting, “They thank you . . . for that! All you said was ‘If you think things are bad now, wait six months.’ ” I suppose I should have been able to offer a cure, but that is not yet available. And the social worker, who had been working with the family for much longer, didn’t get the same volume of thanks as I, “the doctor.” The reason for this was quickly supplied by the second thing families always told us: “No one has ever sat down with us to tell us what was going on, and what we could do,” they said. At first, I assumed they were simply supplying thanks for a meeting, and I didn’t really believe no one was sitting down to discuss prognosis and end-of-life issues about their family member. However, this comment occurred so often, so consistently, that I began to believe over the years of meeting with these families that it was indeed true. No one had taken the time to tell them “what is going on.” The reason for this is evident in the waiting room of any physician’s office. Faced with patients lining up for the typical ten-minute visit, any primary care physician knows that time with a patient, let alone a patient’s family, is more precious than gold. While I’m sure that these patients’ physicians did inform them of the diagnosis, I assume they also took two to three minutes to warn about the impending disaster that was about to befall the patient and the family. But that two minutes—representing the time available— was simply not enough. Families overwhelmed with bad news and the fatigue of care are not able to process or to understand the needs of care. It simply takes time. That time is not available with the crush of patients and the pressures of managed care. We took the time because we thought we should. But the unit was funded by Medicare, and Medicare-funded geriatric psychiatry does not pay as well as other areas of medicine, and family discussions have even worse funding. The hospital, pressed for money and space, closed the unit, even though the occupancy rate was 98% and we were under the Medicare “cap” for spending. We were making all the money we could, and it wasn’t enough. In one of the original health care reform proposals, periodic discussions with elderly patients about their advance directives would be recognized and funded by Medicare. But in some bizarre way, in the news cycle of talking heads with great hair and a smile that ceases only when trying to portray intense concern, this idea of physicians actually being paid to talk with patients about their care was turned into “death panels.” People like their physicians to talk with them. People are generally in favor of physicians getting paid. But the concept of physicians being paid for time to talk with patients and their families about advance directives somehow generated into the fear of decisions about life and death being controlled by the government. The idea was torpedoed not because it was a bad thing, or because people didn’t want it, or because it wasn’t needed. Our experience showed that it was desperately needed, and funding for it was needed just as much—but the idea was transformed successfully into a negative sound byte with a memorable catchphrase. We shouldn’t be surprised.