Ira Byock, director of palliative care at Dartmouth, has spoken out again against assisted suicide in Massachusetts (http://commonhealth.wbur.org/2012/10/paliiative-care-assisted-suicide#more-23626).
In a guest post on CommonHealth, the health blog of Boston radio station WBUR, he writes:
We’ll still require terminally ill patients to give up treatment for their disease to get Medicare to pay for their hospice care. In 2012, 14% of hospice patients in Massachusetts were eventually discharged from hospice care. Is there anything in Question 2 that would guarantee continuance of hospice care for people who get lethal prescriptions? No. It will quite literally be easier to get a lethal prescription in Massachusetts than to have hospice care through the end of your life.
This raises several questions.
First, why is hospice discharging 14% of its patients? The Medicare guidelines say discharge can happen only when the patient moves out of the covered area, for cause, or when hospice determines he is not terminally ill (http://www.cgsmedicare.com/hhh/coverage/Coverage_Guidelines/Discharge_Revocations_Transfers.html).
We’d like to know what percentage of the discharged patients were found not to be terminally ill. Remember that the prognosis for getting a lethal prescription is tied to the prognosis for admittance to hospice. If this many people are being discharged from hospice, doesn’t that reinforce the caution that prognoses are horribly inaccurate?
Byock’s concern seems to be less the inaccuracy of prognoses than obstacles. He points to the fact that Medicare won’t cover hospice for a person who also chooses to receive treatment aimed at a cure. Earlier this year, the Vermont legislature passed Act 60 (http://www.leg.state.vt.us/docs/2012/Acts/ACT060.pdf), which, when and if implemented, will allow Vermonters to be covered for both hospice and curative treatment simultaneously .
Addressing that specific concern would not alleviate Byock’s worries. It is only an example of troubling hospice requirements, of obstacles that keep people from accessing hospice services.
In the light of failed proposals in several states last year to cut off Medicaid funding for hospice care (e.g.,http://www.kxly.com/news/State-Wants-To-Cut-Medicaid-Funding-For-Hospice-Care/-/101270/684712/-/rorup1/-/index.html), Byock’s concern that future cost cutting efforts could include a requirement to choose between hospice care and getting a lethal prescription is right on target.
Given the difference in cost between hospice care and assisted suicide, it requires a leap of faith we are not willing to make to suppose that people will not be steered towards “choosing” the latter. The obstacles to getting hospice care will increase, and there will be fewer obstacles to getting a lethal prescription.