Warning: Who's leading palliative care now?

Elizabeth Wickham
Ione Whitlock, Chief Research Associate
Elizabeth D. Wickham, PhD, Executive Director
September 24, 2007
Copyright © 2007
Reproduced with Permission
LifeTree, Inc.

Beware of medicine's newest craze: palliative care. The hype has only just begun. Within the past two weeks we have seen an article in AARP Magazine, and a column in the New York Times; and like old Doc Kilmer peddling his Swamp Root Remedy, palliative care's promoters are promising everything from no pain to longer life. But palliative care, if not properly understood, can be deadly.

The foremost concern is that palliative care will become yet another tool in right-to-die's imposed death toolkit.

What is palliative care?

Originally billed as "symptom management at the end of life," palliative care is now aggressively marketed as everything from pain relief for the public, to a cost-saving tool for hospitals, nursing homes and insurance companies.

Many pro-life advocates had hoped that palliative care would prove to be the ultimate antidote to the assisted suicide movement. The theory was sound: if patients are offered adequate pain and symptom relief, they will not request assisted suicide as a means to alleviate discomfort. Traditional palliative care - symptom relief when death is imminent - might have accomplished that mission.

However, over the past ten years, palliative care training and certification has been gradually co-opted by the very same right-to-die advocates that palliative care was meant to counter.

Palliative care's leadership

First there was the awful revelation that many leaders in palliative care were in favor of the removal of Terri Schiavo's feeding tube - an act of euthanasia. LifeTree has recorded some of their statements at http://www.lifetree.org/resources/antischiavo.html

Now, there is deep concern about trends at the Center to Advance Palliative Care (CAPC). The Center was founded in 1999 at Mount Sinai School of Medicine in New York City by Drs. Christine Cassel and Diane Meier. It is recognized as the nation's premier training center for development of palliative care programs in US hospitals. As a result of CAPC's program, the number of hospital-based palliative care programs has nearly doubled - increasing from 668 in 2000, to 1,240 in 2005. Through CAPC's Leadership Centers across the United States, over 3,100 health care professionals have been taught CAPC's methods and ethics.

Guidelines for active euthanasia

What few have discussed is the fact that the founders of CAPC have a long history as proponents of physician-assisted suicide.

In 1989 Christine Cassel (at present, president of the American Board of Internal Medicine) joined eleven other doctors to write a well-publicized and controversial endorsement of physician-assisted suicide.1 Three years later, in 1992, Cassel joined Diane Meier and Timothy Quill to write guidelines for physician-assisted suicide - an act as yet illegal in all states.2 This was one year after the New England Journal of Medicine published Timothy Quill's account of how he helped a patient, "Diane," kill herself.3

Enter major funding: A few short years after Meier-Cassel-Quill penned their guidelines for assisted suicide, Meier was encouraged by Robert Butler, MD - founder of gerontology at Mount Sinai, and friend of George Soros - to apply for funding from Soros's newly formed Project on Death in America (PDIA). Meier won the funding, along with colleagues Sean Morrison and Jane Morris, and with Society for the Right to Die board member Judith Ahronheim (now at St. Vincent's hospital in New York). In 1995, with help from Soros and the United Hospital Fund, Meier and colleagues launched the Hertzberg Palliative Care Institute at Mount Sinai School of Medicine.

New semantics, new funding

Cut to 1998: Cassel, Meier, Quill and Morrison write yet another article sympathetic to assisted-suicide, published in New England Journal of Medicine.4 However this time, much to the surprise and approval of many pro-life advocates, Meier wrote an op-ed carried in the following day's New York Times, announcing that she had had a "change of heart" regarding assisted suicide.

 "I now think that the risks of assisted suicide outweigh the benefits," Meier wrote, dodging entirely the moral issue of sanctity of human life. She continues:

"The push to legalize doctor-assisted suicide could not come at a worse time. Spiraling health costs and our aging population have led to radical changes in how care is financed, with doctors and hospitals rewarded for doing less for their patients. ... [L]egalizing assisted suicide would become a cheap and easy way to avoid the costly and time-intensive care needed by the terminally ill."5

Shortly after the "change of heart" op-ed, the Robert Wood Johnson Foundation (RWJF) awarded Meier and colleagues over $5 million to found the Center to Advance Palliative Care. Since then, Meier's group at Mount Sinai has garnered well over $20 million more from RWJF, Commonwealth Fund, Hartford Foundation, National Institutes of Health, and others. In 2005, the Kornfeld Foundation, whose mission is to protect "the right of the individual to choose the time and manner of his or her death, without undue interference by doctors, hospitals, courts, churches, families or society," awarded $3 million to Sean Morrison at the Palliative Care Institute. Last year RWJF promised another $5 million, and radical funder JEHT Foundation paid out $950,000 and has promised an additional $1.5 million.

Her change of heart notwithstanding, Meier has high praise for one of this nation's most notorious euthanizers. Just three years ago Timothy Quill published a book titled "Caring for Patients at the End of Life." Meier's praise is on the cover: "This book is fresh air for doctors who care for seriously ill patients."

These days, Meier and colleagues are busy selling the cost-saving benefits of palliative care. A 2007 presentation by Steven Pantilat, MD, indicates that palliative care can lower a hospital's inpatient costs by as much as $929 per day.6 The Center offers toolkits and coaching on guidelines, policies, procedures, and protocols.7 CAPC offers suggested guidelines for non-oral hydration and feeding in advanced dementia, making the blanket statement that "non-oral feeding/hydration is considered a medical treatment, not 'ordinary care.'"

Meanwhile, CAPC is hawking palliative care to the public as excellent "pain control." At http://www.getpalliativecare.org/, CAPC's website for the public, a blurb reads "'I feel as though I have my life back. I am seeing friends, going to the theater, movies and just having a good time.' - M.B.F., patient" The Center's diagram titled "a New Vision of Palliative Care" clearly illustrates replacement of "curative or restorative" therapy, with that of non-curative palliative care, leading to death. Nevertheless, Meier cautions that to sell palliative care, the hospital must "decouple palliative care from end of life care." She suggests changing the terminology: "call it non-hospice palliative care."

Call it what they will, palliative care means "masking symptoms," and usually results in "letting nature take its course." There are occasions when that course is appropriate, but if improved doctor-patient communication is what is called for, let's not play word games.

On the flip side - some good resources

In the present letter, we have concentrated on who is leading this modern-day palliative care movement, and why we fear the fox has been put in charge of the henhouse. In future letters we will address in greater detail the ethical and political aspects of palliative care as it is currently promoted. Meanwhile, for those who are trying to find their way through the maze of health care and "end of life" issues, we recommend:


"The evaluation of probabilities, founded on waning hopes for recovery when the vegetative state is prolonged beyond a year, cannot ethically justify the cessation of interruption of minimal care for the patient, including nutrition and hydration. Death by starvation or dehydration is, in fact, the only possible outcome as a result of their withdrawal. In this sense it ends up becoming, if done knowingly and willingly, true and proper euthanasia by omission."-Address of John Paul II to the Participants in the International Congress on "Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas," Saturday, 20 March 2004.


Endnotes

1 Sidney H. Wanzer, Daniel D. Federman, S. James Adelstein, Christine K. Cassel, Edward H. Cassem, Ronald E. Cranford, Edward Hook, Bernard Lo, Charles G. Moertel, Peter Safar et al., "The Physician's Responsibility toward Hopelessly Ill Patients. A Second Look," New England Journal of Medicine 32:13 (1989). [Back]

2

2 Timothy E. Quill, Christine K. Cassel and Diane E. Meier, "Care of the Hopelessly Ill. Proposed Clinical Criteria for Physician-Assisted Suicide, New England Journal of Medicine 327:19 (1992). [Back]

3 Timothy E. Quill, "Death and Dignity. A Case of Individualized Decision Making, New England Journal of Medicine 324:10 (1991). [Back]

4 Diane E. Meier, Carol-Ann Emmons, Sylvan Wallenstein, Timothy Quill, R. Sean Morrison and Christine K. Cassel, "A National Survey of Physician-Assisted Suicide and Euthanasia in the United States," New England Journal of Medicine 338:17 (1998). [Back]

5 Diane E. Meier, "A Change of Heart on Assisted Suicide," New York Times, April 24, 1998; Op-Ed. [Back]

6 Steven Pantilat, MD. "Calculating Financial Outcomes for Hospital Palliative Care." March 14, 2007. PowerPoint presentation; last accessed 9/24/07. Dr. Pantilat is director of the Palliative Care Leadership Center at the University of California-San Francisco, a leadership center directed by CAPC. See also "Tools to Conduct Financial Analyses". [Back]

7 Center to Advance Palliative Care, "Guidelines, Policies, Procedures and Protocols," (access after free registration). In particular, see "Non-oral Hydration and Feeding in Advanced Dementia or at the End of Life" [Back]

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