Sen. Warner calls for discussion of end-of-life treatment

WASHINGTON

Two months into his term, U.S. Sen. Mark Warner has marched into the policy thicket that is health-care reform, urging a national discussion on the touchy question of how best to treat terminally ill people.

In a speech to hospital executives this week, Warner called for intensified efforts to educate individuals and families in advance about end-of-life care. With better information, many people would forgo expensive and almost-always-futile treatment for patients near death, he said.

Such measures account for more than one-fourth of Medicare payments and 10 to 12 percent of all health costs, studies suggest.

"We leave it to families to resolve these extraordinarily difficult decisions with little guidance," Warner said. "Other industrialized nations have dealt with the end-of-life issue. It's time we did as well."

Warner also backed a wide range of more conventional health-care reforms, including some that are part - at least in concept - of President Barack Obama's evolving health-care initiative.

The Obama plan was the subject of a White House forum Thursday. Warner did not attend - most invitations went to more senior lawmakers - but the former Virginia governor said he hopes to be part of the health-reform debate Obama has demanded that Congress undertake this year.

Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania, said Warner's remarks put the freshman lawmaker at "a very volatile intersection" in the health-care debate.

Caplan praised Warner for tackling a subject most political leaders try to avoid. When politicians talk about curtailing care in the context of controlling medical costs, he said, many Americans worry that "they're just trying to get me to die faster."

Warner said how and when treatment should be limited or ended as a patient approaches death is "an issue that makes us all uncomfortable." He stressed that he is not advocating a system that denies care to patients and families that want it.

Instead, he said, he wants lawyers, doctors, medical ethicists and religious leaders to collaborate on reforms that would ensure patients have thought through decisions about when and how long to pursue extraordinary treatments.

Warner's "point is well-taken. These things ought to be planned," said Laurens Sartoris, president of the Virginia Hospital & Healthcare Association.

But the line between futile end-of-life treatments and care that can significantly extend life often is hard to discern, he said. Patients and doctors alike are understandably wary of deciding too soon to curtail treatment.

Patients and families also are often influenced by cultural factors, he added. Rural residents are more likely to expect to die at home, while those who live in urban areas routinely expect to go to a hospital and receive aggressive care to the end.

Warner, 54, acknowledged that personal experience has helped shape his thinking on the issue. His mother, who now requires hospice care, has had a long and difficult struggle with Alzheimer's disease.

Caplan predicted it will take more than voluntary efforts by the medical, legal and religious communities to get most Americans to make better decisions about end-of-life care.

Most states now have provisions for living wills, and it's routine for doctors to encourage patients and families to provide detailed directives for terminal care, Caplan said. But relatively few people agree to limit life-prolonging treatments, and many change their minds when a hopeless illness or injury occurs.

When a loved one is dying, "family and friends want to feel like they did every-thing" and the health-care system encourages them to pursue every available treatment, Caplan said. Such treatments often are very profitable for hospitals, and doctors fear they'll face malpractice lawsuits if they hold back, he added.

Steffie Woolhandler, a Harvard Medical School professor and co-founder of Physicians for a National Health Program, argued that there's no evidence the end-of-life planning Warner advocated would reduce health-care costs.

Everyone should plan for end-of-life care, she said, but the key to reducing costs is replacing the private insurance plans that pay for most U.S. health care with a government-run "single-payer" health system.

"There's a tremendous amount of waste" associated with private insurance, Woolhandler said, with companies overcharging by about 13 percent nationally.

Warner co-founded the Virginia Health Care Foundation in the mid-1990s to channel private funds to boost care for uninsured Virginians. He made clear Tuesday that he wants to retain private insurers while cutting costs.

"We must ensure affordable coverage choices for all Americans not just because it is morally right, but because it is essential to making the system work," he asserted.

Warner also said he wants substantial federal investments in computerized record-keeping for doctors and hospitals. Once better record s systems are in place, the medical community must develop national standards "on what works and what does not " in caring for patients, he said.

Doctors and hospitals who follow those standards should get at least some protection from malpractice suits, Warner argued.

"I'll get whacked" by some fellow Democrats for that suggestion, he predicted. "But if you're asking the health-care system to make these dramatic changes... you've got to have the incentives in place to drive that."

Warner said he understands that the public is focused on the $600 billion price tag that Obama has put on the health-reform effort included in the federal budget unveiled last week.

But with annual health-care costs expected to nearly double, to $4.3 trillion, over the next decade, "The direction in which we are headed is simply not sustainable - either for the public sector or for private industry," Warner said.

"Failing to act will still mean cuts in health-care spending."

Dale Eisman, (703) 913-9872, dale.eisman@pilotonline.com