Sarah Palin Photo by Greg Skidmore (CC by SA3.0)
Photo by Greg Skidmore (CC by SA3.0)

Give a dog a bad name and hang him

There is a great opinion piece, “The Retreat from Advanced Care Planning,” in the March 7, 2012 issue of JAMA. Mary Tinetti, a geriatrician at Yale School of Medicine and a MacArthur “genius” fellow, writes about what has happened to Advanced Care Planning (the process of  encouraging patients to communicate their values and preferences about the type of care they wish to receive at the end of life) since the infamous words, “death panels,” were posted on Sarah Palin’s Facebook account in August 2009:

“The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama’s “death panel” so his bureaucrats can decide, based on a subjective judgment of their “level of productivity in society,” whether they are worthy of health care. Such a system is downright evil.”

The idea that the Affordable Care Act would authorize death panels went viral.  The uproar ultimately led to the provision that authorized Medicare to reimburse physicians for the time they spend discussing end-of-life preferences with their patients being yanked from the Affordable Care Act. Such is the power of famous people in an age where remarks are taken at face value and attempts to set the record straight are dismissed as partisan or twisted for political gain.


The response was intimidating

Dr. Tinetti describes being accused by family members of two of her patients of being “part of a government-backed plan to save money by not offering expensive care to frail older patients” because she raised the issue of end-of-life preferences with them. She goes on to say, I was simply doing “what I have always done – ask what the patient’s goals of care were so that I could make care decisions congruent with those goals.” She said after these attacks, she was reluctant to raise the issues with her patients and she says she heard similar stories from her colleagues.

Doctors were not the only ones intimidated by the response to the death panel rhetoric. In the fall of 2010, language that would have included voluntary advanced care planning as a part of the new Medicare annual wellness visits was pulled by the administration, presumably because of media-fueled furor about the topic.  This despite evidence that advanced care planning is, at its core, exactly what we all say we want – patient-centered care.


The provisions were about something else altogether

Now, it doesn’t seem to bother the propagators of the “death panels” myth, that the provisions in the ACA and annual visit regulations related to advanced care planning were focused on authorizing payment for physicians providing this type of counseling. Per Dr. Tinetti, “over the past year, CMS has published several additional rules and regulations including new payment rules and the Hospital Conditions of Participation. …None of these rules or regulations included mention of voluntary advanced care planning.”

She goes on to say “To repair the harm done by the discussion of death panels and by the administration’s apparent retreat on this issue, this important patient need must be depoliticized.” [emphasis added].  She closes by stating, “CMS should assess physicians on how well they perform one of medical care’s most important activities, and physicians should be reimbursed for doing it right.”

An end-of life experience that reflects the dying person’s wishes is not a Republican nor a Democratic campaign issue. Rather, it is one of the most important decisions any of us will ever make. We need to get the politicians out of our exam rooms so that we can do what is right for our patients.


  1. The politicians are in the exam room to stay, I’m afraid, so as physicians you need to accommodate them.

    If doctors know their patients well enough to have these conversations, they know them well enough to know whether believe this right-wing nonsense, since those people rarely keep quiet. As Dave Barry says: “People who want to tell you their religious views rarely want to hear yours.”

    So the “solution” is, have these discussions with everyone except patients who are “severely conservative,” and as for the latter, just give ’em what they think they want.

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