For Memorial Hospital intensive care specialist Dr. Richard Pesce, the correlation of end-of-life counseling with the notorious "death panels" is disheartening.

Dr. Pesce said he regularly encounters family members facing wrenching uncertainties about what treatments their loved ones in the intensive care unit would want.

"More often than not," the patient's end-of-life wishes have never been discussed, he said. "That's why these (planning) conversations with the doctors are so important, before people have gotten into that situation."

The health care bill now in the U.S. House of Representatives states Medicare will reimburse doctors for end-of-life counseling sessions with patients who seek that service. The bill states the discussions would be voluntary, but experts said falsehoods persist that the sessions would be mandatory and would allow government to play a role in the decisions.

Untrue but widely disseminated comments by former Alaska Gov. Sarah Palin and others have helped spread fear and misinformation, said Brooks Jackson, director of

"It would be astonishing if there wasn't debate (over an issue as big as health care reform) ... but it's come unhinged from reality in many cases," Mr. Jackson said.

Dr. Pesce said an end-of-life counseling session can result in a living will, or advance directive. Patients may direct a range of options, from ensuring they get all possible treatments at the end of life to sparing them from unwanted, aggressive measures.

For instance, some seriously ill patients who are not expected to recover might prefer a "do not resuscitate" protocol, meaning they would not receive CPR if their heart or breathing stopped, he said. They would still receive any other desired treatments.

Under the Medicare Prescription Drug, Improvement and Modernization Act of 2003, Medicare already covers end-of-life counseling for terminally ill patients. The provision in Sec. 1233 of the House bill extends that reimbursement to cover Medicare enrollees earlier.


Joe Wilser, a retired pastor who lives in Chattanooga, said he has a living will that clearly explains what kind of end-of-life care he would like to receive.

However, he believes provisions in the House bill could lead to the government denying care for the elderly.

"I don't think (end-of-life planning) should be forced by the federal government on everybody," he said. "It's going to lead to euthanasia just the way it is in Holland and other countries that have socialized medicine."

In 2001, Holland became the first nation to legalize voluntary euthanasia, according to the BBC.

Mr. Wilser is not alone in his fears. An NBC News poll found that 45 percent of Americans polled think it's likely the government will decide when to stop care for the elderly.

In July, House Republican Leader John Boehner, R-Ohio, said in a news release that the end-of-life counseling provision could result in seniors feeling pressured to sign advance directives they would not otherwise sign.

"This provision may start us down a treacherous path toward government-encouraged euthanasia if enacted into law," the statement said.

But Sen. Bob Corker, R-Tenn., said in a meeting with Times Free Press reporters and editors last month that some concerns about the end-of life provisions and rationing in the House health care bill are "overplayed."

He added that the House legislation had "clumsy language" that unnecessarily stirred up fears. The bill could have suggested that such counseling occur at middle age, to avoid perceptions that it is important only for the elderly, he said.

U.S. Sen. Lamar Alexander, R-Tenn., said any government involvement in end-of-life decisions, even reimbursing counseling sessions between patients and physicians, could be dangerous. He said the decisions should rest with doctors and patients.

"I think there's a danger in writing these provisions into the law," Sen. Alexander said.


Other fears about government intrusion into treatment decisions appears to come from a section in the House bill that establishes a comparative effectiveness research center, said Mr. Jackson of

The center would be set up in the Agency for Healthcare Research and Quality to study the effectiveness of medical services and procedures.

He noted that former President George W. Bush for years had a panel established by administrative order to do just that sort of evaluation.

"Most anybody would agree that's valuable information," Mr. Jackson said. "It's another thing entirely to have panels of government bureaucrats who take that information and try to apply it patient by patient and try to decide ... to give this dying patient some treatment or not."

The House bill does not give that kind of power to the government, Mr. Jackson said.

On page 524, the bill states that "nothing in this section shall be construed to permit the Commission or the Center to mandate coverage, reimbursement, or other policies for any public or private payer.''

Dr. Pesce said part of the furor may be blamed on many Americans' idea that modern medicine can fix anything and that death is unnatural.

The topic of death is "the last taboo," he said.

"We're probably responsible for this, the medical profession, and holding out better and better outcomes and (the insistence that) we can always do better," he said. "We can't always do better."

John Kiker, a construction company owner in Dalton, Ga., said he worries that health care reform proposals will undermine the private insurance industry. He's not worried about the end-of-life provisions, however.

"I know I've got my will made out and if I get so far along, I don't want to be put on tubes or life support," he said. "I think a lot of people feel that way and I don't think (end-of-life counseling will) be a bad thing at all."


The House health care reform bill would require Medicare to reimburse physicians for voluntary end-of-life planning sessions with patients. From HR 3200, page 425:

"The term 'advance care planning consultation' means a consultation between the individual and a practitioner ... (if) the individual involved has not had such a consultation within the last 5 years. Such consultation shall include the following:

(A) An explanation by the practitioner of advance care planning, including key questions and considerations, important steps, and suggested people to talk to.

(B) An explanation by the practitioner of advance directives, including living wills and durable powers of attorney, and their uses.

(C) An explanation by the practitioner of the role and responsibilities of a health care proxy.

(D) The provision by the practitioner of a list of national and State-specific resources to assist consumers and their families with advance care planning.

(E) An explanation by the practitioner of the continuum of end-of-life services and supports available, including palliative care and hospice, and benefits for such services and supports that are available under this title.

(F)(i) Subject to clause (ii), an explanation of orders regarding life sustaining treatment or similar orders."