By August 2009, Sarah Palin had found her way around the news media filter. Rather than speaking to the people by speaking to the press, Palin was speaking to the people by posting notes on Facebook.

And why not? It worked just as well. Reporters were so hungry for Palin news that they covered her every missive, no matter how banal or irrelevant to the public debate.

Many were pretty irrelevant. July 31, 2009: “Radio might be in former Alaska Governor Sarah Palin’s plans, but her attorney says a decision hasn’t been made. Robert Barnett disputes reports members of Palin’s team have been testing the waters to gauge syndicators’ interest.” Aug. 1: “There is no truth to the recent ‘story’ (and story is the correct term for this type of fiction) that the Palins are divorcing.” Aug. 5: “Reminder: This is the only official Facebook page for Sarah Palin.”

But on Aug. 7th, Palin said something of interest. Her post was innocuously titled, “Statement on Current Health Care Debate.” It was her first written comment on health-care reform in weeks, and not especially original. Palin was summarizing a speech from Representative Michele Bachmann, who was in turn summarizing an op-ed by Betsy McCaughey, a specialist in inflammatory and incorrect statements about the health-care system.

This game of telephone led to an arresting turn of phrase in Palin’s second paragraph: “death panels.” Eric Kleefeld, a reporter at Talking Points Memo, was the first to notice the comment, and his post about it set off a firestorm. On Aug. 12, Palin posted another Facebook note making clear that she was talking, at least in part, about a provision in the House health-care reform bill authorizing Medicare to reimburse physicians who consult with patients on end-of-life options.

Previously Uncontroversial

Democrats slammed Palin; Republicans rallied to her defense. But the previously uncontroversial provision, which had bipartisan origins — Newt Gingrich had been a loud advocate for end-of-life planning in Medicare, as had Georgia Senator Johnny Isakson — was quickly killed. So too was any hope that the debate over reform would lead to a serious discussion of end-of- life care. Almost overnight, Republicans endorsed Palin’s view of end-of-life planning as a nefarious plot, and Democrats concluded the issue was too troublesome to touch.

Let’s not mince words: This is insane. About one-third of U.S. health-care spending occurs in the last year of life. For most Americans, life ends sometime after age 65, so much of that spending is paid for by Medicare — which is to say, by taxpayers.

In a more rational political environment, we would go much further than the meek provision that Palin so expertly demagogued. Medicare beneficiaries should have to sit down with their doctors and sign a living will. That living will could say: “Do absolutely everything to prolong my life and help me live forever.” But if society is going to assume the responsibility for paying for such care, the least patients can do is clearly spell out how much care society should purchase on their behalf.

The point here isn’t simply, or even mainly, to save money. (And not because it’s somehow crass to talk about money while we talk about medicine.) Living wills don’t actually save that much money. A University of Michigan study found that Medicare beneficiaries with living wills that direct doctors to resist extraordinary measures received pretty much the same amount of emergency care as everyone else.

In part, this is because the last year of life appears much clearer in retrospect than it does at the time to families confronting a loved one’s terminal illness. As one ER doctor wrote, “I sometimes have a hard time telling when someone is in their last day of life, let alone last year.” During a sudden medical crisis, doctors and families have every incentive to err on the side of extra efforts to save a patient’s life; few of us would want it any other way.

A Subtle Role

Rather, what changed for patients with a living will was the treatment they received after the health emergency had happened. Even then, the differences were only evident in regions of the country that spent unusually large amounts on end-of-life care. But in those regions — Florida and New York lead the list — seniors with a living will were more likely to die outside the hospital than seniors without one. Which suggests the living will is playing a more subtle role than simply dictating the terms of emergency care.

“Advance directives were originally designed to allow patients to determine in advance what treatment they would receive in the event of their incapacity,” wrote Doug White and Robert Arnold in an editorial accompanying the Michigan study. “Instead, it may be that treatment-limiting advance directives work not by making the decisions but by giving surrogates and physicians psychological permission to cease life support at some point.”

And that leads to one of the crucial reasons that living wills should be standard: to ease the burden on families and medical professionals who are otherwise left trying to guess the wishes of a patient who is no longer capable of making decisions.

In an affecting essay, Ken Murray, an assistant professor of family medicine at the University of Southern California, described how, in his experience, the patients best able to make medical decisions for themselves — doctors — manage care at the end of their lives.

“Doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently…. They want to be sure, when the time comes, that no heroic measures will happen — that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR.”

What doctors know is that sooner or later, everyone who dies under the supervision of medical professionals comes face to face with a death panel. Eventually, life-or-death decisions need to be made. Without a living will, a panel — perhaps made up of family members, perhaps not — makes crucial decisions without the patient’s input. With one, the patient has a say. It’s long past time for Medicare to encourage patients to recognize that reality, and to plan for it, rather than leave it as an awful surprise for the very end.

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