Matters of life & death - Having to think about the unthinkable

Most people don't like to plan for dying, but in our state of denial, we leave ourselves vulnerable to conditions we would never want. Arrangements for the end of life are essential.

by Steve Lopez

December 14, 2011

"I could show you case after case," said Dr. Neil S. Wenger. "I could bet you million-to-1 odds these patients would not want to be in this situation."

He was talking about patients in critical condition who are "attached to machines, being kept alive" in hospitals, many of them suffering.

A common reason for that, said Wenger, director of UCLA's Health System Ethics Center, is that fewer than one-third of us make our healthcare wishes known in advance of critical illness or injury. So if we end up comatose after an accident, or with severe memory loss in old age, we're kept alive, regardless of the cost and regardless of what our wishes might be or how grim the prognosis.

It's understandable. Nobody wants to think in advance about life ending. In our satisfied state of denial, we want to believe medical advances will keep us healthy until we die in our sleep at a ripe old age. But death doesn't always come on our terms, and failing to face up to other possibilities can put crushing burdens on loved ones — not to mention that soaring end-of-life medical costs are at the center of the national budget crisis.

"We use healthcare resources far out of proportion to any other country on the planet," said Wenger, who researches elder care for the Rand Corp. "We need to have a conversation about where society wants to put its resources [and we] might decide there are certain kinds of life extension that are not as important to us as educating kids and having adequate infrastructure."

Of course, none of us individually can solve all of these societal issues. But there are things we can do to make our own situations better at the end of life. It's never easy to think about your own demise, or the demise of those you love, or to start uncomfortable but necessary conversations about death. But since my father's health began to deteriorate this summer, I've talked to many medical people who say we need to get over our fears. Today, I'm passing along their advice. Consider it your guide to the final frontier.

One of the first decisions to make — in advance of any crisis — is whom you want making healthcare decisions if you're unable to do so on your own because of illness or injury. And that has to be done in writing.

Judy Citko, executive director of the Coalition for Compassionate Care of California, advises completing what's known as an Advance Healthcare Directive. An easy way to learn more about this is to visit her nonprofit agency's website, http://www.coalitionccc.org, which is loaded with good information on planning. And no matter what state you live in, you can get an Advance Healthcare Directive by going to Caring Connections at http://www.caringinfo.org.

The California form, which doubles as a living will, is free and can be printed from the website. On it, you can authorize a loved one or someone else to have power of attorney — or serve as your agent — to make healthcare decisions for you if you're unable. You can indicate whether you want your life "to be prolonged as long as possible" or, alternatively, that you don't want your life "to be prolonged if the likely risks and burdens of treatment would outweigh the expected benefits."

The directive is valid if signed by a notary public or by two witnesses. Another directive, known as Five Wishes, can be purchased online, and an explanation of how it works and where to get one can be found on Citko's website.

She also recommends that people with advanced illnesses talk to their doctors about a form known as POLST, or Physician Orders for Life-Sustaining Treatment, in which patients can indicate whether they want resuscitation, feeding tubes, ventilators and other life-sustaining procedures. The form is usually bright pink to make it easier for emergency responders to locate.

Doctors tell me that a lot of patients say they've signed one form or another, but can't remember exactly what it was or where it is. So be sure to keep the person you've designated as your agent informed about your directives, make several copies and file one with healthcare providers. And make sure to include enough information. I've heard many complaints from patients and doctors that even though forms had been filled out, the patients' intentions are unclear.

Wenger says it's better to avoid listing medical procedures you do or don't want and instead list limitations and compromises you're not willing to endure. A patient might say "no feeding tube" but then be in a situation in which a temporary feeding tube could help return him to relatively good health.

In the spaces provided on the directives, Wenger said, you might write, "I would not be willing to live in a state where I can't recognize the people who are important to me…or where I can't be independent" in managing personal hygiene.

Families should also do their homework on where they want to receive care, said Dr. Bruce Chernof of SCAN, a Long Beach foundation devoted to improving medical and human services for senior citizens.

"Families spend a lot of time thinking about choices when it comes to things like maternity decisions," said Chernof, and they should do the same for elder care, whether it's an outpatient service, a hospital or a nursing home.

Medicare patients can qualify for free in-home hospice care — which includes a wide range of palliative care and services — if they have chosen to forgo curative interventions and a doctor concludes they are likely to be in the last six months of life. Palliative care is also available to those with a serious illness who will continue to receive treatment either in a hospital setting or at home. And rather than think of these programs as death sentences, think of them as a way to get the most out of the rest of your life. Palliative and hospice care can be cheaper than traditional care, but patient satisfaction and even life expectancy are often higher than in traditional care.

If nursing homes are a consideration, you can find ratings at http://www.medicare.gov/nhcompare, and if you'd like to locate an elder-care attorney or find links to other information on aging, go to http://www.aging.ca.gov

None of this is pleasant business, for sure. But keep one thing in mind:

There's a better chance of avoiding taxes than that other thing.

http://www.latimes.com/la-me-lopez-howyoudie-20111212,0,7446994,print.column

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Supreme Court to weigh in on immigration battle

In agreeing to decide on Arizona's tough law on illegal immigrants, the justices join an intense election-year political debate.

by David G. Savage, Washington Bureau

December 12, 2011

Reporting from Washington

The Supreme Court will decide in coming months whether Arizona and other states can target illegal immigrants for arrest, setting the stage for an election-year ruling that will vault the justices into the contentious political debate over efforts to crack down on immigration violators.

The announcement means that the justices will rule next year on three highly partisan issues, including a challenge to President Obama's signature healthcare law and a voting rights case in Texas. Those rulings could play an election role not seen since a 1992 ruling to limit some abortion rights energized women's rights groups and helped propel Bill Clinton into the White House.

Leading Republican candidates for president, caught between appealing to their anti-immigrant base and possibly alienating the growing bloc of Latino voters, have ramped up their debate over whether to arrest and deport the estimated 11 million people who have entered the country illegally or overstayed their visas. The Obama administration, which has deported nearly 400,000 people this year, has contested stronger anti-immigration laws adopted in several Republican-led states.

Defining the limits of state and federal authority will be foremost in the immigration case, as well as in the dispute over the healthcare law. Lawyers for 26 Republican-led states want the healthcare law struck down entirely.

In another highly partisan dispute, the court on Friday agreed to rule on a Texas congressional remapping that figured to give Republicans four more seats in the House of Representatives. Obama's lawyers contend that the plan would deny fair representation to the state's growing Latino population.

The Arizona immigration case will likely decide the fate of stronger enforcement laws adopted in Alabama, Georgia, Indiana, South Carolina and Utah.

At issue is whether states may enforce the immigration laws on their own, or instead must closely follow the lead of the federal government.

The Constitution gave Congress the power to set a "uniform rule of naturalization," and this has been understood to mean the federal government decides who may enter or stay in the country. But the Supreme Court had not ruled broadly for decades on whether states may or may not enforce rules involving illegal immigrants.

In May, however, the court took a step in favor of the states in what may be a preview of the coming case. By a 5-3 vote, the justices upheld a separate Arizona law that denied business licenses to employers who repeatedly hired illegal workers.

The new case began in July 2010 when Obama's lawyers filed suit in Phoenix and argued Arizona had gone too far by enlisting its police to enforce the immigration laws. Under SB 1070, police are required to check the immigration status of people they lawfully stop and suspect of being in the country illegally. The law also makes illegal immigration a state crime.

U.S. District Judge Susan Bolton blocked much of the law from taking effect, and the U.S. 9th Circuit Court of Appeals upheld her decision.

Arizona Gov. Jan Brewer, a Republican who says the state has an "inherent police power" within its own borders, welcomed the court's intervention Monday. The case "is about every state grappling with the costs of illegal immigration," she said.

The court's announcement said Justice Elena Kagan had stepped aside in the case, creating the possibility of a 4-4 split. A tie vote would affirm the 9th Circuit Court's decision, giving a win to the Obama administration and a defeat to Arizona.

Since taking office, Obama's administration has adopted a targeted enforcement policy for illegal immigrants. It seeks to deport those who are convicted of crimes such as drug smuggling or repeatedly crossing the border, not those who are law-abiding. Last year, nearly 400,000 people were deported, a record.

On Monday, the U.S. Border Patrol in Tucson reported a sharp drop in arrests connected to border crossings. It said border apprehensions were down by 41%, to a "level not seen in 17 years."

Polls show Americans are about evenly split on whether they favor stronger enforcement or a "path to citizenship." Nearly half of Republicans and Democrats surveyed by the Pew Center last month said they favored a balanced approach.

The top contenders for the Republican presidential nomination were sharply divided in a debate Saturday when they were asked about the millions of illegal immigrants who live in the U.S.

Former House Speaker Newt Gingrich said longtime immigrants with families in the country should be allowed to stay. "I do not believe the people of the United States are going to send the police in to rip that kind of person out and ship them out of this country," he said.

Former Massachusetts Gov. Mitt Romney objected to this "form of amnesty." He said allowing them "to stay permanently … will create another magnet" drawing more illegal entrants.

The court's ruling will come just as Obama and his Republican challenger are battling for Latino support in closely divided states, among them Nevada, Colorado, New Mexico and Florida.

The president has remained relatively popular among Latinos, despite grumbling among immigrant rights groups about his aggressive deportation policies and his failure to push hard for comprehensive immigration reform.

Antonio Gonzalez, president of the Southwest Voter Registration Education Project, said Obama's initial decision to challenge the Arizona law was enough to ensure his standing among Latinos, regardless of the outcome in court.

"If he wins, he gets the credit, and if he loses, he doesn't get the blame," Gonzalez said.

For the Republican nominee, whoever it might be, the issue is more complex. For months, GOP presidential candidates have sought to appeal to the party's conservative base by stressing their support of tough enforcement of immigration laws.

But by the time the court rules, the nominee may face the political imperative of muting those appeals in order to compete with Obama for Latino support.

http://www.latimes.com/news/nationworld/nation/la-na-immigration-arizona-20111213,0,1039479,print.story

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From Google News

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"Secure Communities" Program Is Not, says New Haven Mayor

NEW HAVEN, Conn. - New Haven Mayor John DeStefano is taking aim at a federal immigration enforcement program he says would disrupt families and damage efforts to promote community policing if it comes to Connecticut.

The program, Secure Communities, has removed some violent, undocumented felons from the country, although opponents say the records show that most of the people detained and deported had no criminal records or only minor violations.

This week, in the heart of the New Haven Latino community, the mayor stated his views:

"This is calling on the state to not honor requests for detainers from the federal government unless the individual's on the FBI Terrorist Watch List, or has been convicted of a violent crime."

A spokesman for Gov. Dannel Malloy said the governor also has problems with the program, and that a federal task force report has cited grave concerns with the way it is being implemented.

Mike Lawlor, Malloy's criminal justice adviser, says the fact that the feds have postponed implementation in Connecticut may mean changes are on the way.

"The governor has asked the immigration officials to reconsider what they're contemplating, and to make sure that if they issue detainers, it's only going to be for the most serious criminals."

At the mayor's news conference, New Haven Police Lt. Luis Casanova, a patrol commander, said that if local police become immigration enforcers, local residents would lose trust in the police and be less likely to report crimes.

"Our department is interested in delivering and ensuring a safe environment, not to instill fear in the members of our community."

He said it's important that victims and witnesses feel they can come forward without fear of deportation.

Alderwoman Migdalia Castro, who represents many of New Haven's Latino residents, said New Haven has made strides in becoming a welcoming city for all, and thinks the program would be a setback.

"One day that you come and pick up individuals from the neighborhood, you divide families. You break up the moving engine that is contributing to this great city, to this great state."

http://www.publicnewsservice.org/index.php?/content/article/23803-1

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