Saturday, December 19, 2009

Coming to Terms With It - Or Maybe Not

In February my employer of sixteen years – the CIGNA insurance company – eliminated my position. This event was hardly a surprise. Sixteen years is a good run at a place like CIGNA. As an executive told me shortly after I was hired, "Well, Bill, you've got the job. Now let's see if you can hold on to it." And so, as I joke to friends, I spent the next sixteen years playing Beat the Reaper, and doing a little work on the side.

So it wasn't a surprise when my number came up and I found myself tossed into that great metaphorical sausage machine called severance. Still it was a shock. I found that I wasn't angry, and I wasn't sad. Occasionally I had twinges of anxiety about the future. But mainly I was just at loose ends. Work had been the main thing in my life (large corporations demand this), and now there was a void on center.

Because I'd been at CIGNA for quite a while, I got a nice severance package – pay continuation for several months, subsidized medical coverage, even a seat at an outplacement agency, where I met people who were angry, sad, and sometimes just in a state of disbelief.

Gradually I began to come to terms with the tectonic shift in my existence, and I even began to discern the outlines of a new life. A rather pleasant life, actually. My retirement savings will be substantially short of plan, and my wife and I are definitely not buying a house in the south of France, but she still has her job. Is it possible that the Great Recession doesn't look like the Great Depression because of the two-income family? After all, lose one job, you still have one left. Just don't lose the second one.

I do want to get a job. I like to work, and we could use the money. The outplacement agency gave us classes, and I enthusiastically threw myself into the job hunt, but gradually, as the weather got warmer this spring, it became clear that I wasn't going to get a job anytime soon. This recognition came slowly, and I had time to come to terms with it. I keep looking, and I think one day I may fall into something.

In the meantime, I've discovered that there's plenty of work in the world, as long as you don't ask to be paid. I started my volunteering back in the winter, working on Michael Turner's campaign for district attorney in Philadelphia. Michael lost in the May primary, but my volunteer career continued to flourish. I became a volunteer runner at Back on My Feet, a running and rehabilitation program for people who live in homeless shelters. Billy, one of our members, recently completed the Philadelphia Marathon. I tutor at Mighty Writers, an after-school program for young students in South Philly.

And, after an interesting internal evolution, I started working for healthcare reform. I was helped in this process by Wendell Potter, an old friend and former chief corporate spokesperson at CIGNA, who started speaking out on healthcare reform in the middle of the year.

It's not easy to say that you spent sixteen years working at something, and that the result was failure. But that was the conclusion I came to. It may be hard for outsiders to understand how strongly we were focused on trying to control costs in health care. Let's face it: We failed. Time for another approach. I came to terms with it.

Still, to paraphrase The Godfather, it was nothing personal; just business. As I said before, I wasn't angry. Then the letter came. Because of my age, when CIGNA eliminated my position it also effectively made me a retiree. So, after a few months on COBRA (COBRA is health insurance for fired people, and the COBRA subsidy was one of the smartest ideas in the stimulus package), I signed up for CIGNA's retiree medical program. It is the only connection that I still have with my former employer.

CIGNA subsidizes a retiree's coverage through a complicated formula. The price was higher than I expected, but much better than the prices on the open market. I came to terms with it.

Then I got the letter. As of January 1, CIGNA is increasing my premium by 48 percent. There's a very complicated explanation for why this is happening. I actually ran the calculation, and it all makes sense, as long as you're living inside that algorithm. I don't live there any more.

I think I'm less annoyed than astonished. And I don't think I'll be coming to terms with this any time soon.

Wednesday, November 4, 2009

Lafayette: We Were There

Lafayette Avenue is, to my mind, the best part of the New York City Marathon. Other parts are more spectacular – running across the Verrazano Narrows Bridge, with New York harbor and lower Manhattan on your left hand, and the vast expanse of the Atlantic Ocean on your right. Other parts are more quaint – Williamsburg, with its Hasidic Jews and young people, and Greenpoint, which seems to be Polish and again young people. Other parts are more manic – the noisy battle up First Avenue in Manhattan, where the leaders usually sort themselves out and the rest of us grind it out on concrete pavement to the Willis Avenue Bridge, all to truly intense spectator support. And other parts speak to my childhood – Fifth Avenue and the jaunt through Central Park. But for me, the best is Lafayette Avenue, near Fort Greene Park in Brooklyn. It's about eight miles into the race, so you're still fresh, and the wide open spaces of Fourth Avenue squeeze down to two lanes of runners, surrounded – cradled – by autumnal trees, brownstones, and many happy spectators. It's where I got to hug and high-five family and friends – people who helped me get where I was and then came out to support me. I had a great race from start to finish, but Lafayette was special. It felt like home.

Monday, October 5, 2009

Do Health Insurers Add Value?

“We need to really spank them.” There we were, in a conference room in a hotel in Philadelphia, a bunch of insurance company bureaucrats, listening as a well-paid consultant outlined our future. This was several years ago, when it became clear that managed care, after some initial success, was failing to control costs in the healthcare system.

The consultant’s “them” – the Other – was the patient. And the new tool – which we would use to spank patients – was called consumer-directed plans. The central idea behind this new tool was that individual consumers didn’t know how expensive health care really is. So we would show them by shifting a lot more of the cost onto their shoulders.

I had my doubts. Not about selling the plans to employers. After all, as the individual’s share of the cost went up, their share would go down. That’s not a tough sell in corporate America. My concerns centered on the unexamined assumption that improved knowledge of costs would alter a patient’s behavior. Would someone in the middle of a heart attack actually stop and shop for the cheapest emergency room? Or even want to go to the cheapest emergency room? Death trumps money, or something like that.

In medicine, we’re often dealing with forces far more powerful than a balance sheet.

I had been a fan of managed care. With its emphasis on wellness and preventive care, I thought there was a real chance to bend the cost curve down. And the messages were simple, the actions within an individual’s control: stop smoking, wear a seat belt, eat right (five servings of fruit and vegetables a day). Get a mammogram, and (gasp!) maybe get some exercise.

All these changes in behavior ran up against deep-seated habits: I didn’t think they would be easy. But I knew they worked.

The real flaws in managed care were less obvious to me at the time, but in hindsight they’re clear.

A Command Economy

First of all, the managed care system was effectively a command economy. This means that a few people at the top make all the decisions. The classic example is the old Soviet Union, with its bottlenecks at the top, where people made decisions slowly and often badly, at least partly because they didn’t have the right information.

In managed care, the insurance companies took on the command role, effectively telling doctors how to practice medicine, often in great detail. Of course this also meant that the range of options available to the patient was restricted.

This could be annoying, often in small ways. I remember years ago going to the doctor with an inflamed cyst on my neck. I wanted it lanced. I had had a similar cyst on my shoulder, years before, and lancing the cyst had worked fine. It did not occur to me when I went to the doctor that I would not get my wish. Instead, my physician, my healer, looked me in the eye and told me that lancing involved a surgeon, and surgeons involved money, and I was going to take aspirin and use warm compresses until the inflammation went away. Which I did. I’m still annoyed. If he’d offered me a range of options, and outcomes, and prices – in other words, a market economy – I think I would have been happier. I might even have taken his advice.

Capitation Completes Role Reversal

The managed care system reached its logical culmination with something called capitation. The insurance companies correctly saw that the fee-for-service system – in which the doctor is paid for each service performed – gave doctors a strong incentive to provide extra services. The command economy was supposed to eliminate this, but it didn’t. And so came the idea that the insurer would pay a set fee for each patient in the doctor’s care – capitation. (Caput means head in Latin, but the doctor actually got the whole body.)

By doing this, the insurers effectively shifted the risk to the doctors, all while continuing to tell them what they could or couldn’t do.

As a result, we had doctors trying to be risk managers, taking out reinsurance so they could stop their loss if a very sick patient threatened to cost more than the fixed rate the insurer was paying under capitation.

So the doctors were in the insurance business, and the insurers of course were effectively practicing medicine with their treatment mandates. It was a neat role reversal. Nobody was doing what they went to school to do. I mentioned this to one of the benefits gurus at work – a vice president. He smiled at me and said, “Bill, it’s not that simple.”

The Romance of Complication

It never is. I’ve often marveled at the love of complication that one sees in insurance companies. Executives habitually defend this complexity by saying they’re providing choice, but I think they just like it.

Years ago this impulse may have been manageable, but with the advent of computers the situation has gotten entirely out of hand. I remember I was at another meeting, this one also about the birth of consumer-directed plans. A very nice vice president from Connecticut was showing how we could empower consumers to build their own plans. In this model every possible option in a plan was placed on a grid, and the consumer was allowed to choose at every point. I believe the grid she was showing was 10 x 10, but this was only a simple example. She looked lovingly over her shoulder at the PowerPoint slide, then looked back at us and smiled. She loved her new toy.

So do these choices influence consumer behavior, or simply confuse the hell out of people? And let’s think about the poor people who work at the company, as call reps and claims processors. It’s not that hard these days to design a plan that’s impossible to administer.

The higher ranks of insurance companies are largely populated by accountants and actuaries. There are lawyers, of course, and even the occasional doctor, but mainly the people in the executive suites like to play numbers games. They think, they know – here’s that unexamined assumption again – that they can use price to influence behavior.

Economic Man and Behavioral Economics

Why are insurance executives so sure they can use price to drive behavior? Because they learned it in school, in economics class, where they met “economic man,” the rational actor who lies behind untold numbers of algorithms, always choosing the best product at the lowest price.

I do wish insurance companies employed more economists. Economic man is an older model. His rationality – his intense numeracy – has been significantly modified in recent decades by the rise of behavioral economics. The joke about the old economic man algorithms was, “That looks great in theory. I wonder how it works in practice.” Behavioral economics goes into the field and observes behavior, then attempts to explain it. It turns out that vendor relationships are “sticky.” In other words, people have loyalty. They may even have trust, say in their doctor. Price is not the only consideration. Who knew?

So playing with numbers only gets you so far. Human psychology – very messy, numbers people don’t like it – often gets in the way of rational decisions. Here’s the second shoe – I alluded to it before. It’s the structure of medical care. While people may shop for a good price when the situation is routine and when they can actually find out what the price is beforehand – I’m thinking of buying a new pair of eyeglasses – a visit to the doctor’s office may not be like that. You may go in complaining of shortness of breath, thinking it’s some kind of nasty cold, and the next thing you know you’re hooked up for an electrocardiogram. Did you remember to ask for the price sheet on that? Then, of course, there are the emergencies. You were crossing the street on a green light, and a driver busy writing a text message knocked you flat. You’re unconscious. How do you ask the ambulance driver for his price sheet?

We live in a world where information is often imperfect (something Hippocrates noted), and where the decision maker is occasionally unconscious. Take that, Economic Man.

Where to Now?

Insurers actually seem to perceive the failure of their efforts to use price to influence behavior. A sign of this is the new push – really, it’s all the rage – for wellness programs. You may remember that wellness was a big deal back in the days of managed care. Then, of course, the idea was that wellness would be managed by doctors and nurses sitting face-to-face with patients. Now we have four-color pamphlets and 24-hour help lines. Why? Because insurance companies don’t pay for doctors to chitchat with patients. They only pay for services rendered, and you’d better have the right ICD code on your claim. (ICD stands for International Classification of Diseases.)

It’s been an interesting several decades in healthcare – a long and winding road. I’d be tempted to feel sorry for the insurance companies if they didn’t have so much money. They’ve made a number of efforts to control costs in the system. They’ve basically failed. They have tried to fill roles better suited to physicians, and things haven’t gone very well there, either.

I haven’t even talked about the uninsured because, for the insurance industry, they are what economists call “externalities” – they simply lie outside the machine that makes the money.

If we look at the situation clearly, we have to ask ourselves, how are the health insurers adding value? Remember: Spanking doesn’t add value.

Monday, September 21, 2009

Hurray for the Distance Run!

What a wonderful race the Philadelphia Distance Run was this year! It was as close to a perfect half-marathon as I hope to see.

With the new wave start, I was able to run freely from the beginning. The course went right past the Liberty Bell and Independence Hall. The weather was nearly ideal­­ — I want to say high fifties and low sixties, light wind, low humidity, a big blue sky and a friendly sun. The food at the end was plentiful, varied, and good. The organizers even took the T-shirts to a new level.

Congratulations to everyone involved!

Don’t Get Sick in Florida

When my wife’s mother had a stroke in the spring of 2001, it launched our whole family on an odyssey that I hope we never have to repeat.

My wife and I and our two children were in Amsterdam on a family vacation when we got the call from her brother, Steven. Ada had had a stroke and was stable but paralyzed on her left side.

We flew home to Philadelphia, and our lives changed. Lois and Steven flew to Florida the next day, and for the next several months they shuttled back and forth, sitting at their mother’s bedside and attempting to manage the medical bureaucracy.

We learned things – things I would have preferred not to know. Both my parents had worked in medicine. They taught me at a young age that medicine has a curing function and a caring function. We found both to be in short supply in Florida.

Let’s take curing first.

Ada had gone to the doctor the day she had her stroke. She complained of numbness and an inability to move several of her left toes. Her doctor knew that she had had a previous stroke several years before, from which she had made a good recovery. He told her she had “nerve damage,” suggested she get a cane, and told her to make an appointment with a neurologist. So she went home and had the stroke.

That’s only the beginning. When Ada had her stroke, she fell and broke her left hip. The fracture was not diagnosed for two weeks.

Here’s the best construction I can put on this. It seems the initial fracture was a subtle hairline. It’s possible to miss such things.

After two days in the hospital, Ada was discharged to a rehabilitation center where she had physical therapy every day. The therapy involved her standing – in great pain – on her broken leg, which in the ordinary course of events would tend to make the fracture larger. Eventually a nurse, who I think had had enough, pointed to the way Ada’s leg was lying on the bed, and said that she had a fracture. The diagnosis was confirmed on X ray, and Ada got her hip pinned.

Now to the caring function. At the rehab center the nurses were, with a few exceptions, surly, uncommunicative, and unresponsive. The meds nurse – the one who dispensed medication – had apparently never heard of breakthrough pain. The nurse’s aides, again with a few exceptions, were surly, uncommunicative, and unresponsive. One of the exceptions, a lovely, caring woman, wound up taking a job in the county highway department because the pay was so much better.

Overall, though, the nurse’s aides were so unresponsive that my mother-in-law gave up trying to go to the bathroom. Even with my wife there, it took up to forty minutes to get an aide to answer a ring. Ada started wearing diapers. She wasn’t incontinent, but the staff made her act as if she were.

Eventually she was well enough to leave the rehab center, and we considered bringing her north. It hadn’t really been an option up to that point.

Ada still wasn’t in great shape, but she had lived in Florida for nearly 20 years, and she wanted to stay with her friends. We thought it might be okay.

She moved to an assisted living facility in Florida, and it was okay for a little bit. Then things started to go wrong. She developed acute pain in her left leg. Nobody (including an internist, an orthopedic surgeon, and a neurologist) knew what it was. An aide accused her of faking it. (There’s an ongoing theme that she was considered a “complainer.”) We added a geriatric case manager, and then we added a private-duty aide, a lovely, caring woman.

Finally Ada was readmitted to the hospital. The pain in her leg was caused by a blood clot – phlebitis, a condition which is life threatening.

The doctor at the hospital prescribed a blood thinner. Then Lois reminded her that Ada’s stroke had been caused by a bleeding blood vessel in the brain, and suggested that, in view of this patient’s history, a blood thinner might be contraindicated. Exit blood thinner.

The hospital also ran a chest X ray, and Ada had some huge tumors in her lungs. They hadn’t been seen on prior X rays – one taken when she had the stroke, and one a few months later.

We ordered up an air ambulance and moved her north, to a nursing home just outside Philadelphia, so she could be near her family at the end. A week later, and about seven months after her stroke, she was dead.

This ending was inevitable. What was not inevitable was the amount of suffering and humiliation she endured for seven months because of slipshod medical and nursing care.

People suggested that we sue for malpractice – and, of course, that brass ring of litigation, the award for pain and suffering. We were disinclined to do it because we didn’t think her pain was fungible – it couldn’t be converted to money. And I don’t believe that suing people causes them to improve their behavior – it simply causes them to improve their defenses.

I don’t have any answers. But I do know this. We need some.

Monday, September 14, 2009

What the Greeks Knew

Recently I was rereading the plays that Sophocles wrote about Oedipus and his family, and it struck me: This whole mess got started with a traffic dispute.

One day Oedipus was tooling down what passed for a highway in ancient Greece, and he found his way blocked by a man in a chariot who, with the help of his servants, tried to force Oedipus off the road. The charioteer may not have been entirely the pompous ass that we may think. After all, the road was probably a narrow one-lane dirt track, and it appears that Oedipus was on foot, so it would have been easy enough for him to stand aside, much as I do when I'm commuting to work and an 18-wheeler decides to change lanes.

This, however, was ancient Greece, where there were no rules of the road and, frankly, not a whole lot of common sense. So words came to blows, and Oedipus killed the charioteer (who, unbeknownst to him, was his biological father), as well as an indeterminate number of servants (Oedipus originally thinks he did them all, but apparently one escaped to tell the tale, in which Oedipus is not one man but a large band of robbers — yet another testimony to the untrustworthiness of eyewitnesses).

And so the whole sorry machine of multigenerational tragedy is set in motion, with Oedipus marrying his mother and putting his eyes out, and his two sons killing one another on the battlefield in front of Thebes in a dispute over who should be running things, and his daughter Antigone (who is also his sister) getting sentenced to death for trying to bury one of the brothers who lay dead on the battlefield.

And that's the short version. I'm very happy we have traffic lights and yield signs.

And yet anybody who drives knows that savagery of Greek proportions is never very far away from us. We are human, as they were, and we are given to fits of anger, irrational over-response (escalation, we called it, back during the Vietnam war), and masterful, ingenious self-justification.

Which brings me to the point of this little essay­­ — the issue of gun control. I have some opinions about the Second Amendment to the Constitution, which I'll get to in a minute, but I do think there's a deeper issue here — human nature, and what we humans need to do to live together in peace.

Do we really want everybody to be walking around with a loaded pistol? The argument is put out that an armed society is a polite society. I'd like to see the historical evidence for that. (The situation in Iraq might make a good counterexample.) There also seems to be an unexamined assumption that law-abiding citizens will use their guns appropriately, unlike the criminals who of course have limited impulse control, are highly suggestible, and are given to fits of irrational rage.

Come to think of it, how many American motorists have I just described? So maybe we shouldn't put the guns in our cars; maybe we should just keep them in the house, for home defense. And when, while celebrating Halloween, your wife screams in terror that a goblin is at the door menacing her, are you going to get your gun out of the closet? Okay. And when the goblin keeps gesticulating because he thinks he's going to a party at your house, when the party is actually at an identical house two doors down, what are you going to do? Maybe it would have been simpler to call 911.

The Supreme Court has ruled that there is an individual right to bear arms. Whatever the legal merits of this decision, it is clearly a travesty for those who care about language or history. Still, I don't feel like refighting that battle. What I'd rather do is look at the first part of the Second Amendment, which states, "A well-regulated militia, being necessary to the security of a Free State ..."

This part of the amendment tells us something important about the world in which the Framers lived. In colonial days — Massachusetts may be the purest example — every able-bodied man was automatically in the militia and could be called to active duty at any time. The French call it levĂ©e en masse, or the nation in arms. Over the last several centuries America has moved away from the concept of universal military service, most recently by abolishing the draft.

Without the draft, I suppose we are all in that great unorganized reserve that will surely rise up to fight any foreign invader, however ineffectively. If we don't believe some fiction like that, are we not ignoring the original intent of the Framers?

So let's look at the term "well-regulated." We may not call people to active duty, but do we not, under the Second Amendment, still have a duty to train people in the use of firearms — and the consequences of their use?

As part of that training, I think people should be required to go to a big-city emergency room on a Saturday night. Just about any Saturday night will do. Stay until the bars close, and watch the gunshot victims get wheeled in — including the "unresponsive patients," aka the dead. People need to know in vivid terms what pulling a trigger is all about.

Thursday, September 3, 2009

Politics in the Rain

I wrote this back in the spring, shortly after the primary elections in Philadelphia.

On the morning of Sunday, May 3, I was standing on the Marine Parade Ground in Philadelphia’s old Navy Yard. It was raining.

I was handing out political flyers for Michael Turner, who was running for District Attorney. The recipients were among the 23,000 runners who had just completed the Broad Street Run, a ten-miler that starts in the northern part of the city, at Central High School, and runs pretty much in a straight, flat line south on Broad Street, scooting around City Hall about halfway, and finishing in the Navy Yard.

It’s a great race. I’ve run it a bunch of times, and it’s always been a thrill.

After about an hour, I was quite thoroughly wet, and I started to wonder why I was there. I could be at home, dry, eating a nice breakfast cooked by my wife (she likes to do that on weekends), and reading the Sunday paper. I didn’t stay with that thought very long, because right underneath it was what I really wanted to be doing. I wanted to be running the race.

Every time I talked to a runner, this feeling got stronger. I’d approach them as they were crossing the parade ground to go back to their cars, or the subway. They’d already had the chance to eat a little something and recover a bit, but they were still in that marvelous afterglow that lasts until the leg muscles start to stiffen. I’d congratulate them on their run, and be rewarded with the most beatific smiles. Then I’d talk to them a bit about Michael. They didn’t mind the switch. Quite a few of them thanked me for coming out and offering the information. And then they’d be off, some of them already starting to limp, and I’d be on to the next runner.

Afterwards I took the subway to my home stop at Broad and South, and as I came up from the rabbit hole I found myself looking at the Arts Bank. It’s a small, very nice performance space in an old bank building. And I remembered the Russians. A few years ago I had been in almost the same spot when a young man handed me a flyer. It was for a performance later that day at the Arts Bank by a troupe of Russian circus artists.

My wife and daughter and I weren’t doing anything else, so we went. The Russians were quite good, and we were a large part of the audience. As I recall, there were more performers than spectators.

Sometimes flyers aren’t enough. On Tuesday, May 19, they weren’t enough. Not only did Michael Turner lose, but the election came close to setting a new record for low turnout in Philadelphia.

Think of it. There are 1.1 million registered voters in Philadelphia. Nearly 900,000 of them are Democrats. The winner in the Democratic primary attracted a little more than 40,000 votes. (There is a general election in November, but it is widely considered to be a formality.)

This is not my idea of majority rule.

My wife and I volunteered on the Obama campaign. We registered voters, made phone calls, handed out flyers, made buttons. And we put up campaign workers in our home. One of them, whom I came to call The Mighty Quinn (not his real name), showed up after the primary, but months before the general election. I have never seen anybody, including my daughter, use a cell phone more.

I had no idea what he was doing, but my wife employed the expedient of conversation and soon knew what was going on. As she put it, “They’re identifying every vote in Pennsylvania, and then figuring out how to get it.”

The Obama campaign has come to be known for its novelties – the use of the Internet for fund raising, the enormous crowds that appeared, seemingly at the drop of a hat. But the real secret was they did it all – from mass communication on TV through one-on-one community organizing. And they were very methodical.

I have two thoughts about all this. First, the Obama people are a lot smarter and tougher than I realized during the presidential campaign. Second, the rest of us have a lot of catching up to do.

Saturday, August 22, 2009

End of Life Counseling

My brother has a 1966 Land Rover. It’s 43 years old. Not bad for a car, or I should say truck. His wife used to commute in it between Manhattan and New Jersey, but now he keeps it at his place in upstate New York. Over the years he and Scott, who runs a garage in the nearest town, have developed a hobby of keeping the Rover running. As I recall, this once involved replacing all four brakes – only one was functioning. Carburetors and things like that have come and gone. The speedometer didn’t work for about a decade, so the mileage is a bit understated. Recently Scott replaced the rear springs and shock absorbers and welded a new rear quarter frame in place because the old one had rusted out.

I hasten to add that my brother only drives the Rover to the dump, or transfer station as it’s now called, at a pace that would please a Victorian dowager. Cars that are 43 years old do have their limitations. Oh, and he also uses the Rover to drive around in the fields and pick up stones for the stone walls that he likes to build.

The lesson that I draw here is that it is possible to keep some vehicles on the road virtually indefinitely.

What does this story have to do with end-of-life counseling? Simply this: People are not automobiles. We grow old, and at some point we get sick, or perhaps we simply wear out, and we die.

Many, many people have a hard time accepting this simple fact of life. After all, isn’t there a pill for everything, or possibly an operation, perhaps a transplant?

Well, frankly, no. The lack of realism that surrounds the end of life in this country sometimes astounds me.

But then I have an unusual background. I come from a medical family. My father was a doctor – a surgeon – and my mother was a nurse until they got married. His hello line was, “Have you seen Snow White?” And their first date was Walt Disney’s Snow White, at Radio City Music Hall.

During his sixties, my father contracted hepatitis from a needle stick while performing a surgery. The hepatitis severely damaged his liver, which (I’ll spare you the details) led to something called esophageal varices. Occasionally the blood vessels in his esophagus would burst, and he would vomit blood. On his last admission, he warned my mother to insist that the ambulance bring whole blood, because he knew he would not survive the trip to the hospital without it.

There was an operation, called a portal-caval shunt, that my father opposed because the outcomes were often extremely poor. However, faced with the option of death, he agreed to the procedure. I have often thought that he did this for us, and not for himself.

The surgery was successful, and my father was a vegetable with non-functioning kidneys. He went through several rounds of dialysis, in the hope that his kidneys would restart. Didn’t happen. And so, one evening, in a rather scruffy lounge at St. Luke’s Hospital, daddy’s doctor, whom we had all known for many years, sat down with my mother, my brother, and me, and suggested it was time to make my father comfortable and let nature take its course. We agreed.

Years later my mother, having fought breast cancer to a standstill, having fought leukemia to a standoff, came down with cancer of the pancreas. She wanted to stay up in the country, which was where she had been born and grown up. We discussed bringing her to the city and pursuing aggressive therapy. She didn’t want it. She was done. She knew it. She could feel it in her body. She died in the country. Most of the time she was at home, but she spent the last few weeks in hospice. I was sitting next to her when she took her last breath.

One of the great benefits of facing facts is that you may get an opportunity to say goodbye. We had that with my mother. With my father we did not. I recall, as he was heading in for surgery, saying that we’d talk again soon. He looked at me with a look that I did not understand at the time, and replied that he certainly hoped so. That was the last time we talked.

I cannot begin to tell you how important I think end-of-life counseling is. I’m to an age where it’s not just the older generation that’s dying – it’s my generation. And still I see the mind-set. Fix me, Doc. Roll me into the shop and bolt on a new carburetor. Well, maybe. But maybe, in your case, it’s not possible. Or maybe the treatment would inflict agony out of all proportion to the few days of life to be gained.

I do believe this conversation should be between the doctor and the patient, or the patient’s family. But it should take place.