Hospice Is Becoming a Chain Business - Forbes

 

Large multi-agency, multi-state hospices are fast become the primary source of end-of-life care in the U.S.

According to a new study, chains cared for nearly half of all hospice patients in 2011, a dramatic increase from a decade before when small organizations (mostly non-profits) provided three-quarters of all care. And my own review of their financial reports suggests the biggest chains have grown even more since 2011.

The paper, authored by David Stevenson of Vanderbilt University and Jesse Dalton, David Grabowksi, and Haiden Huskamp of Harvard Medical School, was published in the January issue of Health Affairs (firewall). The authors did not look at the relative quality of care at any of these facilities. Nor did they calculate how long patients remained in hospice care at the chains. But they shed valuable light on how the business of end-of-life care is changing.

Hospice care is overwhelmingly funded by Medicare. And payment rates are generous enough that for-profits have long made inroads into this care model. The new study shows that, like many in the medical care industry, hospices are scrambling to consolidate so they can benefit from the economies of scale and marketing advantages of being big. Publicly-traded companies are responding to investor demands for increasing revenues.

Small non-profits still served more patients than for-profit chains in 2011, but Stevenson and colleagues found their share has been shrinking rapidly. In 2000, they cared for about 53 percent of enrollees. By 2011, they were caring for only about 37 percent. Over the same period, the for-profit chains’ share of enrollees grew from about one-quarter to nearly half. Non-profit chains accounted for roughly another 10 percent.

in 2000, a typical for-profit chain operated 5.6 agencies with 2,300 enrollees. By 2011, those firms owned an average of seven agencies with an average roster of 2,700 Medicare patients, according to the study.  By contrast, a typical mom-and-pop for-profit cared for only one-tenth as many people–about 220.

In some cases, corporate hospices are not just growing, they are getting huge. The paper reports that in 2011, the five largest for-profit chains owned 283 agencies with 190,000 patients. But the biggest players have grown even more since.

Hospice Is Becoming a Chain Business - Forbes

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Assisted suicide debate in United Kingdom: House of Lords on death with dignity.

In spite of their soul-destroying socialism, the Brits engage in a civil, constructive debate over an emotionally charged subject. So that’s how it’s done…

Last month, a spellbinding 10-hour debate to legalize physician-assisted dying took place in Britain’s House of Lords. Since Americans are unfamiliar with this legislative body, it bears mention that most peers in the upper house of Parliament have been appointed for life for their experience in public service or for their outstanding level of achievement in a given field. Accordingly, many of the bills introduced are not shackled by political constraints, as is the case in the U.S. Congress, but instead address urgent social issues that warrant and receive thoughtful consideration.

Assisted suicide debate in United Kingdom: House of Lords on death with dignity.

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Our unrealistic views of death, through a doctor’s eyes - The Washington Post

 

Doing something often feels better than doing nothing. Inaction feeds the sense of guilt-ridden ineptness family members already feel as they ask themselves, “Why can’t I do more for this person I love so much?”

Opting to try all forms of medical treatment and procedures to assuage this guilt is also emotional life insurance: When their loved one does die, family members can tell themselves, “We did everything we could for Mom.” In my experience, this is a stronger inclination than the equally valid (and perhaps more honest) admission that “we sure put Dad through the wringer those last few months.”

At a certain stage of life, aggressive medical treatment can become sanctioned torture. When a case such as this comes along, nurses, physicians and therapists sometimes feel conflicted and immoral. We’ve committed ourselves to relieving suffering, not causing it. A retired nurse once wrote to me: “I am so glad I don’t have to hurt old people any more.”

Our unrealistic views of death, through a doctor’s eyes - The Washington Post

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The gift of hospice - Pittsburgh Post-Gazette

An op-ed I wrote about the difficulty of navigating the hospice benefit in these days of increased scrutiny…

There are those who continue to pose the question: If hospice is meant to be end-of-life care, why do some patients get “discharged?”

The answer is two-fold. One reason is ever-changing patients and illnesses.

A growing percentage of hospice patients have illnesses with outcomes that are hard to predict. In the past, cancer was the dominant hospice diagnosis. Now, the portion of hospice patients with cancer — one of the more-predictable diseases — has declined. Today, non-cancer diagnoses (such as dementia or heart disease) account for more than 63 percent of hospice admissions, according to the National Hospice and Palliative Care Organization.

The other reason for discharge is simply that reputable hospice organizations are paying close attention to the new rules. Most hospices are more careful than ever about the patients they admit and the patients they keep in their care.

The gift of hospice - Pittsburgh Post-Gazette

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Bounced From Hospice - NYTimes.com

Good piece about the dilemma faced by all hospices – is this patient going to die within 6 months?

One can sympathize with hospice organizations caught in this squeeze. Determining which patients will likely die within six months has always been difficult, especially with conditions like heart disease or dementia, whose trajectories can be unpredictable. To avoid being penalized if they guess wrong, hospices are taking no chances.

At least, that’s true of hospices operating according to the regulations and honoring the movement’s historic mission. The Post attributed much of the jump in discharges to the way for-profit hospices have come to dominate the field, enrolling ineligible seniors for long stays to bolster corporate bottom lines, then dumping them to evade Medicare sanctions. (The Times has also reported on growing hospice costs.) Whistleblowers and the Justice Department have sued several large national chains to stop these practices.

But I worry about families who have agonized about the decision and finally called for help, then feel betrayed when hospice withdraws, even though their relatives can regain hospice care when they decline further. They shouldn’t get caught in this crossfire.

Bounced From Hospice - NYTimes.com

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Medicare rules create a booming business in hospice care for people who aren’t dying - The Washington Post

Long article about hospice, and the possible abuse of the system by for-profit hospices.

Hospice patients are expected to die: The treatment focuses on providing comfort to the terminally ill, not finding a cure. To enroll a patient, two doctors certify a life expectancy of six months or less.

But over the past decade, the number of “hospice survivors” in the United States has risen dramatically, in part because hospice companies earn more by recruiting patients who aren’t actually dying, a Washington Post investigation has found. Healthier patients are more profitable because they require fewer visits and stay enrolled longer.

The proportion of patients who were discharged alive from hospice care rose about 50 percent between 2002 and 2012, according to a Post analysis of more than 1 million hospice patients’ records over 11 years in California, a state that makes public detailed descriptions and that, by virtue of its size, offers a portrait of the industry.

The average length of a stay in hospice care also jumped substantially over that time, in California and nationally, according to the analysis. Profit per patient quintupled, to $1,975, California records show.

This vast growth took place as the hospice “movement,” once led by religious and community organizations, was evolving into a $17 billion industry dominated by for-profit companies. Much of that is paid for by the U.S. government — roughly $15 billion of industry revenue came from Medicare last year.

At AseraCare, for example, one of the nation’s largest for-profit chains, hospice patients kept on living. About 78 percent of patients who enrolled at the Mobile, Ala., branch left the hospice’s care alive, according to company figures. As many as 59 percent of patients left the AseraCare branch in nearby Foley, Ala., alive. And at the one in Monroeville, 48 percent were discharged from the hospice alive.

Medicare rules create a booming business in hospice care for people who aren’t dying - The Washington Post

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The French way of cancer treatment | Anya Schiffrin

An account of cancer care in France.

When my dad began to get worse, the home visits started. Nurses came three times a day to give him insulin and check his blood. The doctor made house calls several times a week until my father died on December 1.

The final days were harrowing. The grief was overwhelming. Not speaking French did make everything more difficult. But one good thing was that French healthcare was not just first rate — it was humane. We didn’t have to worry about navigating a complicated maze of insurance and co-payments and doing battle with billing departments.

Every time I sit on hold now with the billing department of my New York doctors and insurance company, I think back to all the things French healthcare got right. The simplicity of that system meant that all our energy could be spent on one thing: caring for my father.

That time was priceless.

The French way of cancer treatment | Anya Schiffrin

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I Watched My Patients Die of Treatable Diseases Because They Were Poor | Alternet

 

There’s a popular myth that the uninsured—in Texas, that’s 25 percent of us—can always get medical care through emergency rooms. Ted Cruz has argued that it is “much cheaper to provide emergency care than it is to expand Medicaid,” and Rick Perry has claimed that Texans prefer the ER system. The myth is based on a 1986 federal law called the Emergency Medical Treatment and Labor Act (EMTALA), which states that hospitals with emergency rooms have to accept and stabilize patients who are in labor or who have an acute medical condition that threatens life or limb. That word “stabilize” is key: Hospital ERs don’t have to treat you. They just have to patch you up to the point where you’re not actively dying. Also, hospitals charge for ER care, and usually send patients to collections when they cannot pay.

My patient went to the ER, but didn’t get treatment. Although he was obviously sick, it wasn’t an emergency that threatened life or limb. He came back to St. Vincent’s, where I went through my routine: conversation, vital signs, physical exam. We laughed a lot, even though we both knew it was a bad situation.

One night, a friend called to say that my patient was in the hospital. He’d finally gotten so anemic that he couldn’t catch his breath, and the University of Texas Medical Branch (UTMB), where I am a student, took him in. My friend emailed me the results of his CT scans: There was cancer in his kidney, his liver and his lungs. It must have been spreading over the weeks that he’d been coming into St. Vincent’s.

I went to visit him that night. “There’s my doctor!” he called out when he saw me. I sat next to him, and he explained that he was waiting to call his sister until they told him whether or not the cancer was “bad.”

“It might be one of those real treatable kinds of cancers,” he said. I nodded uncomfortably. We talked for a while, and when I left he said, “Well now you know where I am, so you can come visit me.”

I never came back. I was too ashamed, and too early in my training to even recognize why I felt that way. After all, I had done everything I could—what did I have to feel ashamed of?

UTMB sent him to hospice, and he died at home a few months later. I read his obituary in the Galveston County Daily News.

I Watched My Patients Die of Treatable Diseases Because They Were Poor | Alternet

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Elder Law: Kin may be held liable for care - Pittsburgh Post-Gazette

Elder Law: Kin may be held liable for care - Pittsburgh Post-Gazette: In July 2005, the Pennsylvania General Assembly passed the "Filial Support Law," commonly known as Act 43. As we approach the seven-year anniversary of the re-codification of this law (it previously existed in the Welfare Code from the 1930s and was re-codified in the Domestic Relations Code for modern usage), there have been increasing instances of facilities pursuing family members to pay for care, usually for parents' care in a long-term care facility.

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Gov. Bobby Jindal’s administration reverses planned elimination of Medicaid hospice program - The Washington Post

Gov. Bobby Jindal’s administration reverses planned elimination of Medicaid hospice program - The Washington Post

BATON ROUGE, La. — Louisiana Gov. Bobby Jindal’s administration scrapped plans Wednesday to shutter the state’s Medicaid hospice program in February, meaning the state will continue to provide end-of-life care to people on their death beds who can’t afford private insurance.

Jindal’s health secretary Bruce Greenstein made the announcement as hospice program supporters were gathering for a candlelight vigil on the state capitol steps to protest the cut. Greenstein said his department will use grant funding to cover the hospice costs this year.

The stupidity, economically speaking, and the heartlessness, you know, human being-wise, of some of these self described "Christians" (ChristoRepublicanus Americanus?) is astounding.

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End-of-Life Health Care - NYTimes.com

End-of-Life Health Care - NYTimes.com

Fortunately, advance planning for end-of-life decisions has been going on for years and is continuing to spread despite the demagogy on the issue in 2009. There is good evidence that, done properly, it can greatly increase the likelihood that patients will get the care they really want. And, as a secondary benefit, their choices may help reduce the cost of health care as well.

Many people sign living wills that specify the care they want as death nears and powers of attorney that authorize relatives or trusted surrogates to make decisions if they become incapacitated. Those standard devices have been greatly improved in recent years by adding medical orders signed by a doctor — known as Physician Orders for Life Sustaining Treatment, or POLST — to ensure that a patient’s wishes are followed, and not misplaced or too vague for family members to be sure what a comatose patient would want.

Fifteen states, including New York, have already enacted laws or regulations to authorize use of these forms. Similar efforts are under development in another 28 states. The laws generally allow medical institutions to decide whether to offer the forms and always allow patients and families to decide voluntarily whether to use them.

With these physician orders, the doctor, or in some states a nurse practitioner or physician assistant, leads conversations with patients, family members and surrogates to determine whether a patient with advanced illness wants aggressive life-sustaining treatment, a limited intervention or simply palliative or hospice care.

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Stunning Healthcare Overture from Bipartisan Group of US Senators - 2007

Healthcare Legislation in This Congress? - Michael Barone (usnews.com)

I followed Ezra Klein's link to this letter from 10 Senators, 5 Republicans and 5 Democrats, written just two years before President Obama took office! Read it, as it is stunning how far the Republican Choo Choo has gone around the bend.  [Courtesy USNews.com and Michael Barone.]

Now Wyden and nine other senators, five Democrats and five Republicans, have sent the following letter to Bush. Very interesting.

In addition to Wyden, the letter was signed by Republicans Jim DeMint of South Carolina, Robert Bennett of Utah, Trent Lott of Mississippi, Mike Crapo of Idaho, and John Thune of South Dakota, and Democrats Kent Conrad of North Dakota, Ken Salazar of Colorado, Maria Cantwell of Washington, and Herb Kohl of Wisconsin.

The text of the letter follows:

February 13, 2007

The Honorable George W. Bush
1600 Pennsylvania Avenue
Washington, D.C. 20500
Dear Mr. President:

As U.S. Senators of both political parties we would like to work with you and your Administration to fix the American health care system.
Each of us believes our current health system needs to be fixed now. Further delay is unacceptable as costs continue to skyrocket, our population ages, and chronic illness increases. In addition, our businesses are at a severe disadvantage when their competitors in the global market get health care for "free."
We would like to work with you and your Administration to pass legislation in this Congress that would:
1)Ensure that all Americans would have affordable, quality, private health coverage, while protecting current government programs. We believe the health care system cannot be fixed without providing solutions for everyone. Otherwise, the costs of those without insurance will continue to be shifted to those who do have coverage.
2)Modernize Federal tax rules for health coverage. Democratic and Republican economists have convinced us that the current rules disproportionately favor the most affluent, while promoting inefficiency.
3)Create more opportunities and incentives for states to design health solutions for their citizens. Many state officials are working in their state legislatures to develop fresh, creative strategies for improving health care, and we believe any legislation passed in this Congress should not stymie that innovation.
4)Take steps to create a culture of wellness through prevention strategies, rather than perpetuating our current emphasis on sick care. For example, Medicare Part A pays thousands of dollars in hospital expenses, while Medicare Part B provides no incentives for seniors to reduce blood pressure or cholesterol. Employers, families, and all our constituents want emphasis on prevention and wellness.
5)Encourage more cost-effective chronic and compassionate end-of-life care. Studies show that an increase in health care spending does not always mean an increase in quality of outcomes. All Americans should be empowered to make decisions about their end of life care, not be forced into hospice care without other options. We hope to work with you on policies that address these issues.
6)Improve access to information on price and quality of health services. Today, consumers have better accessto information about the price and quality of washing machines than on the price and quality of health services.
We disagree with those who say the Senate is too divided and too polarized to pass comprehensive health care legislation. We disagree with those who believe that this issue should not come up until after the next presidential election. We disagree with those who want to wait when the American people are saying, loud and clear, "We want to fix health care now."
We look forward to working with you in a bipartisan manner in the days ahead.

Skyrocketing costs! Competetive disadvantage! Universal access to health care! Class warfare! Inefficient US health care! Wellness! Prevention! Cost effectiveness! Compassionate end of life care! Expanding palliative care services! Health care in the US is broken!

Who knew Jim DeMint was a socialist before he was a Tea-Partier?

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Taking Responsibility for Death - NYTimes.com

Taking Responsibility for Death - NYTimes.com:

My mother drew up her directives in the 1980s, when she was a volunteer in the critical care lounge of her local hospital. She once watched, appalled, as an adult daughter threw a coffeepot at her brother for suggesting that their comatose mother’s respirator be turned off. Because the siblings could not agree and the patient had no living will, she was kept hooked up to machines for another two weeks at a cost (then) of nearly $80,000 to Medicare and $20,000 to her family — even though her doctors agreed there was no hope.

The worst imaginable horror for my mother was that she might be kept alive by expensive and painful procedures when she no longer had a functioning brain. She was equally horrified by the idea of family fights around her deathbed. “I don’t want one of you throwing a coffeepot at the other,” she told us in a half-joking, half-serious fashion.

There is a clear contradiction between the value that American society places on personal choice and Americans’ reluctance to make their own decisions, insofar as possible, about the care they will receive as death nears. Obviously, no one likes to think about sickness and death. But the politicization of end-of-life planning and its entwinement with religion-based culture wars provide extra, irrational obstacles to thinking ahead when it matters most.

As someone over 65, I do not consider it my duty to die for the convenience of society. I do consider it my duty, to myself and younger generations, to follow the example my mother set by doing everything in my power to ensure that I will never be the object of medical intervention that cannot restore my life but can only prolong a costly living death.

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'How Many of You Expect to Die?' - NYTimes.com

'How Many of You Expect to Die?' - NYTimes.com:

The third option, death following extended frailty and dementia, is everyone’s worst nightmare, an interminable and humiliating series of losses for the patient, and an exhausting and potentially bankrupting ordeal for the family. Approximately 40 percent of Americans, generally past age 85, follow this course, said Dr. Lynn, and the percentage will grow with improvements in prevention and treatment of cancer, heart disease and pulmonary disease.

These are the elderly who for years on end must depend on the care of loved ones, usually adult daughters, or the kindness of strangers, the aides who care for them at home or in nursing facilities. This was my mother’s fate, and she articulated it with mordant humor: The reward for living past age 85 and avoiding all the killer diseases, she said, is that you get to rot to death instead.

Those suffering from physical frailty, as she was, lose the ability to walk, to dress themselves or to move from bed to wheelchair without a Hoyer lift and the strong backs of aides earning so little that many qualify for food stamps. These patients, often referred to as the old-old, require diapers, spoon-feeding and frequent repositioning in bed to avoid bedsores. Those with dementia, most often Alzheimer’s disease, lose short-term memory, fail to recognize loved ones, get lost without constant supervision and eventually forget how to speak and swallow.

What all of these patients need, Dr. Lynn said, is custodial care, which can easily cost $100,000 a year and is not reimbursed by Medicare. The program was created in 1965 when hardly anyone lived this long.

“We’re doing this so badly because we’ve never been here before,” Dr. Lynn said. “But the care system we’ve got didn’t come down from the mountain. We made it up, and we can make it up better.”

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How Medicare Fails the Elderly - NYTimes.com

How Medicare Fails the Elderly - NYTimes.com:

"HERE is the dirty little secret of health care in America for the elderly, the one group we all assume has universal coverage thanks to the 1965 Medicare law: what Medicare paid for then is no longer what recipients need or want today. "

Goes on to delineate some of the problems with the Medicare payment system, that are not news if you've been paying attention, but always good to get it out there for further discussion.

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Palliative Care May Trump Heroic Measures in Life Expectancy | Miller-McCune Online

Palliative Care May Trump Heroic Measures in Life Expectancy | Miller-McCune Online

Another commentary regarding the NEJM Palliative Care article, health reform and a quote or two from me (Thanks, Joanne!)

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AMA Morning Rounds on NEJM Palliative Care Article

Early palliative care may prolong survival, enhance quality of life in patients with advanced lung cancer.


The New York Times (8/19, A15, McNeil) reports that a trial "paid for by the American Society of Clinical Oncology and private philanthropy" appears to "shed new light on the effects of end-of-life care." In fact, it "confirmed what...specialists had long suspected," that is, patients with "terminal lung cancer who began receiving palliative care immediately upon diagnosis not only were happier, more mobile, and in less pain as the end neared, but they also lived nearly three months longer." The paper appears in the New England Journal of Medicine.



Notably, "palliative care specialists lament that their image as the medical world's grim reaper deprives patients and their families of care and support that can ease the burden of serious illnesses that exact a steep physical, psychological, and social toll," the Boston Globe (8/19, A1, Smith) reports on its front page. "All too often, they said, patients and doctors outside their field equate palliative medicine with hospice care, even though hospice is the refuge for people who have stopped aggressive treatment and whose death is imminent." But, "palliative care...is available at any juncture during a life-threatening illness and, at its core, is designed to make living with a serious ailment more comfortable, incorporating everything from exercise to counseling to pain medication."



The current study illustrates that and is "one of the best tests yet of palliative care," the AP (8/19, Marchione) reports. It should also "ease many fears about starting it soon after diagnosis, doctors say." Researchers at the Massachusetts General Hospital (MGH) began their study by looking at "151 people newly diagnosed with cancer that had spread beyond the lung."



Seventy-seven of the "newly diagnosed patients were assigned to receive palliative care along with the standard treatment for the cancer," while the "other 74 patients received the standard treatment without palliative care," the Los Angeles Times "Booster Shots" (8/18, Roan) blog reported. The team eventually discovered that "patients receiving palliative care...scored higher on measures of quality of life and enjoying the time they had left. They also were more likely to express their wishes regarding resuscitation at the end of life."



What's more, those "who received palliative care in addition to standard care had...a 50 percent lower rate of depression and they lived 2.5 months longer than patients not receiving palliative care early," HealthDay (8/18, Doheny) reported.



MGH's Jennifer S. Temel, MD, told WebMD (8/18, Mann), "We were surprised by the magnitude of impact that palliative care had on quality of life, which normally decreases over time in these cancer patients, and the magnitude of the impact it had on depression." And, "the survival benefit was the most surprising thing," she added. "Cancer care and palliative care are not mutually exclusive." Bloomberg News (8/19, Cortez), the Wall Street Journal (8/18, Hobson) "Health Blog" and MedPage Today (8/18, Bankhead) also covered the study

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Forum: Before you die, speak up

Forum: Before you die, speak up:

I am an intensive care physician. My days are mostly spent working with a dedicated, caring team resuscitating people from septic shock and respiratory failure back to health.

Unfortunately, many of our patients, already near the end of life with serious advanced illnesses, would not want and will not benefit from these heroic measures that we've inflicted on them -- but the paperwork and orders necessary to prevent them are not in place.

In these cases, we work, a bit too late, to put things right and to do right by these people who entrust us to do our best for them. We are privileged to help those who will get better and to comfort those who will not. But we can do better.

I wrote this a few years ago, but it has become pertinent again along with these pieces written by Gary Rotstein, health reporter for the Pittsburgh Post-Gazette:

End-of-life questions often go unasked

Disabled worry lives not valued

So now, they are bookmarked in the blog.

UPDATE: two recent op-eds in the Pittsburgh Post Gazette of note:

The last days of our lives: Our health-care system needs to provide better, more thoughtful end-of-life care.
Wednesday, August 26, 2009
By Dr. Robert Arnold and Nancy Zionts

Sunday Forum: Forget the euthanasia talk -- end-of-life care is needed
It's time to debunk the misconceptions about provisions in the health-care reform bill, says RAFAEL J. SCIULLO
Sunday, August 23, 2009

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Health care reform: What is costly overuse, what is humane?

Health care reform: What is costly overuse, what is humane?:

This is the piece Betsy McCaughey read from on The Daily Show last night, regarding EOL care and the horrors of HR 3200.

"My problem, as a physician who has practiced medicine for decades, is that I just can't predict with certainty what is end-of-life care, nor can I determine for another individual the meaning of 'quality of life.'"

Well that's the whole point, isn't it? It s not the physicians choice it is the patient's choice, the patient's wishes that count. It is entirely the point of advance care planning and advance directives that it is up to the patient to decide what he or she wants. Our responsibility a physicians is to give them the best information that we can, imperfect as it is, and help them come to decisions that best reflect their wishes and goals.

And, no, we cannot predict with certainty when a person is exactly at the end of life - and I suspect that this author and Ms. M. would only except a definition of end of life as minutes away - but I do have a wealth of experience to go on, and I think it is unprofessional to allow families to cling to miracle scenarios for survival.


And here's another gem:
"I would be loath to talk a person on dialysis or in a wheelchair from a stroke into forgoing antibiotics for a pneumonia that may itself be treatable."

Well, so would I, because that is not the role of a physician, is it? Jeebus. Jude the Obtuse.

Ms. M. read this part:
"These and other provisions of the health choices act frankly scare me. As a physician, I took an oath long ago to put my patient's interests above all else, but provisions in the bill have a quality of coerciveness that make me wonder if I can fulfill my oath."

You have a higher duty to be honest with your patients and not blow smoke up their rears, telling them that this next chemo, this next procedure, this next indignity, is always worth it.

As I'm putting together this post, it infuriates me to consider countering this stupid, stupid, stupid, uninformed, heartless, obtuse rhetoric yet again.

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Dr. Alvin "Woody" Moss on West Virginia Public Radio

Below is a link to Dr. Moss’s interview with Beth Vorhees on WV Morning on health care reform and end-of-life care.

Link to listen--
http://www.wvpubcast.org/newsarticle.aspx?id=10811

Well done, Woody!

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