ObamaCare’s $1 Billion Community Organizing (and rationing) Project

Here’s a scheme that’s sure to fundamentally transform America’s health care system, from top down and bottom up. The Administration is pairing Alinsky-style organizing with Berwickian rationing, and using your tax dollars to do it.

In a series of YouTube videos posted last fall, Joanne Lynn, MD (right-to-die activist, bioethicist, and wife of Rev. Barry Lynn of Americans United for Separation of Church and State) described a $1 billion “care transitions” project that was established via Section 3026 of the Affordable Care Act (Obamacare).

The new Innovation Center at CMS is spawning community-based organizations through the federal QIO network. CFMC – the Colorado QIO – is the National Care Transitions Quality Improvement Organization Support
Center (Integrating Care For Populations and Communities, or ICPC).  The map above is by Traci Archibald, MBA, presented at the 2012 Annual Meeting of the American Geriatrics Society)

Lynn explains that “care transitions” means “how you move across settings” in healthcare. The Centers for Medicare & Medicaid Services (CMS) at HHS has been bothered that their clientele — elderly, frail fee-for-service patients — keep going back to the emergency room after they are discharged from the hospital. According CMS, “unnecessary hospital re-admissions” cost roughly $12 billion a year. Supposedly one in five patients returns to the hospital, but Lynn remarks that “in some areas, even higher rates apply; some populations certainly return more often.”

The answer: Use the federal government’s QIO network to establish community-based organizations for health care (re)distribution.

In response to the perceived crisis, CMS is starting with one billion dollars to change health care delivery systems across the country. Lynn says half a billion for “Community-Based Care Transitions Program” (CCTP), and the other half billion goes to “Partnership for Patients.” (Elsewhere, CMS describes CCTP as a sub-project of Partnership for Patients.) Lynn calls CCTP a “marvelously fertile endeavor,” and hopes that the CCTP demonstration project will spawn thousands of coalitions across the country:

“. . . [CCTP is] a very interesting program; half a billion dollars over five years, trying to have leadership organizations in the country – leadership communities, really – figure out how you can build community, . . . reduce the rate of hospitalizations and re-hospitalizations, by involving community-based organizations….”

These test sites will be the foundation for a permanent restructured delivery system over the next few years.

The Partnership for Patients “stakeholders”: left-wing nonprofits, crony capitalists, big labor and big government. (Graphic: from National Quality Forum presentation, April 2012)

Though the coalitions are local, the federal government determines which organizations are allowed on the team. Lynn says that to qualify for funding, the lead organization must be

“. . . a community-based organization which has adequate representation of the provider stakeholders and adequate representation of the consumers on its board – so it’s a very special organization – Medicare has determined that public organizations like a Department of Health can qualify, and that Area Agencies on Aging can qualify, but you’ll have United Way agencies and others that might be able to do this

The end result will be a coalition with clout.

The coalition will have its own board and will funnel large amounts of money. The organization is paid a flat rate per person, but then the organization decides how to allot the funds, determining which patients will receive more services, and which patients will get less. Lynn explains:

The community-based organization is the one that will get paid; they must be working with one or more hospitals. It’s an advantage to be working with hospitals with high re-admission rates. You submit an application that gives a blended rate, that says for every patient in our target population, we will be paid a certain amount, and then we will figure out, within ourselves, the patients that need a whole lot of services, and the patients who need less.

Joanne Lynn is not just a random observer. Lynn is an insider. She spent about a year advising CCTP’s headquarters in Colorado. During the mid- to late-‘90s she collaborated with Donald Berwick and his Boston-based Institute for Healthcare Improvement in projects aimed at decreasing hospital admissions by increasing the use of living wills and other advance directives. (Not surprisingly, before he left CMS, Donald Berwick was one of CCTP’s principal champions.) Lynn is probably best known for devising “Medicaring,” a program that manipulates Medicare reimbursements to discourage chronically ill patients from requesting life-saving measures.

Lynn recognizes that developing coalitions across the country will be tricky. She warns that people will be suspicious at first. She advises,

You need to build a level of trust, and then you need to govern by consensus, probably, for a while; and then figure out . . . what’s the governing board really going to look like; are we going to incorporate; are we going to be able to take on grants or funding; are we going to be able to take on the management of any records, or monitoring the situation, or speaking to the public? You have to think a couple years down the road.

This is where the Alinsky-style organizing comes into the picture.

Organizing for Health poster, originally posted at the website of  Colorado Foundation for Medical Care (CFMC)

The QIO for Colorado  Colorado Foundation for Medical Care (CFMC) – brought in Organizing for Health to help train and recruit organizers for coalition building via an online seminar that ran from February through May of this year.  CFMC is the national coordinating center for a CMS program called Integrating Care For Populations and Communities (ICPC), and as such CFMC helps community-based organizations apply for the CCTP program.

Organizing for Health is spearheaded by Marshall Ganz and his department at Harvard’s Kennedy School of Government.  From the Organizing for Health website:

Building on experience with Marshall Ganz, known for his campaigns with Cesar Chavez and California’s migrant grape workers in the 1970s, and Barack Obama’s 2008 grassroots presidential campaign, Kate Hilton, JD, MTS, is leading a team focused on supporting the capacity of leaders to organize and create sustainable conditions for transforming health and care.

For the record: Ganz focused on faith-based organizing, and his proteges at Organizing for Health specialize in leveraging faith-based organizations as well. The two trainers for the CFMC series – Kate Hilton and Ella Auchincloss – picked up community organizing experience while working for the Episcopal Church. Kate Hilton, the daughter of a hospice doctor, brings conflicts over end-of-life decisions into the debate. She has done community organizing through Donald Berwick’s Institute for Healthcare Improvement, the Mott Foundation, National Council of La Raza, and The Middle East Initiative at Harvard University.

Ella Aunchinloss, director of the Hauser Center for Nonprofit Organizing at Harvard’s Kennedy School of Government, stressed throughout CFMC’s four-month training series that there are many “change theories,” but community organizing involves using resources to build power, with emphasis on collective action.

A slide from the CCTP training session conducted by Organizing for Health

“If the change you want to see involves mobilizing people and involves mobilizing all of the resources available by virtue of that collective, then you’re using the right theory of change for the challenge that you face. To give you an example, if you wanted to find a cure for cancer, organizing as a theory of change may not be the right theory. . . .If there was a scientific breakthrough that did involve the use of a scarce resource of, say, some sort of or drug protocol, you might consider using community organizing in order to shift the power dynamics that make that drug protocol either scarce or scarce to your community.”

Slide from Organizing for Health training. The “opposition” were two physicians who wanted to care for sick patients.

In one session, participants were taught how to “map actors.” They were taught how to identify constituents (Auchincloss reminds the organizers that “patients are not constituents”), and and how to target supporters and competitors who have resources to which the movement wants access. Mapping also includes identifying who is the “opposition.” Auchincloss turned to one of the QIO members to provide a real-life example of mapping actors. It turns out the “opposition” was a team of physicians who said they were there to treat sick people. Doctors do usually treat sick people; that’s a good thing. Nevertheless, the physicians were identified as resisters because supposedly they just wanted to make money.

Hilton and Auchincloss, in the footsteps of their mentor Ganz, taught the organizers to begin their public relations campaigns with a “story of self”, a personal anecdote that will tug at their audience’s heartstrings, or conjure a fear. Organizers were told to cull their community for stories of “intolerable situations” to “create a compelling story or narrative of why people need to take action.” The series ended on May 24 with a call to action: “Contact a patient or family representative in your community by June 15th to learn what you can about their experiences.”

Sharpen your discernment skills; the propaganda blitz is on its way.

The Wisdom of an Obamacare Doc

Just over a week ago, Wesley Smith bloggedthat Diane Meier Speaks Wisdom.  As discussed in an earlier post here at Belbury Review, Smith’s column left a misleading impression that Dr. Meier might be pro-life.  Now Smith’s story is popping up in all sorts of places (for example here and here and here).

The story was this:  Last month, at the end of an hour-long speech in Vermont, Dr. Diane Meier explained why she is against assisted suicide  (video of entire speech is here).  Great.  Good that she is against assisted suicide.  But here is the really important question:  Where is the virtue in renouncing assisted suicide while, at the same time, working to establish (dare we say it) death panels?

Titled “Palliative Care:  A Cure for Meaningless Suffering,” Meier’s talk had little to do with medicine and a lot to do with politics.  Here are some samples:

[click photo to go to video page]
“The palliative care patient population [is critical because they are] the 10% of Medicare beneficiaries who have five or more chronic conditions.  And that group of Medicare beneficiaries accounts for two-thirds of all spending.  OK? . . . The sick Medicare beneficiaries are driving the overwhelming majority of spending.”
She wants single-payer healthcare (socialized medicine):

When you guys [in Vermont] pass the first single-payer bill, maybe there will be a job for me [applause] Because maybe you guys will establish a rational model and the rest of us will fall like dominoes.

Mocking conservatives:

And here’s the New Yorker, commenting on our political situation.  It’s two guys hauling themselves through the desert, and one guy says “rescue be damned; our Conservative principles will see us through.

Same old lies:

[Regarding quality]:  We know that about 50 million Americans have no health insurance at all, and therefore no access to healthcare.  And we know that there is a great deal of preventable mortality that is associated with not having health insurance.

More lies, and a threat:

And as President Obama said both during his campaign and afterwards with the healthcare reform debate, healthcare spending is THE primary threat to the American economy and way of life.  . . .There was talk about this in the ’90s . . .   The smart money is that this time we’ve got to get real about it, and get control over this open spigot, or as what I like to say to my colleagues, “The party’s over, guys.”

Embarrassed to be an American:

The US [spending] is so far above all our neighbor countries, it’s breathtaking and embarrassing to be an American . . .

That evil old traditional fee-for-service is like heroin:

It’s not fair to expect the US government to be able to change the US’s addiction to fee-for-service overnight.  Those of us in medicine know you don’t take an addict cold turkey off of his or her heroine overnight; you have to taper, or the patient will die. So I would argue that fee-for-service is an ADDICTION in this country.  We are addicted to it; many people make a lot of money on things the way they are, and are determined not to have them changed.  It has to be a gradual process of change.  And that gradual process is what’s built into the health reform bill.  Very gradual increases in paying people for quality; helping people to get used to working under a fixed budget, which we used to call capitation, but now we call it accountable care organizations and patient-centered medical homes, and bundling strategies.  These are all politically correct terminology for capitation; and gradually increasing levels of capitation.  Now, that was very effectively bashed both during and after health reform, as rationing and euthanasia.  And it was very easy to attack it as rationing and euthanasia, but the fact remains that unless we are able to think about both quality and costs, we will become a third world nation ourselves, just because of healthcare spending.”

Come to think of it, candy makers and farmers are evil too:

The people on the committee I was working on were trying to get that Food Safety Law passed, and so many interests groups – from both the people who make candy and sell it in the machines in schools, to the Small Farms Administration that did not – small farms did not want to be restricted on what pesticides they could use – so that was a huge lobby – everything was a negotiation.  It’s really hard to do good.  But, the voice of the people is determinative, and if we are not talking to and engaging the people and the public the value of our work, we will have no voice; so public awareness is crucial.

Take money from healthcare and put it into social goods (redistribution):

We have no resources for social goods.  New York State . . .between prisons and health care, spends 90% of its budget.  That leaves 10% for everything else:  schools, prenatal care; everything.  I mean, what kind of society are we, if those are the only things we think are worth spending money on

Comparative effectiveness (Berwick’s thing):

[on Comparative effectiveness] This is has become a political football labeled rationing and euthanasia and death panels.  Death panel caricatures have made this topic completely untouchable.  You…They won’t even talk about comparative effectiveness research; that’s CODE for rationing and euthanasia in Washington at this point.  And as my colleague Bob Wachter said in a masterpiece of understatement, “American political discourse is not yet mature enough to support realistic discussion about difficult issues.”

Another way to ration:

The Affordable Care Act – health reform – basically seeds expansion of new delivery and payment models – all of them aimed to improve the value equation by setting limits on spending, and paying for quality or penalizing for poor quality.  So actually just as a consumer would not buy a washing machine that Consumer Reports said was terrible, the government is saying “we oughta be paying for what helps people, and not for what doesn’t help people.  [Editor’s note:  See Competitive Enterprise Institute, “Consumer Reports Becomes National Snitch,” for how this might work.]

The really sick people are the expensive people . . . If you talk to them, they’ll do the right thing:

Palliative care is central to the success of health care reform.  And the reason for that is, that [pause] you have [pause] When you take the time to talk to patients and families about what is really happening, to them medically, what the medical treatment options are, and the pros and cons of those treatment options, and you take the time to understand what patients are hoping for in the future, and what their fears are in the future, 90% of the time patients make much more conservative choices.

[break transcript]

The palliative care patient population [is critical because they are] the 10% of Medicare beneficiaries who have five or more chronic conditions.  And that group of Medicare beneficiaries accounts for two-thirds of all spending.  OK? So 90% of all Medicare beneficiaries spend almost nothing.  They’re healthy.  They don’t need much.  The sick Medicare beneficiaries are driving the overwhelming majority of spending. . . . My particular hope for influencing policy is to make this case at both the state and the federal level:  if we intend to get a handle on costs, and improve quality at the same time, it will not be possible without fully integrated palliative care

President Obama explains how palliative care works: “At least we can let doctors know — and your mom know — that you know what . . . maybe you’re better off not having the surgery, but taking the painkiller.”

End-of-life “conversations” began in Bush years, but Rockefeller wrote the bill

Yes, the Bush administration did introduce a “discussion” benefit as part of the 2003 Medicare Prescription Drug, Improvement, and Modernization Act (also known as the Prescription Drug Bill, or MMA — signed into law as PL 108-173).  However, there was no end-of-life counseling involved in the discussion.  The session was a one-time only “initial preventive physical examination” now known as the “Welcome to Medicare” exam.  The consultation was to consist of “a physical examination (including measurement of height, weight, and blood pressure, and an electrocardiogram) with the goal of health promotion and disease….”

End-of-life counseling did not come into the picture until 2008 when a bill sponsored by Charles Rangel (D-NY) added advance care planning to the “Welcome to Medicare” exam.  That “benefit” (passed in 2008 and available in 2009 as the MIPPA benefit) paid the doctor to talk to seniors one time to encourage them to make end-of-life plans.

But the social planners pushing for Obamacare feared that one benefit didn’t go far enough in terms of cost containment. In introducing further legislation later in 2009 (S.1150), Sen. Jay Rockefeller (D-WV) took credit for creating the MIPPA benefit, but complained that very few patients chose this end-of-life counseling:

[The 2008] Medicare Improvements for Patients and Providers Act [MIPPA], PL 110– 275, took a significant step forward toward improving advance care planning. MIPPA included a provision that I authored, requiring physicians to provide an advance care planning consultation as part of the Welcome to Medicare physical exam. Unfortunately, less than 10 percent of new enrollees use the Welcome to Medicare visit. The MIPPA provision also does not address the advance care planning needs of existing Medicare enrollees.

This lack of counseling was costing the government money.  Rockefeller worried that “80 percent of all deaths occur in hospitals—the most costly setting to deliver care.”

His answer was to expand the incentive via S.1150, portions of which later became section 1233 of the Obamacare legislation and were dropped after public outcry. S.1150 featured multiple counseling sessions and enabled what Charles Lane of the Washington Post called the “’formulation’ of a plug-pulling order.”  Rockefeller said in introducing the new, improved benefits as part of S.1150

The legislation . . . establishes physician payment under Medicare, Medicaid, and CHIP for vital patient advance care planning conversations. It provides help in documenting decisions from these conversations in the form of advance directives and in the form of actionable orders for life sustaining treatment. It also takes steps to address the problem of accessing advance directives when needed, including state grants for electronic registries.

While it may not duplicate the now deleted section 1233 of the Obamacare legislation, this newest CMS rule now enforces more intrusive end of life counseling.  Instead of the single “Welcome to Medicare” benefit Rockefeller found so inadequate in 2008, the new rule pays providers to conduct such  “conversations” repetitively (as in S.1150) only now they will occur during the annual “wellness” visits like those established in Obamacare Section 1233.

Ultimately, S.1150, and Section 1233 of the Obamacare legislation and this new CMS ruling all share an intent that is even more insidious than that found in the original MIPPA “Welcome to Medicare” benefit.



POLST: “self-determination” or imposed death?

“POLST” is short for “Physician’s Orders for Life Sustaining Treatment.” It is a so-called “advance care planning” document; a page or two of medical instructions designed to follow a patient from one setting to another. In Oregon the form is still called POLST, but in other states it has taken on a variety of names such as POST, MOLST, or MOST.  It was devised for sick and elderly people, and lists treatments they might wish to forgo.  Any patient in a nursing home or a patient with an “advanced illness” would qualify.  Emergency teams and first responders are trained to use POLST.  When the patient’s condition worsens, or when the patient is transferred to a new location, the POLST form is reviewed and the patient is asked again whether he/she really wants antibiotics, “artificial” hydration/nutrition, and so forth.  The check marks on the page are instantly transformed into “physician’s orders” or “medical orders.”

By design or not, POLST is also an effective cost containment device.  Earlier this year POLST’s designers at the OHSU Center for Ethics in Health Care issued a Statement on the Fiscal Impact of the POLST Paradigm, maintaining that (emphasis added):  “an ideal health care system would honor individual preferences while allocating health care resources efficiently.”  The report went on to demonstrate that in numerous studies POLST increased efficiency by preventing “expensive hospitalizations.” [1]

Autonomous?  Think coached.

The bioethicists who devised the POLST Paradigm hyped the documents’ use as tools for dignity and autonomy. [2] The documents do leave the door wide open to an “autonomous” decision to hasten death.  This is particularly true in Oregon and Washington where “comfort care” includes assisted suicide.

However, assisted suicide is only one concern.  POLST is more apt to facilitate imposed death.

POLST owes its existence more to Oregon’s experiment with health care rationing than it does to the state’s assisted suicide experiment.  In fact, POLST grew out of an effort in the late 1980s by Portland area hospital ethics committees (not patients) who were considering how to limit “futile treatments.”  Eventually ethicists came up with a document that would discourage providers and patients from requesting treatments that were “not medically indicated” – i.e., treatments not considered appropriate by a panel of “experts.”[3]

Shortly after Oregon’s legalization of assisted suicide in 1994, the document was given a name that tested well in focus groups, emphasizing that these were orders “for life-sustaining treatment.” The document was fine-tuned under the direction of an ethicist mentored by Mark Siegler of the MacLean Center for Clinical Medical Ethics at the University of Chicago (where Valerie Jarrett’s father was senior scholar).  To assist in testing and implementing the document, the bioethicists engaged the help of Oregon Health Decisions — a group of community organizers and left-leaning activists who had formed Oregon’s “citizen parliaments” that created Oregon’s infamous rationing lists.

Who funded it?

Perhaps it is no surprise that George Soros’s Project on Death in America was one of the earliest funders of the POLST venture at OHSU.  Among other funders were the Greenwall Foundation, the Robert Wood Johnson Foundation, and Nathan Cummings Foundation.  At the time, the Cummings Foundation was also funding Ezekiel and Linda Emanuel for a study of caregivers’ burdens.  The Greenwall Foundation was known for its funding of bioethicists who favored “death with dignity.”  Later, in 2008, Greenwall would also grant $40,000 toward a study on how to determine which Alzheimer’s patients should be allowed to vote. Recipient of the grant was Charles Sabatino – director of the American Bar Association’s Commission on Law and Aging, and POLST activist.

Following is a sketch of what POLST is and is not:

POLST is not the traditional “legal transaction”

  • Although a POLST form looks like a contract, usually displaying signatures of patient and provider, it is not a traditional legal transaction.  Charles Sabatino says POLST reflects a “paradigm shift from [the traditional] legal transactional model to a communications model.”[4]
  • POLST does not require a physician’s signature; nor does it require the signature of the patient or proxy.  The POLST Paradigm Task Force “recommends” that POLST require a patient/proxy signature, but the signature is definitely optional, depending upon regional requirements.[5]

More like “a process”

  • POLST is not so much a document as it is “a process.” One advisor to the Senate HELP committee made the pitch for POLST last summer:  “The process of completing a POLST form is [not only] a values clarification process, but one that results in specific and explicit medical orders” [6]
  • “The process” is repetitive and often conducted when the patient and proxy are under duress, as the patient’s condition changes.  In many states, the form has multiple lines for multiple interviews. “The process of goal clarification requires intense, time-consuming, face-to-face conversations with patients and/or family members” triggered by what the providers perceive should be “realistic options” for care.[7]
  • “The process” can be initiated by someone other than a physician, and that is usually the case.  According to POLST advocates, “nurses, social workers, admissions coordinators, and nursing home administrators are typically the front-line implementers of POLST.  They facilitate POLST discussions at the time of admission (or sometime later), record patient preferences, and then refer the form to the physician for signature.”[8] This means that on one day a Catholic physician might counsel his patient to request hydration, only to find that, on the next day, an admissions coordinator or social worker reviewed the orders with the patient (or proxy) to “clarify” away the previous day’s decision.

What triggers “the process”?

  • The definition of an eligible candidate varies widely.  A recent National POLST Paradigm report suggested POLST is triggered by “advanced illness.”
  • In some states, health care professionals are trained to identify prospects by asking themselves the question, “would you be surprised to see this person dead in a year?” (a prompt that was devised by a physician at Franciscan Health System West — one of the health systems that participated in Donald Berwick’s “Improving Care at the End of Life Collaborative ).

Are the documents legal in every state?

  • The documents’ legal status vary dramatically from state to state.[9] In Oregon, for example, POLST couldn’t move forward without passage of liberalized surrogacy laws.  Even after that, the task force decided to bypass the legislature to gain full implementation, and so pushed for a liberalized rule from the Oregon Board of Medical Examiners.  The new rule provided “both a mandate and a legal shield” for first responders, who would be key to implementing POLST.[10] Susan Tolle, MD, of the POLST Paradigm Task Force warned “the POLST form functions within the context of Oregon’s liberal advance directives law and would require modification for use in some other states (for example, those without surrogacy provisions)”[11]In Washington State, the advance directives statute had prohibited  surrogate decision-makers from making Do-Not-Resuscitate (DNR) decisions for a patient. With pilot-testing already in progress, POLST activists stepped in and pressured the state’s Department of Social and Health Services (DSHS) to reinterpret the statute.  With the help of local media and “frightening articles in major media,” DSHS revised their interpretation and approved POLST.[12]

 

  • Though the applicable laws and regulations vary dramatically from one state to the next on issues such as surrogacy, assisted suicide, scope of practice for first responders, POLST activists are working toward making the documents “fully transportable,” i.e., forcing states to honor out-of-state documents.

Goal-oriented process.  Whose goal?

The problem with POLST is not that it allows patients to hasten their own death.  The problem is that POLST facilitates imposed death.  It creates an illusion of “self-determination” while fostering consensus ethics.  It is vague as a legal document, and the iterative, goal-oriented process is designed to reduce the use of what some ethicists call “inappropriate” treatments, but what others may call ordinary and life-enhancing.  The documents may be used by a wide range of health care workers, many of whom do not know the patient personally.  In short, the POLST process rigs the system in favor of pressuring the patient and family.

Although not writing about POLST specifically, bioethicist Wesley J. Smith has illustrated the effect of this sort of process:

I hear often from people who believe they or their aged/ill/disabled loved ones are being pressured into refusing treatment–usually not by being brow beaten or yelled at–but from a constant, drip, drip, drip of conversation after conversation after conversation, which only end when the patient agrees to what the doctor or ethics committee want.  In this phenomenon of the never-ending-conversation, people often perceive an attempt to wear them down by sheer exhaustion into acquiescing.[13]

Smith’s “drip, drip, drip” sums up the POLST process rather well.


[1] The National POLST Paradigm Task Force., Statement on the Fiscal Impact of the POLST Paradigm (Portland, OR: Center for Ethics in Health Care, Oregon Health & Science University, 2010).

[2] Lewis-Husk, Lee, and Michael J. Garland. The First Decade, ed. Susan W. Tolle and Gary T. Chiodo. Portland, OR: The Center for Ethics in Health Care, Oregon Health Sciences University, 1999.  Also:  Myra J. Christopher and Jeri Spann, “Oregon Health Decisions:  Lighting the Way to Common Ground,” State Initiatives in End-of-Life Care, October, 1998.

[3] Patrick M. Dunn and others, “A Method to Communicate Patient Preferences About Medically Indicated Life-Sustaining Treatment in the out-of-Hospital Setting,” J Am Geriatr Soc 44, no. 7 (1996).

[4] Charles Sabatino and Myra J. Christopher, “Advance Planning:  From a Transactional Model to a Communications Approach (Slide Presentation),” in The Changing Face of Health Decisions (American Bar Association, 2008).

[5] Oregon POLST Task Force, “Guidance for Oregon’s Health Care Professionals,”  (Portland, OR: Center for Ethics in Health Care at Oregon Health & Science University, 2009).

[6] Diane E. Meier and Larry Beresford, “POLST Offers Next Stage in Honoring Patient Preferences,” J Palliat Med 12, no. 4 (2009).

[7] Ibid.

[8] Myra J. Christopher and Jeri Spann, “Implementing End-of-Life Treatment Preferences across Clinical Settings,” State Initiatives in End-of-Life Care, April 1999.

[9] Susan E. Hickman and others, “The POLST (Physician Orders for Life-Sustaining Treatment) Paradigm to Improve End-of-Life Care: Potential State Legal Barriers to Implementation,” J. Law Med. Ethics 36, no. 1 (2008).

[10] Christopher and Spann, “Implementing End-of-Life Treatment Preferences across Clinical Settings.”

[11] Susan W. Tolle, “Care of the Dying: Clinical and Financial Lessons from the Oregon Experience,” Ann Intern Med 128, no. 7 (1998).

[12] Judy L. Meyers and Rose Mary Volbrecht, “The Story of the POLST Form: How a Grassroots Effort Can Make a Difference in End-of-Life Care,” DNA Reporter (Delaware Nurses Association) 30, no. 2 (2005).

[13] Wesley J. Smith, “”Obamacare: Column Illustrates the Potential for ‘Never Ending Conversation’ End of Life Counseling Pressure,” in Second Hand Smoke (https://www.firstthings.com/blogs/secondhandsmoke/2010/04/04/obamacare-column-illustrates-the-potential-for-never-ending-conversation-end-of-life-counseling-pressure/, 2010).