End-of-life health care is important, folks

Three years ago, at the height of the debate over health care reform, there was an uproar over a voluntary provision that encouraged doctors to discuss with Medicare patients the kinds of treatments they would want as they neared the end of life. That thoughtful provision was left out of the final bill after right-wing commentators and Republican politicians denounced it falsely as a step toward euthanasia and “death panels.”

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…

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.

The health care professional then signs a single-page medical order telling emergency medical personnel and other health care providers what to do if the patient is incapacitated. In most states, the patient or surrogate must also sign the medical order to indicate informed consent. The orders are conspicuously highlighted in a patient’s electronic medical record and follow patients from one setting to another — such as a hospital emergency room or nursing home — so that any health professional handling the case will know what interventions the patient might want…

No matter what the death-panel fearmongers say, end-of-life conversations and medical orders detailing what care to provide increase the confidence of patients that they will get the care they really want. In some cases, that could well mean the request to be spared costly tests, procedures and heroic measures that provide no real medical benefit.

RTFA for a broad understanding of your rights. It’s easy to drag your feet and put off a living will. The prospect ain’t exactly thrilling. But, do it – pay attention to the suggestions in this article and push your physician to cooperate if they must be pressed. Most are already ahead of you on this question.

Op-Ed: Supporting a minimum tax for the wealthy


Orange Creamsicles rule!

Suppose that an investor you admire and trust comes to you with an investment idea. “This is a good one,” he says enthusiastically. “I’m in it, and I think you should be, too.”

Would your reply possibly be this? “Well, it all depends on what my tax rate will be on the gain you’re saying we’re going to make. If the taxes are too high, I would rather leave the money in my savings account, earning a quarter of 1 percent.” Only in Grover Norquist’s imagination does such a response exist…

…Let’s forget about the rich and ultrarich going on strike and stuffing their ample funds under their mattresses if — gasp — capital gains rates and ordinary income rates are increased. The ultrarich, including me, will forever pursue investment opportunities.

And, wow, do we have plenty to invest. The Forbes 400, the wealthiest individuals in America, hit a new group record for wealth this year: $1.7 trillion. That’s more than five times the $300 billion total in 1992. In recent years, my gang has been leaving the middle class in the dust.

A huge tail wind from tax cuts has pushed us along. In 1992, the tax paid by the 400 highest incomes in the United States (a different universe from the Forbes list) averaged 26.4 percent of adjusted gross income. In 2009, the most recent year reported, the rate was 19.9 percent. It’s nice to have friends in high places…

Even if they’re bought-and-paid-for.

This outrage points to the necessity for more than a simple revision in upper-end tax rates, though that’s the place to start. I support President Obama’s proposal to eliminate the Bush tax cuts for high-income taxpayers. However, I prefer a cutoff point somewhat above $250,000 — maybe $500,000 or so.

Additionally, we need Congress, right now, to enact a minimum tax on high incomes. I would suggest 30 percent of taxable income between $1 million and $10 million, and 35 percent on amounts above that. A plain and simple rule like that will block the efforts of lobbyists, lawyers and contribution-hungry legislators to keep the ultrarich paying rates well below those incurred by people with income just a tiny fraction of ours. Only a minimum tax on very high incomes will prevent the stated tax rate from being eviscerated by these warriors for the wealthy.

Above all, we should not postpone these changes in the name of “reforming” the tax code…All of America is waiting for Congress to offer a realistic and concrete plan for getting back to this fiscally sound path. Nothing less is acceptable.

It doesn’t really offend Congressional Republicans when one of the wealthiest investors in the United States tells the truth about taxes and investing. After all, they already ignore science, history and ethics. No surprise about the addition of sound economics to the body of knowledge ignored by demagogues.

California cove filled to overflowing with nature’s beauty – and way too much bird poop!


Yes – the white stuff on the rock is bird poop
Photo by brianne.leary

Come here for the sights. (There is not a more majestic spot to watch the sun set over the Pacific.) Or come for the sounds. (The waves crash against the rocks, and the sea lions bark at one another on the bluffs.)

But don’t come for the smell.

In beautiful La Jolla Cove, art galleries and coffee shops meet a stretch of unspoiled cliffs and Pacific Ocean. Home to former presidential candidates (Mitt Romney has been spotted pumping his own gas here in recent days) and seal colonies alike, the neighborhood provides one of this city’s primary tourist draws.

But the smell, a pungent stench that emanates from the accumulation of bird feces on the rocks, has become a growing problem. And strict environmental regulations in the cove have stymied the city’s efforts to address the problem before it drives tourists and businesses away, effectively roping the rocks off with red tape.

“I’ve lived here my whole life, and the smell from the birds has never, ever been as bad as it is now,” said Megan Heine, the owner of Brockton Villa Restaurant, which overlooks the cove from a historic building that has been on the cliffs for more than 100 years. She said guests asked about the stench so frequently that her wait staff had become adept at explaining its cause…

Until a few years ago, the smell was never a problem because the bluffs were open for people to walk on. But since the rocks were closed off, partly because of safety concerns, sea gulls and cormorants have taken over, their droppings have piled up and the smell has grown more acrid by the day.

…Because the waters in the cove are part of a coastal area specially protected by the state, multiple state regulatory agencies would have to issue permits before the agents could be used, a process that regulators have indicated would probably take at least two years

For the moment anyway, there seems to be little city officials can do except hope for winter rainstorms, which in years past have washed the rocks and alleviated some of the smell.

“We need to consider a range of alternatives for cleaning the rocks, and one of those could be no project, just sit and wait for rain,” said Kanani Brown, an analyst for the California Coastal Commission, one of the regulatory agencies. “I know that’s not ideal for local businesses, but that’s historically been the approach.”

Got a smile from me. I had forgotten how strong seagull poop could smell; but, I surely remember it from my kidhood.

Growing up on the New England coast, we were a family that relied on subsistence fishing to supplement my father’s civil service paycheck. At least one day of each weekend, year-round was spent either on a certain local breakwater at the entrance to the city harbor – or at the end of a pier originally built to bring visitors in from a ferryboat to a nearby amusement park.

The park is long gone. Probably the pier, too. But that breakwater survived hurricanes and I imagine it’s still there. And on a sunny summer afternoon, the favorite places for seagulls to congregate and argue and poop – could wrinkle your nose hundreds of yards away.

What should children read?

…English teachers across the country…begin to implement the Common Core State Standards, a set of national benchmarks, adopted by nearly every state, for the skills public school students should master in language arts and mathematics in grades K-12.

The standards won’t take effect until 2014, but many public school systems have begun adjusting their curriculums to satisfy the new mandates. Depending on your point of view, the now contentious guidelines prescribe a healthy — or lethal — dose of nonfiction…

David Coleman, president of the College Board, who helped design and promote the Common Core, says English classes today focus too much on self-expression. “It is rare in a working environment,” he’s argued, “that someone says, ‘Johnson, I need a market analysis by Friday but before that I need a compelling account of your childhood.’ ”

This and similar comments have prompted the education researcher Diane Ravitch to ask, “Why does David Coleman dislike fiction?” and to question whether he’s trying to eliminate English literature from the classroom. “I can’t imagine a well-developed mind that has not read novels, poems and short stories,” she writes.

Sandra Stotsky, a primary author of Massachusetts’ state standards (which are credited with helping to maintain that state’s top test scores) challenges the assumption that nonfiction requires more rigor than a literary novel…

A striking assumption animates arguments on both sides, namely that nonfiction is seldom literary and certainly not literature. Even Mr. Coleman erects his case on largely dispiriting, utilitarian grounds: nonfiction may help you win the corner office but won’t necessarily nourish the soul.

As an English teacher and writer who traffics in factual prose, I’m with Mr. Coleman. In my experience, students need more exposure to nonfiction, less to help with reading skills, but as a model for their own essays and expository writing…

What schools really need isn’t more nonfiction but better nonfiction, especially that which provides good models for student writing. Most students could use greater familiarity with what newspaper, magazine and book editors call “narrative nonfiction”: writing that tells a factual story, sometimes even a personal one, but also makes an argument and conveys information in vivid, effective ways…

Narrative nonfiction also provides a bridge between the personal narratives students typically write in elementary school and the essays on external subjects that are more appropriate assignments in high school and beyond. David Coleman may dismiss self-expression. Yet he recommends authors, like the surgeon and medical writer Atul Gawande, who frequently rely on personal storytelling in their reporting.

Think about this, RTFA for more detail. I can’t easily come down on the side of the author because my own experience was exactly the opposite. My parents taught me to read before I entered kindergarten and virtually everything I read was fiction, fiction of every imaginable kind.

My parents subscribed to two monthly book clubs. And the centerpoint of Saturday was the 4-mile roundtrip my mom walked with my sister and me to and from the nearest neighborhood Carnegie library. A building I worship to this day. About the only non-fiction I read was autobiographies – a suspect category if there ever was one.