Funding of euthanasia and palliative care: “horribly distorted”

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Dr Ben Gray is a very interesting doctor and one of the few who could claim to be a hippie at the time: https://www.otago.ac.nz/news/news/otago824426.html.

It graduated from Wellington Clinical School first class in medicine when it was established as part of the University of Otago. Gray worked as a general practitioner for over 30 years, first at Waitara in Taranaki, then at the Newtown Union Health Service in Wellington.

Waitara had a large Maori population while Newtown has a very diverse population with significant numbers of refugees from many parts of the world. This allowed Gray to experience long-term condition management, cross-cultural care, and interprofessional practice.

Ben Gray joined the Department of Primary Health Care and General Medicine in 2006 as a Senior Lecturer where he is now Associate Professor. He obtained a master’s degree in bioethics and health law and is active in the Australasian Association of Bioethics and Health Law.

Questioning the health priority of medical assistance in dying

Now he has published (October 22) a thought-provoking online article by the University of Otago: https://blogs.otago.ac.nz/pubhealthexpert/is-funding-euthanasia-a-health-priority -for-aotearoa-new- zealand-part-2 /.

Gray wonders if funding for euthanasia should be a health priority for New Zealand’s public health system, especially in relation to palliative care. In summary, he argues that providing equity of access to physician-assisted dying without equity of access to palliative care completely undermines the goals of the End of Life Choice Act. The funding mechanism of the Act means that the choice is skewed in favor of physician-assisted dying and away from palliative care.

Drawing on the experience of the US state on the northwest coast of Oregon that introduced euthanasia, Gray concludes that it is very likely that physician-assisted dying in Aotearoa would be primarily adopted by a small number of mostly educated white people.

Objective of the financial mechanism

He then cites the recently announced goal of the new legislation’s funding mechanism to provide “… funding for health care practitioners to provide assisted dying services is to support equity of access to services. assisted death for eligible persons ”.

For the purposes of assisted dying, “health practitioners” are physicians and nurse practitioners (the latter should not be confused with registered nurses.

In order to understand Gray’s argument, it is important to understand that fully funded does not mean sufficiently funded. This means that there is no additional legal revenue stream for patients. Invariably and in this context, fully funded means underfunded.

Physicians and nurse practitioners employed in a private capacity can claim official government fees, but cannot charge patients a co-payment. Physicians and nurse practitioners employed by the district board of health can provide assisted dying services in this capacity, but they cannot claim these costs.

Dr Gray rightly observes that this funding objective means that assisted dying is different from the vast majority of other services provided in general medicine and in private specialized hospital practice; that is, it is fully funded by the government. The main exceptions to this rule are maternity services, immunization services and care for children under 14.

From there, he identifies two important issues. First, why has this fully funded “end-of-life choice” priority been given when the government does not fully fund many other services, especially palliative care.

Second, the level of funding becomes essential to the implementation of the Act. If the funding does not cover the cost of providing these services, very few people can be expected to provide these services.

Gray is correct that fully funding euthanasia and not fully funded palliative care mocks the title of the law. He describes the “choice” between fully funded physician-assisted dying and severely underfunded palliative care as “horribly skewed”. Responding to calls to increase funding for euthanasia would be even worse if there was no fight against underfunding for palliative care.

Pressure on public hospitals

The referendum held in conjunction with the 2020 general election and the legislation it enabled aimed to legalize assisted dying. From November 7, it will be legal to provide assisted dying within the framework of the law. Gray observes that there was nothing in the referendum, or in the discussion in preparation for the passage of the legislation, which focused on whether it should be fully funded.

He notes that, while this remains to be seen, it is very likely that it will significantly limit the already limited number of GPs ready to provide assisted death. If this is correct, it will leave public hospitals faced with a request for assisted dying at a time when their services are already in high demand.

Gray also recognizes the additional pressures the Delta variant of Covid-19 is expected to create for hospitals. He asks, “Do we want our hospitals to prioritize medical assistance in dying over cancer treatment, elective arthritis surgery, or endometriosis?” This alarming situation has been compounded by the government’s turnaround in its response to the pandemic.

Dr. Gray’s diagnosis

Ben Gray’s diagnosis is that physician-assisted dying should be available like almost all other community-based services, partially funded by existing government capitation payments for general practice, with a patient co-payment to reflect the cost of providing the service.

He believes this would fulfill the obligation to legalize assisted dying without further increasing the inequity in health funding and increasing the demand for stretched public hospital services.

I find Dr. Gray’s point compelling even though, as he acknowledges, the need to fully fund palliative care remains.

Currently, palliative care is recognized as an essential health service. Therefore, the majority of funding for hospices comes from the government. But the hospices remain seriously underfunded and there are no charges for the patients. Instead, hospices must depend on regular community fundraising. Currently, they are expected to raise over $ 77 million nationally.

In pleading for a “yes” in the referendum, a common reason given was the difficulty of accessing palliative care. Palliative care specialists, nurses and others working in hospices provide excellent care for the terminally ill under difficult circumstances where resources are insufficient. But many terminally ill patients find it difficult to access them when they need them.

Dr. Gray’s co-payment solution for assisted dying makes sense given the “horrible distortion” he artfully identifies. But a better solution would be to fully fund palliative care, including hospices. I have every reason to believe he would support this.

Originally posted here.

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