[Congressional Record Volume 143, Number 152 (Tuesday, November 4, 1997)]
[Senate]
[Pages S11627-S11628]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




              ADVANCE PLANNING AND COMPASSIONATE CARE ACT

  Ms. COLLINS. Mr. President, last week I was pleased to join with my 
colleague from West Virginia, Senator Rockefeller, in introducing S. 
1345, the Advance Planning and Compassionate Care Act which is intended 
to improve the way we care for people at the end of their lives.
  Noted health economist Uwe Reinhardt once observed that ``Americans 
are the only people on earth who believe that death is negotiable.'' 
Advancements in medicine, public health, and technology have enabled 
more and more of us to live longer and healthier lives. However, when 
medical treatment can no longer promise a continuation of life, 
patients and their families should not have to fear that the process of 
dying will be marked by preventable pain, avoidable distress, or care 
that is inconsistent with their values or wishes.
  The fact is, dying is a universal experience, and it is time to 
reexamine how we approach death and dying and how we care for people at 
the end of their lives. Clearly there is more that we can do to relieve 
suffering, respect personal choice and dignity, and provide 
opportunities for people to find meaning and comfort at life's 
conclusion.
  Unfortunately, most Medicare patients and their physicians do not 
currently discuss death or routinely make advance plans for end-of-life 
care. As a result, about one-fourth of Medicare funds are now spent on 
care at the end of life that is geared toward expensive, high-
technology interventions, and rescue care. While four out of five 
Americans say they would prefer to die at home, studies show that 
almost 80 percent die in institutions where they may be in pain, and 
where they are subjected to high-technology treatments that merely 
prolong suffering.
  Moreover, according to a Dartmouth study released earlier this month, 
where a patient lives has a direct impact on how that patient dies. The 
study found that the amount of medical treatment Americans receive in 
their final months varies tremendously in the different parts of the 
country, and it concluded that the determination of whether or not an 
older patient dies in the hospital probably has more to do with the 
supply of hospital beds than the patient's needs or preference.
  The Advance Planning and Compassionate Care Act is intended to help 
us improve the way our health care system serves patients at the end of 
their lives. Among other provisions, the bill makes a number of changes 
to the Patient Self-Determination Act of 1990 to facilitate appropriate 
discussions and individual autonomy in making difficult discussions 
about end-of-life care. For instance, the legislation requires that 
every Medicare beneficiary receiving care in a hospital or nursing 
facility be given the opportunity to discuss end-of-life care and the 
preparation of an advanced directive with an appropriately trained 
professional within the institution. The legislation also requires that 
if a patient has an advanced directive, it must be displayed in a 
prominent place in the medical record so that all the doctors and 
nurses can clearly see it.
  The legislation will expand access to effective and appropriate pain 
medications for Medicare beneficiaries at the end of their lives. 
Severe pain, including breakthrough pain that defies usual methods of 
pain control, is one of the most debilitating aspects of terminal 
illness. However, the only pain medication currently covered by 
Medicare in an outpatient setting is that which is administered by a 
portable pump.
  It is widely recognized among physicians treating patients with 
cancer and other life-threatening diseases that self-administered pain 
medications, including oral drugs and transdermal patches, offer 
alternatives that are equally effective in controlling pain, more 
comfortable for the patient, and much less costly than the pump. 
Therefore, the Advance Planning and Compassionate Care Act would expand 
Medicare to cover self-administered pain medications prescribed for the 
relief of chronic pain in life-threatening diseases or conditions.
  In addition, the legislation authorizes the Department of Health and 
Human Services to study end-of-life issues for Medicare and Medicaid 
patients and also to develop demonstration projects to develop models 
for end-of-life care for Medicare beneficiaries who do not qualify for 
the hospice benefit, but who still have chronic debilitating and 
ultimately fatal illnesses. Currently, in order for a Medicare 
beneficiary to qualify for the hospice benefit, a physician must 
document that the person has a life expectancy of 6 months or less. 
With some conditions--like congestive heart failure--it is difficult to 
project life expectancy with any certainty. However, these patients 
still need hospice-like services, including advance planning, support 
services, symptom management, and other services that are not currently 
available.
  Finally, the legislation establishes a telephone hotline to provide 
consumer information and advice concerning advance directives, end-of-
life issues and medical decision making and directs the Agency for 
Health Care Policy and Research to develop a research agenda for the 
development of quality measures for end-of-life care.
  The legislation we are introducing today is particularly important in 
light of the current debate on physician-assisted suicide. As the 
Bangor Daily News pointed out in an editorial published earlier this 
year, the desire for assisted suicide is generally driven by concerns 
about the quality of care for the terminally ill; by the fear of 
prolonged pain, loss of dignity and emotional strain on family members. 
Such worries would recede and support for assisted suicide would 
evaporate if

[[Page S11628]]

better palliative care and more effective pain management were widely 
available. I ask unanimous consent that this editorial be printed in 
the Record at the conclusion of my remarks.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  (See exhibit 1.)
  Ms. COLLINS. Mr. President, patients and their families should be 
able to trust that the care they receive at the end of their lives is 
not only of high quality, but also that it respects their desires for 
peace, autonomy, and dignity. The Advanced Planning and Compassionate 
Care Act that Senator Rockefeller and I have introduced will give us 
some of the tools that we need to improve care of the dying in this 
country, and I urge my colleagues to join us in this effort.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Iowa.

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