Sunday, December 21, 2014

Kule Yule Tidings 2014

Melé Kalikimaka e Hau’oli Makahiki Hou! 

My hope is this Holiday Season finds you and yours in good health and spirits. As I write, mana pours from above onto parched westlands. The small creek behind my house has swelled beyond its banks and onto nearby roads. Funny how three years of drought can change ones perspective of minor, local flooding. Let it rain, let it snow, let it snow. 
Bill, John & I - Switzerland
(Click the photo once to enlarge. Click X in upper right corner to return to text.)
LBz 2014: In recent years I’ve had an eye on my Bucket List, adding and reprioritizing. This year I checked off a big one. I spent 5.5, late-summer weeks in Europe hiking with friends. The trip was built around hikes in the Alps and fjords. Huts are sprinkled throughout the Alps along the Swiss Haute Route (haute = hut, pronounced “oat”). They provide hot dinners and breakfasts, cold showers and warm beds; reservations required. We learned the Swiss detest desecration of their land with cleared campsites and fire rings. The hut system allows hikers to travel lighter-faster-farther. To that end, the huts are 8-10 miles apart and shortly after breakfast, off you go toward your next hut. Its a fascinating and well marked trail system supported seasonally throughout many European countries.
We met many wonderful hikers and my pack weighed a fraction of what it did last year in the high Sierra. We’ve never done a “supported” hike before, we had  sherpa/guides, Swiss cheese and chocolate at every break - FUN! We will definitely do another such hike and I have my eye on the Inca Trail in 2016.
Prague @ night
Our route between hikes was sprinkled with old world cities and fishing villages turned Atlantic oil ports: Salzburg, Prague, Oslo, Stäväńger, Haugesund, Bergen, Stockholm, and Amsterdam. We visited UNESCO World Heritage sites in each location. Many of the old cities are tourist traps littered with trinket shops but if one can look beyond the kitsch, the architecture and stories are quite interesting. Prague has the esteemed reputation as a rare, old city spared annihilation during the bombing raids of WWII. Overrun first by the Nazis then the Soviets, they have returned palaces to them that can prove ownership. We toured the Lobkowicz Palace and viewed handwritten scores by Beethoven and Handel! We took guided walking  tours in Stockholm and Amsterdam and learned their secrets and hideaways. I wore a fitbit pedometer during the entire trip. Most days, we walked ten miles.
me @ Preikestolen - 2500' down
The fjords were fantastic, breathtaking and a must return destination. Back onto the Bucket List with Norway! Turns out Norway shares latitude and weather with Anchorage, AK (with which you may remember, I am quite familiar). One of our premiere hikes to Kjerabolten (pronounced Sheerabutn) was rained out with its peak literally in the clouds. Of our hike to Preikestolen - the  pictures say it all.
We toured the palace in Stockholm just days before the opening of parliament. When a parade of plumed horseman and empty carriages passed us, we raced to stand out front, to see the King and royal family depart.
“You saw the KING?” the hostess of our B&B asked with incredulity. “I haven’t even seen the King!” We proudly displayed the photo of her King waving in our  direction.
early Rembrandt self-portrait
The Rijksmuseum (Dutch Master’s museum) in Amsterdam is also back on the Bucket List. There we stood before Van Gogh and Rembrandt self-portraits, Rembrandt’s The Night Watch (which is enormous) and some of his early attempts at playing with light. I am a Vermeer fan and the Kitchen Maid was just exquisite. The museum provided iPhone-ish devices into which one entered a code to hear a brief history of these priceless works. Photos ALLOWED - without flash natch. Amsterdam has several such museums, each requiring at least one full day of exploration. We did visit Rembrandt Square where many of his characters are brought to life in full-scale bronze  sculptures.
The Kitchen Maid - Vermeer
I have two complaints about northern Europe: 1) it IS the land of milk, cheese and meat. They do not suffer vegetarians well. I spent almost 30 days eating Italian food because it was the only way to eat vegetarian. 2) Many of the old cities thrive on the backs of tourists with value added taxes as high as 25% but have made few, if any provisions, for these tourists to pee! I was so annoyed. Even pay toilets are an acceptable alternative to NO toilets.
Their citizens were wonderful. We had many trip-angels help us buy train tickets and head us in the right direction, write a list of things to do in their city, recommend restaurants, help us at the washrei (laundromat) and backrei (bakery).
“I don’t usually help tourists,” the young woman said after walking us to the train kiosk, helping us purchase tickets and sitting with us on the train to Oslo, “But you were so friendly on the plane.” 
“Keep helping tourists!” I called back, waving as we de-trained.
Stävävańger, Norway
“You’ve had a good experience in Norway?” the young man asked as he stuffed his clothes at the washrei. “We’ve been friendly and helpful?” 
“Yes, people have been very friendly and helpful,” I confirmed nodding.
“That’s good,” he nodded once with some finality, “Because we are known to be not so friendly.” He worked for a company that made machine parts for Atlantic oil drillers and spoke of family in Seattle.
We met Sierd Jongstra, a lovely Dutch oilman from Friesland, while prowling the harbor for nighttime pictures. In the end, we traded emails and I sent photos.
Talk to strangers - you will meet the most fascinating people!
Toward the end of our journey, a new Bucket List idea was seeded. That is, to live in Europe for several months post-retirement (which approaches more quickly than I can believe). Take my bicycle outfitted with baskets for food and goods - that way I can assemble my own raw, live, green foods. Live in northern Europe earlier when the weather is moderate and allows for quick excursions north, to the fjords for instance, when the weather forecast is clear. Then move to experience southern Europe and the Mediterranean. European extended holiday now added to the list in addition to visiting every US National Park.

post reconstruction
I finished two major home remodel items this year - the travertine floors and removal of my living room’s back wall. My home backs to a dedicated greenbelt/animal corridor and I envisioned opening it from the moment I stepped inside -  and now, the reality is beautiful and tranquil. My dear friend/gen contractor Wade did exceptional work and captured my vision, turning this small, tract-house into my home.
I finally wrapped my backyard oaks in lights - something I’ve been wanting to do for years. You’ll be happy to know I employed my climbing harness and rope to get 30-feet up. I think it took me longer to remember how to properly tie the figure-8 knot than it did to wrap the trees!
My cul-de-sac and street continue to hold biannual BBQs that promote cohesion and “neighborliness”. I love living on Gardner Court with the Courties!

I continue to work in the Neurology Memory Clinic at Kaiser. It is sad and necessary work to help families understand, then care for persons who’s brains are UN-learning - its counter-intuitive. I do find myself missing the worlds of diabetes and cardiac surgery where patients get better, go home and have an opportunity to reverse disease.
Yoga continues to reign as my preferred sport though tendonitis in my left wrist has curtailed some arm balancing and handstands. I find greater physical challenges by deepening the pose and spiritual connection in its meditative practice.
I continue to blog at though home construction, disruption and travel seriously slowed my pace in 2014. 

Lael & Darth 9/2014
In news of the family: While I was away, niece Lael married longtime sweetie Darth. Family reports the wedding was magical - and on the beach in Hawaii - natch. My great niece and nephew seem to grow before my eyes and I am thrilled to receive new pictures every few days over our shared iPhoto stream. If you haven’t connected your family in this way - you must! I feel so much more connected, even from 2000 miles away.
On a much sadder note, in a matter of weeks we lost both my Uncle Sonny and Aunt Gert. Theirs was the home in which we gathered every NY eve and day. Uncle Sonny would start strumming his guitar as we scurried for our ukuleles. He called out the chords, we followed and sang Hawaiian songs in kanikapila (Hawaiian jamming). Now and again an aunty or cousins would rise and dance the hula. At midnight, the racket began - strings of ten (or hundred) thousand firecrackers lit in rapid succession to ward off evil spirits in the new year. Wonder why I am always home at new years? I learned the true meaning of aloha in their home and theirs is a devastating loss for our clan. Knowing that he was ill, I flew home for four days in November and we three had a wonderful visit. I am thankful for the foresight and resources allowing those last acknowledging and loving moments with them both. Indelible is their imprint on our hearts.

What’s in store for 2015? 
Mom & her twin Milly turn 90 in April and we are planning a party for the girls. So my next trip to the islands will be in April.
The annual, national nurse practitioner conference is in New Orleans and I hope to combine that with visiting several friends in the east. Also planning a visit Cancun in September - a European hiking reunion of sorts. There we will tour the Mayan pyramids and lounge on the beach. I am researching the possibility of spending a week in Yosemite as a volunteer with the Yosemite Conservancy. Typically this involves trail restoration of some sort with park employees and other volunteers. It will involve sleeping in a tent at a remote location. Right up my alley! Its a great way to combine volunteerism and a park visit during the summer. They reportedly have many more applicants than spots so keep yer fingers-n-toes crossed for me!
That’s all folks! Would love to hear from you too. Sending you joy and Hau’oli Makahiki Hou!


Saturday, November 29, 2014

A Skeptic Dissects z Nursing Strike

This blog is an attempt to distill the communications and issues that lead to the two-day work stoppage across Northern California’s Kaiser Permanente (KP) facilities. In my mind, California Nurse’s Association (CNA) had not built a strong case for strike. Nonetheless, they received a clear mandate from my colleagues. Ever the skeptic, I saved every 2014 communication from both organizations, just knowing I would want to follow the breadcrumbs. 

“The union is a double-edged sword.” If I’ve said that once, I’ve said it a thousand times. I appreciate that my wages and benefits are the spoils of hard fought battles. That nurses can work twenty-plus years for a healthcare system and retire without medical benefits remains the norm. Excepting the state and feds, Kaiser was early to grant healthcare benefits to retirees. The union did that. We affectionately call our pay and pension package the golden handcuffs and I believe nurse retention spares Kaiser the largest expense in any healthcare budget - the hiring and training of nurses. The union did that - that however, is no mandate to heed every word like chiseled tablets from the mountain.

Context is decisive. My context for CNA is not a powerful one. Our last contract was ratified September 1, 2011. Contract negotiations were secreted between CNA and Kaiser arbiters. The rank and file were notified post-hoc and encouraged to ratify. It was a different time, profit margins were thin and Kaiser was anxious to settle the behemoth budgetary item. The contract was bounteous, included raises during a time of high, national unemployment and economic downturn. Generous beyond expectation, we were universally thankful and thrilled.
CNA’s chief arbiter visited each campus to explain the new contract and encourage ratification. I found one phrase unsettling. “They are… scared of us,” he said smugly to the rank and file, “Yeah, scared is a good word.” And not for the first time, I wondered about supporting such an organization. 
That same organization called for a one-day work stoppage twenty-two days into that brand-spanking-new contract to support other, non-KP RNs and KP optical techs in union contract negotiations. A union representative visited each site to encourage nurse participation. I entered the fray brandishing my newly-minted-copy of the Agreement between Kaiser Permanente, Kaiser Foundation Hospitals, the Permanente Medical Group, and CNA dated 9/1/2011 - 8/31/2014.
Page 116 Section I - No Strikes or Lockouts 4023 addressed the issue: There shall be no strikes, lockouts or other stoppages or interruption of work during the life of this Agreement. 
“How do you reconcile a call for a work stoppage with this new contract?” I asked pointedly, after reading the passage aloud.
“We have a past practice,” the union representative said.
“This contract says no strikes, lockouts or other stoppages or interruption of work during the life of this Agreement,” I reiterated. “It does not say except for past practice.” We were diametrically and equally opposed, entrenched and immovable. Some nurses, elated with the new contract, saw heeding CNA’s call-to-action as homage due. Honoring the contract and one’s word seemingly fell upon deaf ears. All told, 23,000 nurses from numerous healthcare systems heard and heeded the call - a CNA flex-of-muscle, described as “the largest-ever strike by nurses.”
That nurses would stage a work stoppage, in direct conflict with our new and very generous contract, and for issues unrelated to Kaiser RNs was unfathomable to me. That CNA would call for such an action was unconscionable. CNA became suspect and the minions who, without question, would do their bidding? I viewed as uninformed and ignorant. I penned a letter of dissent to Sac Bee’s Letters to the Editor that went unpublished. But context is decisive and subsequent calls-to-action by CNA are met with fervent skepticism and scrutiny.

Fast forward to 2014. The Kaiser-CNA contract was set to expire 8/31/2014. 
In April, Dr. Robbie Pearl, Kaiser’s CEO, was filmed at The Permanente Medical Groups shareholder meeting. “A big threat is that our nurses union has a contract coming up this year that will not get settled. There is no way it gets settled. And so we are looking at strikes inevitably coming up sometime in the latter part of 2014, heading into 2015.”
As early as May 2014, CNA emails to membership pointed to the 2014, 21.7 billion dollar profit while care units were short-staffed or shut down. 
With contract negotiations scheduled to begin 7/24, CNA encouraged RNs, on July 20th, to set aside 2% of each paycheck as a Patient Protection Fund and sought a written commitment to do so. A Patient Protection Fund  “for our patients and ourselves if Kaiser fails to work with us…” A strike fund, by any other name, is still a strike fund. Sadly, seemingly both sides were entrenched before negotiations had even begun. Score: 15-love, point-CNA for the pre-emptive strike.

As I walked toward my office on July 23rd, I was asked to sign a petition urging Kaiser to bargain in good faith.
“Isn’t that a given?” I asked. 
“No,” the nurse said, shaking her head.
“I don’t think the best strategy for negotiations is to go in with guns blazing,” I said moving on, “Sorry, I won’t sign that.” Score: love-all, penalty point-CNA for un-sportsman-like conduct.

The first day of bargaining was re-scheduled for July 31st, 2014. CNA reported that Kaiser failed to show, so they marched to Kaiser’s corporate offices in Oakland and read their opening statements in the lobby - which was covered by the national news. Kaiser had been working for weeks to obtain an agreement to meet at a neutral location, at which they waited on the appointed day. Apparently, CNA never agreed to that venue. To their detriment, Kaiser failed to widely broadcast their version. Score: 15-love, point-CNA, everyone loves a David beats Goliath tale.

CNA, framing their demands around patient care and safety, delivered 38 proposals to the bargaining table. As early as August 14th, CNA represented their proposals focused on “working conditions and changes for improved patient care and services” while Kaiser’s rebuttals allegedly cite “cost containment”. (Cost containment will seem ludicrous later with reports of Kaiser’s, record, $12,000,000 daily profit in 2014.) CNA showcased the death of a bay area toddler as proof that services were lacking.  Score: 30-love, point-CNA for strumming the heartstrings. It’s difficult for many to see issues beyond the death of a child.

On August 21st, CNA employed a time-tested-tactic, the old bait and switch. “No takeaways in light of record profits.” With that declaration, a two-pronged attack was launched and the battle subtilely shifted from patient care and safety only, to sharing in the loot. Leaflets addressed corporate profits and CEO salaries. ACE! Score: 40-love, point-CNA, for stirring stinky bait into the pot, muddying the waters and altering the debate.

PAUSE IN THIMK (this was a phrase my university math prof used to indicate a sidebar)
No margin; no mission. Where do new, digital mammogram machines come from? From the margin. Where do new hospitals come from? The margin. Where do newer, designer drugs like expensive insulin pens subsidized by pharmacy programs come from? Yep, you guessed it; from the margin. Where does my very substantial paycheck and pension come from? Righto - the margin. 
As one who has owned a small business, I understand the cost of business, a P&L statement and the margin. While current and historic evidence of income inequality and its deleterious effects on society is well documented, that discussion is for a future blog. Nonetheless, I view CEO pay and corporate profits as a separate issue, unrelated to my own W-2. During my 35 years of nursing, my wages have increased 7-8 fold. Kaiser nurses are well paid, possibly some of the highest paid nurses in the country (uh... = world). When one points to CEO and corporate greed, must one address the three fingers pointing back at self?
End Pause in Thimk

9/11 - CNA reported, “Kaiser informs us that they have no interest in the majority of our proposals.” Did Kaiser actually say this? Unlikely. Counter-proposals are part of the game and do not infer no interest - that's what a rejection is for. There is no record of Kaiser rejecting any of the proposals. Kaiser’s accounting of negotiations on 9/11 are collegial and collaborative. They propose extending the contract 60-days and adding numerous bargaining days. Score: 40-15, point-KP for bargaining in good faith.
As negotiations proceeded, nurses were encouraged to attend the bargaining sessions, to witness the process first hand. Carpools were organized across northern California and CNA filled the bargaining venue with chanting RNs. At one point, Kaiser’s negotiating team refused to continue and called for an arbiter to arbitrate the arbitrations on the grounds that they did not feel safe. Excuse me - is this a professional nurse's association or the Teamsters? Score: 30-all, point-KP for professional conduct, penalty point-CNA (and attendant nurses) for behaving like thugs.

On September 30th, CNA proffered its last proposal - one for Ebola preparedness including supplemental insurance in the event that Ebola is contracted at work.
October 8th - Kaiser’s response to the Ebola Proposal included creating a CNA/KP task force to incorporate best practice and ensure all voices/concerns are addressed. CNA scoffed and spun this into: “Kaiser is responding with a proposal with the lowest common denominator. Kaiser is using our patient’s lives as bargaining chips. Kaiser’s lack of preparedness matches how they treat us every day when they fail to prepare for admissions, discharges and sick calls. It is clear they are unwilling to embark on a sufficient Ebola preparedness plan in an effort to limit costs.” 
Here, CNA effectively taps into national nursing outrage that frontline nurses were inadequately protected at Texas Presbyterian, while proper personal protective equipment was available onsite. Undoubtedly, mistakes were made; mistakes for which Texas Pres has apologized and paid. But methinks Texas Pres was a long time ago and far, far away from where we are now. That was then; this is now. Score: 40-30, point-CNA for effectively personalizing the debate and tapping into the outrage required to mobilize the minions.
10/15 - Kaiser is “unwilling to spend any of the $12 Million in daily profits on ensuring adequate relief for nurses.” Score: point and Game-CNA for guerrilla warfare that effectively demonizes Kaiser at every opportunity, tossing in every bone and stirring the pot. Game Score: CNA-1, KP-0.

Burnout: the condition of someone who has become physically and emotionally tired/spent after doing a difficult job for a long time. One symptom of burnout is anger. 
I left the Emergency Department because I was becoming a person I didn’t like. I was angry: angry at patients, angry at home, angry at work, angry at friends, angry with my parents and family. I’ve spent years working on self, finding that which nurtures my soul - returning to myself. “You are more you,” a friend said. Exaaactly. I know many angry nurses; the workplace can be a cauldron, little kindling required to light the fire.
To combat burnout and boost mental health, Kaiser has an Employee Assistance (counseling) Program and an employee wellness program called LiveWellBeWell that is unmatched in the industry. There are processes to escalate concerns of workplace violence, sexual harassment, and unsafe practice, to name just a few. Programs are free too all but employees must actually participate (engage, document, submit) to receive the benefits.
This is not to say that cases of harassment and unsafe practice do not exist; only to say that there are options to anger and strikes.
End Pause in Thimk

Game 2
10/16 - “CNA told Kaiser that we are willing to settle our contract today providing there were NO TAKEAWAYS.”
Regarding the Ebola Proposal: “Kaiser’s refusal to agree to this proposal further solidifies that Kaiser is putting profits before the safety of nurses and our patients.” Note: Kaiser did not refuse but countered. I'm sure CNA knows the difference.
I view this communique as critical. First, while CNA claimed 39 proposals addressed patient care and safety - they are clearly willing to chuck the entire body of work for no takeaways in pay and pension. Really? Didn’t they just commit the exact offense they accused Kaiser of in the next line? Of putting profiteering before the safety of nurses and our patients?
Score: love-15, point-CNA for cleverly/effectively couching double-speak for political gain whipping the nurses into a frenzy.

10/20 - Petition to Authorize Bargaining Team to Call Strike if Necessary 
“We have been bargaining for several months and it is clear that Kaiser is not interested in putting its $12 million per day in profit towards the provision of safe patient care. …Kaiser has the resources to settle our contract …but obviously they have no intention of settling our contract without coming after our benefits.” 
Note: Not agreeing to no takeaways is not the same as proposing takeaways. At this point in the game, Kaiser has deferred financial discussions. Rather, they propose settling most of the 39, non-financial proposals before discussing pay and pension. But notice how CNA framed this as “they are coming after our benefits.”
They may come after our benefits but that has not been proposed. I will hardly strike over something I fear Kaiser might do. But fear is a powerful motivator. When my physician friends express confusion with the issues” its because issues are difficult to discern in the stewing cauldron stirred by CNA. This strike, best I can tell, was not about issues but emotions. Bubble, bubble, toil and trouble. Score: love-30, point-CNA for obvious reasons.

10/30 - Notice Issued for 2 Day Strike
CNA got their mandate from Northern California Kaiser nurses to strike, and in an am-a-a-a-zing coincidence, coordinated Kaiser’s work stoppage to precede a (yet to be declared) National Day of Action by nurses for Ebola preparedness. Ask yourself; does my employer need to be penalized with a day of strikes because their Ebola Policy changes with the evidence? Aren't you glad it does? Score: love-40, point-CNA for coincidental planetary alignment with the moon in the 7th house and Jupiter aligned with Mars. Does anyone feel even remotely manipulated? Think nurses - THINK!

From California to Maine, registered nurses plan to make their voices heard louder on Nov. 12 with a National Day of Action for Ebola Safety Standards.
This comes after hospitals across the country refuse to set proper safety protocols and training with optimal personal protective equipment.

To their detriment, Kaiser all too sparsely leaflets its nurses with position statements and their disappointment in the rhetoric and tactics of CNA. Their information is tempered, a welcome sprinkle on the flames fanned by the frequent CNA communiques. A sprinkle nonetheless - inadequate and infrequent. Kaiser needs a counter-terror blogger, one to call a-spade-a-spade; an impartial voice with an eye for half-truths and spin.
On Novemember 7th, Kaiser's Leadership responded with an email to employees: “The union’s use of Ebola as a rationale for a strike is not justified. We are very disappointed about the nurses union's decision to call for a strike. The reasons it is giving for striking are simply not supported by the facts. To date, CNA leadership has… continued to label KP publicly as unprepared, which is not true and is stoking unnecessary fear.” Score: 15-30, point-KP for stating the obvious - albeit ineffectual.
Buried at the bottom of that 11/7 email, I found this: If you have questions: We understand that you may be hearing conflicting or confusing information from different sources. Please visit For the Record (, our website that provides updates, answers to frequent questions, and KP’s perspective on bargaining and other important topics. WHAT???
Dear Bleader (blog reader), you know me to be a voracious reader and consumer of information. Trust me when I say, November 7th was the first I’d learned about a Kaiser website for bargaining information. Truth is, it is not solely dedicated to bargaining though bargaining dominates the website at this time. Shame on me and shame on KP. Score: love-30, penalty point-KP for failing Employee Communications 1.0.
November 13th: the day following the strike, Kaiser’s Leadership sent a conciliatory email: “We especially want to express appreciation for the many hundreds of nurses who chose to put their patients first and came to work. On behalf of our patients, we thank you for your dedication and commitment.”  
“With this unfortunate work stoppage behind us, we welcome back those nurses, engineers, and other employees who were not here during the strike. We know you will resume providing excellent care in your departments, your care teams, and at your patients’ bedsides.” Score: 15-30, point-KP for diplomacy and inclusivity.
November 20th: CNA claims victory and responsibility for improvements to the Cal OSHA Ebola policy announced November 14th. Score: 15-40, point-CNA for effectively using circumstance to their advantage.

I spoke of the strike with a non-Kaiser, nursing friend. “Wait a minute,” she cut me off, “Isn’t Kaiser a great place to work?”
I wonder - are we better off after a two-day work stoppage? I fear not. I am cautious in speaking with those who supported the strike. I am curious about their view - so different from my own - and  wonder about the decision-points leading to their willingness to strike. 
As the game continues, Kaiser is seemingly outmatched in propaganda and spin. I have spent hours sifting through data for this distillation. Few have the time or want for such a summary; few will read this blog. No matter as my blogs are typically (no exception here) the place to address that which niggles and gnaws and to observe the distillate.

I recently listened to an interview with Arie Kruglanski, an Israeli researcher, psychologist and terrorist expert. He points to the black-and-white, right-and-wrong, rigid versus nuanced thinking of extremism as juvenile, underdeveloped but providing a place for one to become part of a larger whole. He cautions that victims often become as extreme as their oppressors and cites his mother country as an example. Finally, he discussed decreased cognitive complexity as exemplified in one’s inability to digest many points of view and extremism and entrenchment as causal for literally dumbing-down.
I continue to be unmoved by CNA and have been known to call them rabid. It is for me to move forward carefully, that I am not equally rabid from the opposite side of the net and court. Life is not back-and-white, mostly methinks, we inhabit the vast fields of gray.

Rumi said it most eloquently - Out beyond ideas of wrongdoing and rightdoing there is a field. I’ll meet you there.

Sunday, July 27, 2014

On Death & Dying - Part 3

Please excuse my nearly two-month absence. I was managing another piece of home transformation: from tract home to tranquil retreat. (Sayonara fireplace - joi gin glass (literally “again see”). I continue to open and remove walls to bring the outdoors in  - allowing nature to nurture.

Another hiatus is imminent as my European Holiday quickly approaches: hiking in the Alps and fjords. We intend to post the 10-best photos each day to facebook.

In Part 3, I will discuss how fear keeps us from having meaningful, reformative conversations in this country. How threats of Granny Death Panels and cost-saving rhetoric keep us stuck, outraged and unable to make common sense reform.

Death is the cessation of all biological functions that sustain a living organism. Plain, simple, easy-peasy. “The cessation of all biological functions that sustain a living organism.”
The nature of death and mortality has been a concern of all religious traditions and philosophical inquiries. Death - the final frontier, the great unknown. We surround it with meaning including judgements of good deaths versus bad deaths. We attach beliefs of resurrection, reincarnation or rebirth, or that consciousness permanently ceases to exist - known as eternal oblivion.
Our judgements and beliefs are entwined with cultural and generational perspectives. They color our world and act as filters such that we believe our perspectives as truth. Defending our perspective as truth keeps us stuck. Can we agree that gravity is a universal truth? Birth and death are universal truths - but everything between forceps and stone is subject to interpretation and perspective. I contend that your truth, while assuredly shared, is not a universal truth. If one can start the discussion of death from that place of non-judgement, without moral or ethical overtones, then a real conversation can be had that will honor all opinions and perspectives and allow people to find their path to death.

Lets examine some of these beliefs that keep us from meaningful dialogue.
Morality - Morals refer to an individual’s own principles regarding right and wrong.  Notice it is an individual’s own, not a dominant belief imposed upon others. 
Culturally, we have a strong moral code around suicide. This was never more evident than in the events surrounding The World Trade Center and 911. Did you know that more than 200 people fell or jumped from the burning towers? How do we know that? Because they were photographed and the people within the buildings were vaporized. But DNA identification could be made from the remains on the sidewalks below. 
Sometimes, a single image captures it all - such is the photograph by Richard Drew of The Falling Man. It ran in The New York Times on 9/12/2001 to such outrage and vehemence that the photo was buried for years. Our response to such a photo is visceral, it touches places we don’t want to go, so we push back.
The Falling Man documentary is a wrenching watch and an effort to identify the falling man. It first aired in the UK in 2006 and finally in the US 18-months later (interesting delay donchya think?). In their search, they interviewed many families. Despite describing the internal temperature of the upper floors as climbing to 2000 degrees Fahrenheit, families protested, “That is NOT my father/uncle/brother/son/cousin. My father/uncle/brother/son/cousin would never jump. He was a devout Catholic and he would NEVER do that.” 
One woman’s beautiful swan dive was filmed, making her easily identifiable by her family. She had been a member of her high school diving team. She was survived by a husband and two young children. “She had a choice,” her husband said. “If she jumped,” he shrugged in resignation, “She jumped.” Interviews captured family struggles with their views of suicide even in extreme circumstance.
The fall was said to take about ten seconds. It would vary according to body position and time to reach terminal velocity — around 125mph —  but if someone fell head down with their body straight, as if in a dive, it could be 200mph.
All deaths in the attacks except those of the hijackers were ruled to be homicides due to blunt trauma (as opposed to suicides). The New York City medical examiner's office said it does not classify the people who fell to their deaths on September 11 as "jumpers". These people were forced out by the smoke and flames or blown out.” ~Wikipedia
In his article entitled, The 911 victims America wants to forget: The 200 jumpers who flung themselves from the Twin Towers who have been ‘airbrushed from history’, Tom Leonard states, “Even now, nobody knows for certain who they were or exactly how many they numbered. Perhaps worst of all, surprisingly few even want to know. … some considered that to choose to die showed a lack of courage. And in this country of intense religious fervor, many believe that to be a jumper was to choose suicide rather than accept the fate of God - and suicide in whatever circumstances is considered shameful or indeed, a sin that will send you to Hell.”

“How can anyone know what one would do in a situation like that, having to choose how you go from this Earth” The notion that she jumped is consoling to surviving spouse Jack Gentul in some ways, in that she exercised an element of control over her death. “Jumping is something you can choose to do,” he said, “To be out of the smoke and the heat, to be out in the air, it must have felt like flying.”
Notice if in this reading you feel resistance, outrage or disgust. It is THAT, that keeps us from meaningful dialogue about death. 
What is my point? My point is: if we cannot find a place to stand like Jack Gentul, a place of compassion and generosity for the other, we cannot even begin to have meaningful conversations about death that will include other points-of-view, belief systems, and circumstance. And I contend, any conversation that includes choice must include assisted death for the terminally ill as separate and distinct from a conversation for suicide.

Ethics -  Ethics and morals both relate to “right” and “wrong” conduct. However, ethics refer to the series of rules provided to an individual by an external source, e.g. their profession or religion. 
I’ve just proposed (and perhaps demonstrated with the jumpers of 911) that right and wrong can be circumstantial and that each case must be examined on its own merit. 
Is it ethical for companies to withhold birth control and abortion services? Its legal but some would argue not ethical. Would we withhold testicular care because it could affect reproduction? Is abortion ethical? Its legal but many would argue, unethical.
Who remembers the British woman who died in Ireland several years ago because, after fetal demise, she could not get an “abortion”? She died of sepsis with a dead, rotting baby in her womb. But that was an unusual case, you say. Maybe; maybe not.
Is it ethical to hasten death by withholding food and fluids voluntarily? Its illegal in many states but conversely, is it ethical to force-feed the "decisionally competent" choosing to hasten death via starvation? What about prisoners? Do we force-feed prisoners on hunger-strikes? As a matter of fact - we do.
Where is that boundary between personal/patient autonomy and the right of personal choice versus the sanctity of life from a religious perspective, or the concept of “do no harm” from a medical perspective?
’Tis a very slippery slope indeed. 

Value - The overwhelming majority of Americans who die are elderly and covered by Medicare. The Congressional Budget Office reports that one-quarter of all Medicare spending occurs in the last year of life. Medicare spending in 2013 was $586 BILLION - yes - with a capital B. One-quarter of that equals $146.5 BILLION … spent in the last year of life. Clearly not a good value. If we do not address this black hole, the Baby Boomers will bankrupt the country.
In Harvard Business Review’s The Strategy that Will Fix Health Care, its authors propose that Providers must lead the way in making value the overarching goal. “At its core is maximizing value for patients: that is, achieving the best outcomes at the lowest cost.” They cite six components, the second of which is: Measuring Outcomes and Costs for Every Patient. “The only true measures of quality are the outcomes that matter to patients.” The metrics can be translated into reportable outcomes: amputations and blindness and dialysis and heart attacks and stroke and death. 
Research says patients are interested in survival, then recovery and sustainability of health. When healthcare systems track and report outcomes that matter, in a way that is meaningful to patients, patients will be empowered in their choices.
How does this overlay onto real life?
Three weeks ago, an acquaintance’s 80-something, year-old grandfather was found to have a mass in his brain that was likely cancerous. They scheduled a biopsy. 
“Why?” I asked.
“Because they need to find out if its cancerous,” he said.
“No they don’t,” I argued. “At his age, it will not change his treatment. If its benign, they will not cut his head open to remove it. If its cancerous, they will not cut his head open to remove it. Chemo and radiation therapies will be poorly tolerated at his age... and brain cancer? At that age? Com'on - the chances of survival are slim to none; the surgery alone could kill him. So really, why do the biopsy at all; why do they need to know? It won’t change anything. Let him live out his days.”
They did the biopsy - it was cancer. Then they said he was not a surgical candidate and he should go home to make his peace. Which he did - and he was dead within 14-days. So why did they do the biopsy? I knew from cross-country and without ever having laid eyes on the patient that he was not a surgical candidate, nor would the biopsy results change the treatment course. They MUST have known that before the biopsy. 
Why did they do the biopsy and how much did that cost?  I dunno - when I am at my most cynical and sarcastic, and in a fee-for-service world where doctors get paid by the procedure, I assert it was because someone had a mortgage payment due.
This is a perfect example of: $146.5 BILLION … spent in the last year of life on ultimately, futile care.

I have another one - I was discussing no-CPR orders on those of advanced years. 
“I disagree,” my cousin said, “If someone is in a restaurant and chokes on some food, you should try to save them.”
First - this points to confusion in terms. The Heimlich Maneuver for choking is NOT CPR.
In 1996, The New England Journal of Medicine published an analysis of three popular series: “ER,” “Chicago Hope” and “Rescue 911.” Two-thirds of those victims survived CPR and were discharged back into their active lives. So a misinformed American public thinks CPR is survivable and beneficial? Statistics show a different and grim reality.
From the American Heart Associations website: Nearly 383,000 out-of-hospital cardiac arrests occur annually. 88% occur at home; less than 8% survive. What they do not track or report is - the percentage of survivors that are viable. After 80, only 3.3% survive to hospital discharge - this from Dr. David John, former geriatrics chairman of the American College of Emergency Physicians. Of that 3.3%, some are not viable.
You wanna gamble on being some fraction of the 3.3% who survives AND is viable? That’s how people end up in the ICU on a ventilator while their family rings their hands and struggle with the guilt-laden task of unplugging Granny.
Let me reiterate: When healthcare systems track and report outcomes that matter, in ways that are meaningful to patients, they will be empowered in their choices. In an informed, rational world, the fully informed grandfather chooses for no biopsy and no CPR. But nothing surrounding death is rational unless one has time to discuss and digest the issues.

When we try to address these emotionally laden and highly personal issues, people like Sarah Palin talk about Granny Death Panels - a term coined during the 2009 legislative battle over the Affordable Care Act. She charged that language in the bill reimbursing doctors to counsel patients about living wills, advanced directives and end-of-life care options would ultimately judge them “worthy of medical care” … or not.
Fellow blowhards - oops-did I say that with my out-loud voice? Let me start over: Other prominent and highly respected Republicans including Newt Gingrich, Glenn Beck, Rush Limbaugh and Michelle Malkin took up the call and backed Palin's statements. One poll showed that after it spread, about 85% of respondents were familiar with the charge and of those, about 30% believed it true.
Is it any wonder that a meaningful, national dialogue regarding End-of-Life options and care is elusive?

Patients who live with an incurable and progressive disease often have to accept many losses. Their lives may be filled with pain, physical limitations, dependency on others, and a decreasing ability to engage in activities that once were a source of joy and satisfaction. Some people can accept such limitations with grace and good will, but for others, the inability to have a voice that is heard or to make a choice about dying that is respected is an intolerable affront to their personhood. Many in this group want to know that there are still options and choices available to them during this time. Only the person living with the terminal illness can know when the burdens of living outweigh the benefits.
For the most part, people do not fear death - what they fear, and wish to avoid, is unnecessary suffering during the dying process.” Michael White, JD in his testimony before the CA Assembly Comm. on Aging and Long-Term Care  2/19/2013.
The tension exists between beliefs that EoL choices should be founded mainly honoring the sanctity of life versus compassion for those who are suffering. Said another way, sanctity based on religious and moral principles versus compassion based on respect for personal autonomy.
If we concur with Harvard Business Review, that healthcare is moving toward “maximizing value for patients: that is achieving the best outcomes at the lowest cost”, consider that EoL care in this country is in for an e-ticket ride. We bundle and improve diabetes care (estimated to affect 50% of us) but neglect the conversations for change in EoL care (guaranteed to affect 100% of us). We are ill prepared for death because like anything, preparation requires attention and intention. The last year of life is the most expensive though reports clearly demonstrate that money makes no difference.
Perhaps we can take a page from the Hospice playbook and have conversations for how we want to live until we die. What's important to you right now? What are you hoping for? What are you afraid of? What is quality of life to you? If this were to happen; could you live with it? What about that? And that? 
Could we switch off the auto-pilot of life and have conversations to really know one another, what we value and brings precious meaning to our lives? Could we help bring that value and fulfill on such desires? What would life be like if your loved ones helped fulfill on your deepest desires? Well, that'd be a life worth living; wouldn't it? There are some who contend that being known is our greatest desire.

Notice that I have no answers, only questions. But I hope this series has given you pause and opened your eyes to those hidden forces that exert pressure on your choices in life and End-of-Life. My intention is that you start conversations in your family, honest, uncomfortable conversations about who and what are important to you and how you want to live until you die - then do it. Live how you want to live - until you die. Live out loud and true to your heart.

What are the elements that leave me feeling like I live with heart? I’ve distilled it down to five things: meaningful work, music, exercise, writing, and spending time with those I love. I work to put two or more of these elements into each day.
Confucius said: Wheresoever you go, go with all your heart. As a reminder, this phrase was painted on my wall, the one removed during the remodel. The men doing the work were so taken with it that unbidden, they cut it out and saved it. It speaks to me, it spoke to them. Let it speak to you. 

Wheresoever you go, go with all your heart. ~ Confucius

Sunday, May 25, 2014

On Death & Dying - Part 2

In Part 2, we will start to examine the healthcare industry, reimbursement and how that affects our end-of-life (EoL) choices and care.

A good death. What is a good death? Most Americans are united in this thought - we want to die at home, in our own beds; preferably in our sleep and surrounded by those we love.  

My Uncle Bill did that. He had the BEST death. Uncle Bill was 96 when his solitary kidney started to fail. Not his mind - his body. For the last week, he filled his home with family. People brought great vats of food, sat around and talked story. Uncle Bill called the mainland to express his love, “You were my favorite family,” he said, “And I love you.” This from a man who rarely said, “Boo.” (To see a full accounting of Uncle Bill, scroll to March, 2011: Moon Chee Eulogy.) Uncle Bill died the way most of us want, methinks, with his wits and family about him. He drifted into sleep and faded from this world while the Packers bruised the Steelers in Cowboys Stadium during Superbowl XLV.

What made his death the best death? Lucidity and painlessness.  How does one meet a good end? Start with a good life - not from a moral sense but from a health sense. You know the drill: no smoking, curb the eating to maintain a normal weight, limit the hooch (but not the hoochie-coochie) and exercise daily. Why? Because a lifestyle that discourages chronic disease, while no guarantee, is a step toward a good death.
Only 10% of Americans die thusly. The rest die in hospitals and nursing homes where - if an Advance Directive and/or POLST (Physician Orders for Life Sustaining Treatments) are not clear and filed - staff is obligated to a prescribed course of rib-breaking, resuscitative efforts. Let me reiterate the opening lines in Part 1 of this series: the medicalization and mechanization of death, OUR obsession with intervention and saving the patient, is robbing us of our right to die in peace. Sometimes, saving the patient is not the best course of action.

Trajectories toward death. The four common disease trajectories are: sudden death, terminal illness, organ failure and frailty.  Sudden death needs no explanation. Its my personal favorite though more difficult for family and friends. 
An example of terminal illness is malignancy; patients function quite well until the last few months of life. Steve Jobs, for instance, continued in his role as CEO of Apple just months before his death.
Organ failure is characterized with disease exacerbation-resolution round-robins in a slow spiral of decline. Chronic Obstructive Pulmonary Disease  (COPD) and Congestive Heart Failure (CHF) follow this slower trajectory. Ultimately, we all die of organ failure, something  eventually stops: our heart, liver, kidneys or brain. 

Frailty is a state of low function and steady deterioration; they fade away. You can see frailty - they are waif thin and feeble. The open heart team’s term of endearment for the frail was “potato chip.” If a patient was called "a little potato chip", I was on notice to be extra, EXTRA careful. After a decade on that team, my personal opinion is to avoid ALL procedures on potato chips. They are brittle, they break - then they die.

Given the current trend of dying in institutions, lets examine the forces exerted there that affect our choices.
Reimbursement. Healthcare Effectiveness Data and Information Set (HEDIS) is a widely used set of performance measures in the managed care industry. HEDIS was designed to allow consumers (patients) to compare health plans against each other and against regional and national benchmarks (outcomes). “An incentive for many health plans to collect HEDIS data is a Centers for Medicare and Medicaid Services (CMS) requirement that health maintenance organizations (HMOs) submit Medicare HEDIS data in order to provide HMO services for Medicare enrollees under a program called Medicare Advantage.” In essence, one must collect/report HEDIS data to become eligible and accredited as a Medicare provider. Care is tailored to the metric. Succinctly: No play; no pay. 

Who/what is covered by Medicare? This info taken directly from, the Medicare website:
Medicare is a health insurance program for: people age 65 or older, people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or kidney transplantation).
Part A covers hospital insurance, skilled nursing facilities (but not custodial or long-term care), hospice, and some home health.
Part B covers medical insurance (physician services and outpatient care), physical and occupational therapy, and some home health.
Prescription Drug Coverage includes an annual, per person, medication budget.

But what does HEDIS have to do with end-of-life? There are numerous non-HEDIS interventions that promote healthy behaviors resulting in long-term cost effectiveness, a good life and a good death.
Did you see the movie Escape Fire (recommended in my Halloween and Healthcare blog of November 2013)? In it, a cardiologist alludes to HEDIS when she says, “I can spend an hour talking to a patient about diet, exercise, their health consequences, something that can change the course of their health, and receive reimbursement of about $45.00. In that same hour, I can take a patient to the cath-lab, insert a cardiac stent, something that is a temporary fix, and receive $1500.00. The system is crazy!” Who is going to devote time to non-reimbursable treatments?
In senior care, Medicare reimbursement is the pink elephant in the room. Follow the money. Until late last year, evidence-based, disease reversal programs for diabetes and heart disease were not reimbursable though they are shown to prevent disability, save lives and money. Go figure. Who is going to devote time to non-reimbursable treatments? As a consequence of reimbursability, I predict rapid growth in disease reversal programs.

A little known provision of the 2003 Bush/Medicare expansion prohibited government (the largest purchaser of medications) from bargaining on drug pricing. Huh? This act of government munificence to Big Pharma (the pharmaceutical industry) and Congressional malfeasance toward seniors was, by some estimates, a gift equalling a half-TRILLION dollars over the ensuing decade and largely contributes to the Medicare donut hole.
Medicare and the drug coverage gap (donut hole): In 2014, the Medicare drug allowance is $2850. Once that amount is exceeded, people fall into the coverage gap or donut hole. What does that mean? It means they will pay nearly 50% of their retail pharmacy bill for the rest of the year. 
For example: A month’s supply of insulin pens - either mealtime or bedtime - costs nearly $400. If the patient takes both types of insulin (as many do), their pharmacy expenditure for insulin alone costs nearly $800/month. They fall into the donut hole in just 3.5 months. 
As responsible clinicians, we try to switch our patients off all high cost, “designer” drugs that guarantee a dunk-in-donut - only to be accused of being miserly to "save Kaiser money." I’ve seen patients hit the donut hole mid-year with pharmacy bills exceeding $1000 per month thereafter. That’s unaffordable for most. 
Without the ability to negotiate prices on behalf of its citizenry, drug prices in the US remain artificially high, to the detriment of our population. And THAT’S why people buy medications online from Canada and Mexico. But I digress.

Intermission: Lest you think I disapprove of Medicare, let me say this. It is one of two programs responsible for keeping most seniors solvent through the great recession of 2008. It is administered at a fraction of the cost that private companies charge, and over all, it works well. Examples like the Big Pharma bequest rests squarely on broad and unaccountable, Congressional shoulders. A largesse borne by the American medication consumer, er… all of us. Grrr…
Further, Medicare oversight and fraud detection is funded separately by Congress - an appropriation that consistently gets the short-shrift. Hence - Medicare fraud can be very expensive - and again, a cost borne by the taxpayer - natch. Grrr again.

So what does Medicare have to do with dying? The overwhelming majority of Americans who die are elderly and covered by Medicare. In fact, the Congressional Budget Office reports that one-quarter of all Medicare spending occurs in the last year of life. ONE-QUARTER OF ALL MEDICARE SPENDING OCCURS IN THE LAST YEAR OF LIFE??? Medicare spending in 2013 was $586 billion - yes - with a capital B. One-quarter of that equals $146.5 billion … spent in the last year of life. Why? Because, I contend, EoL choices are limited and skewed.

What is Medicare’s position on dying and Death with Dignity? 
“Among patients, one significant segment of the population is precluded from taking part … people covered solely by Medicare, Medicaid or the military health plan, TRICARE. Under the national Assisted Suicide Funding Restriction Act of 1997, it is illegal to use federal funds to cause or help cause someone's death.” (I thought federal funds were used in prisoner executions by lethal injection. Turns out states bear that cost.) In other words, Death with Dignity medications are not reimbursable by Medicare.
Notice that the legislation is entitled the Assisted Suicide Funding Restriction Act.  This from Michael H. White, JD, mediator, attorney and former board member of the Death with Dignity National Center. “A terminally ill person who wishes to have the benefit of all medical resources that are available, or not, has that choice. However, a person who wishes to have the assistance of a physician in the dying process - either due to unremitting pain and suffering or the absence of adequate quality in life - does not have that choice.” We have the right to refuse care but not to end life. So we choose - to the tune of $146.5 billion in 2013.

Michael H. White again, “For a terminally ill person who wishes to end his or her life, the nonviolent choices available in California are (a) terminal sedation - that is, being rendered unconscious by a physician to end unremitting pain and suffering - and withdrawal of food and hydration until death occurs, or (b) electing to cease taking all food and hydration until death occurs, in short, starvation. In either case, a person's discomfort may be palliated by medical support and supervision.”
What does that mean really? In Choice A, the dying person is put into a drug induced sleep until starvation and dehydration ends life. Choice B is the same as Choice A without sedation. Some choice - we treat our pets with more compassion.

One opponent said, “So long as there are bridges and tall buildings from which a dying person can jump, there is no need for a law that would permit a physician to prescribe medication to end a person's life.” Let me reiterate, we treat our pets with more compassion.
White asserts that we would not subject death penalty prisoners to death by starvation or walking the plank from bridge or building. Why then do we limit the legal options of the terminally ill to waiting, starvation, jumping, and guns? 
There is much stigma with suicide and until we shift just the verbiage from Assisted Suicide to Death with Dignity or Right to Die or Assisted Dying, there is little room for dialogue. 

Death with Dignity - On October 27, 1997 Oregon passed the Death with Dignity Act, allowing physicians to prescribe a lethal dose of drugs to certain, terminally ill patients. Often called physician-assisted suicide by opponents, strict criteria for eligibility exists. People must be residents of the state (no EoL vacations), be deemed mentally competent and terminal, with less than six months of life, by two physicians. In Washington state, the request for the cocktail must occur twice verbally, once in writing and repeated over time. In Oregon, the cocktail costs about $400. Guess we don’t need Medicare after all.
Opponents included the American Medical Association, some disability-rights advocates, and more socially conservative religious groups, such as the Roman Catholic Church, Orthodox Jews and evangelical Protestant denominations. 
Widespread fear that abuse would lead to early demise for financial reasons and to end the burden of care have not been substantiated. In its first decade, only 292 terminally ill people availed themselves of the statute. Hardly a fire-sale.
A judges ruling on January 13, 2014 made New Mexico the fifth state in the US to allow terminally ill, mentally competent patients the right-to-die. The five states include Oregon, Washington, Montana, Vermont, and New Mexico.

What about Hospice and a good death? “Hospice is not about how you want to die; its about how you want to live until you die” says Dr. Michael GuntherMaher, Hospice Director at Kaiser Permanente in Sacramento. Well that shifts the context a wee bit; donchya think? 
Currently, to receive hospice care, patients must agree to forego any further attempts at curative treatments. That makes some hesitate, as if enrolling in Hospice is surrender. In fact, in 2011, the national median length of hospice service was a mere 19 days. 
Hospice caregivers are skilled at easing the transition to facing death. “The ideal would be that everybody finds peace with their dying, and that takes time,” says Dr. E. Szmuilowicz of Northwestern University’s Feinberg School of Medicine. “If we don’t give people that time, we are really robbing them of the potential to find some peace.”

CMS is intending to test a new model. It is well known that hospice services can improve the quality of life AND reduce Medicare expenditures. What if patients didn’t have to choose between Hospice and curative treatments? In a multi-year pilot, CMS will test just that in patients with advanced cancer, chronic obstructive pulmonary disease, congestive heart failure and HIV/AIDS. 
Who wouldn’t rather have quality care at home? I foresee a day when that will occur regularly but we’re not there yet, in part due to rules of reimbursement. History shows that hospice care is restricted by the either-or choice at EoL, by fears that hospice care equates to little or no care, that giving in is giving up. Additionally, funding for Hospice care has become progressively circumscribed by increasingly strict criteria.
In short, EoL choices and care are limited by the legalities of one’s resident state, reimbursements, and money. Patients can and do choose from a large menu of lifesaving measures. But when care is futile and its time to face death, the menu is unnecessarily spare. Medications can relieve much pain and suffering while we wait. And if they don't? Its slim pickins.
or at least that’s how it looks from this corner of the ring. 

In Part 3, I will discuss how fear keeps us from having meaningful, reformative conversations in this country. How threats of Granny Death Panels and cost-saving rhetoric keep us stuck, outraged and unable to make common sense reform.