2014 Congress of Delegates

End-of-Life Care, Tobacco Control, Immigrant Discrimination Draw Fervent Testimony

October 23, 2014 01:40 pm Chris Crawford Washington –

Delegates to the 2014 Congress of Delegates here addressed end-of-life care planning, tobacco control and discrimination against immigrants, among other topics, and adopted a number of resolutions during the Oct. 21 business session.

Oregon alternate delegate Elizabeth Steiner-Hayward, M.D., of Portland, points out that the now widely used "Physician Orders for Life-Sustaining Treatment" form originated in her state. About four years ago, Oregon passed legislation to develop a statewide registry for these forms.

End-of-Life Care Planning

During the Reference Committee on Health of the Public and Science hearing on Oct. 20, attendees discussed a resolution that addressed the implementation of centralized registries of documents indicating individuals' preferences for end-of-life care.

Michigan alternate delegate Jennifer Aloff, M.D., of Midland, who helped craft the resolution, testified that the Michigan delegation has already been working with its state legislature to create a centralized durable power of attorney (DPOA) clearinghouse. The bill that spurred the creation of the database was signed about 1 1/2 years ago, but development of the resource is still in process.

"As we went through those discussions, we realized that with all of the other things that family physicians are facing, it takes a while to have an informed discussion with your patients on DPOA," said Aloff. "So if there were educational resources and a centralized site where they could go with their family members to lead them through the process, it could be helpful."

Story highlights
  • During the Oct. 20 Reference Committee on Health of the Public and Science hearing, members discussed a resolution that addressed implementation of centralized registries of documents indicating individuals' preferences for end-of-life care.
  • Two resolutions delegates adopted aim to better control tobacco use and educate members on the latest research on the subject.
  • Another measure adopted asked the Academy to urge federal and state government agencies to ensure routine, evidence-based health care screening and access to treatment for newly immigrated populations and support policies to better care for immigrants, refugees and asylees.

She noted that although the AAFP has some great resources available on its website on this subject, it doesn't yet have a policy on the accessibility of such documents.

Washington alternate delegate Gregg VandeKieft, M.D., of Olympia, spoke in support of the resolution. VandeKieft holds a certificate of added qualifications in hospice and palliative medicine from the American Board of Family Medicine and is presenting twice on the topic during the Assembly this week.

Plenty of confusion surrounds this issue, said VandeKieft, noting, for example, that an email he received just two hours before the hearing carried the subject line "Family confused as patient chooses DNR on Tuesdays, Thursdays and Saturdays only." He commended the resolution's authors on not just including the widely used "Physician Orders for Life-Sustaining Treatment" (POLST) and similar forms but also specifically including the DPOA for health care decisions.

Oregon alternate delegate Elizabeth Steiner-Hayward, M.D., of Portland, pointed out that her state was the originator of the POLST form, and, about four years ago, Oregon passed legislation to develop a statewide registry for these forms.

"When a patient completes this form, it gets entered in the registry and the patient gets sent a magnet sticker for their refrigerator and something for their wallet with their registry number on it," said Steiner-Heyward. "Family members know that it's there, and paramedics and health officials have access to the system very easily.

"Let's not let the perfect become the enemy of the good, and let's figure out ways to encourage these registries on a state-by-state basis because they will make a huge difference in making sure our patients get what they want in their last days and months of life."

In its report, the reference committee offered a substitute resolution that supported the implementation of centralized registries and mechanisms encouraging the uploading of advanced directives, DPOA and POLST forms, and do not resuscitate orders to the systems. The measure also advocated developing centralized Health Insurance Portability and Accountability Act registries and tools to ensure this information is readily accessible to medical decision-makers when a patient presents or transfers to a new facility. Delegates adopted the substitute resolution.

Tobacco Control

Two other resolutions delegates adopted took direct aim at tobacco use and the need to educate members about the latest research on the subject.

The first resolution asked the AAFP to advocate that tobacco product sales cease in all pharmacies and stores containing a pharmacy department.

Student delegate Douglas Borst, M.D., of Coeur d'Alene, Idaho, speaks in favor of a resolution to address immigrant discrimination, saying, "The immediacy of this crisis and the specificity of its needs deserve special attention from our body."

North Carolina delegate Mott Blair IV, M.D., of Wallace, put it succinctly: "You can't really say that you 'live at the corner of happy and healthy' if you sell tobacco products."

Alternate resident delegate Diana Mokaya, M.D., of San Jose, Calif., also supported the resolution, saying residents and students have consistently stood against tobacco in their respective congresses. "This is consistent with what we do in our day-to-day lives," she said.

The second tobacco-related resolution sought Academy recognition of 50 years of sustained anti-tobacco efforts by family physician Alan Blum, M.D., of Tuscaloosa, Ala. The measure also called on the AAFP to educate members about the tobacco-related resources Blum created as part of the Center for the Study of Tobacco and Society at the University of Alabama and to "encourage state academies, family physicians, and granting agencies to help both utilize the resources of the Center and help support its digitization."

Florida alternate delegate Dennis Saver, M.D., of Vero Beach, suggested amended language in his reference committee testimony. But even in so doing, he noted, "If the resolution simply said, 'Alan Blum is a national treasure,' we could have gone with that."

In the end, the reference committee proffered -- and delegates adopted -- a substitute measure that simply asked that the AAFP educate members about the center and encourage them to use its resources.

Immigrant Discrimination, Health Care Disparities

Another resolution that drew plenty of discussion addressed discrimination against immigrants and related health care disparities. The resolution called on the Academy to urge federal and state government agencies to ensure routine, evidence-based health care screening and access to treatment for newly immigrated populations and to support policies to better care for immigrants, refugees and asylees.

California alternate delegate Jay Lee, M.D., M.P.H., of Long Beach, explained that the resolution was inspired by the efforts of a coalition of family physicians and pediatricians alarmed at language recently used in relation to an influx of migrant children across the Mexican border. For example, he said some press coverage has suggested these children are carriers of Ebola.

"We know that scare-mongering distracts policymakers from addressing the root causes of the violence that is driving many of these kids to migrate from Central America and other countries and from the obligation we have to protect the well-being of these children," he said.

Lee said that despite the fact that these migrant children represent only a small fraction of those crossing the borders into the United States, such misinformation has inaccurately portrayed them as disproportionally responsible for cross-border transmission of disease. This perpetuates a longstanding legacy of discrimination rooted in factual inaccuracy, he added.

Student delegate Douglas Borst, M.D., of Coeur d'Alene, Idaho, said these children have real health concerns, including mental health issues and the trauma that has driven them from their home countries.

"For students who are concerned about access to health care for and the protection of at-risk populations, this is a clear place where the AAFP can lead by using our contacts and relationships with government agencies -- state and national -- public health organizations and other physician groups to advocate for this humble population," Borst said. "The immediacy of this crisis and the specificity of its needs deserve special attention from our body."

Ultimately, delegates agreed with the reference committee's recommendation that the resolution be adopted.

Other Issues

Delegates referred the following measures to the Board of Directors for further review. These resolutions called on the AAFP to

  • consider creating a policy suggesting individual states require students and parents to see a licensed health care professional before claiming a personal belief exemption for vaccination,
  • support prohibiting the sale and/or distribution of all raw or unpasteurized milk and milk products for human consumption in the United States,
  • support the elimination of antibiotic use in livestock for nontherapeutic purposes, and
  • develop patient-centered, evidence-based educational materials regarding the use of recreational marijuana.

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