Saturday, April 4, 2026
'When Shared Decision-Making Becomes Medical Paternalism'
"Why haven't they scheduled your dad for his feeding tube placement? They just want another family conference."
I sighed and told my mother we may have to fight. The physicians caring for my father seemed ready to overrule her decision, even though she held his medical power of attorney. When I spoke with an intern, I explained that our family had not changed its mind about the course of treatment. We simply wanted to know when the feeding tube would be placed.
Her response stunned me. "We refuse to place it," she said. "And we have the right to refuse anything."
Calmly, I explained that, as a physician myself, I know that doctors may decline to perform a procedure for ethical or professional reasons, but they are also obligated to transfer care or find someone willing to provide it. The ultimate decision about my father's treatment rested with our family -- specifically my mother.
What should have been a conversation about care became a confrontation about authority. Increasingly, families are finding that "shared decision-making" in medicine is giving way to something else: physicians overriding patient and family wishes in the name of "knowing what is best." Hospitals often promote "shared decision-making" as the ideal model of care. Yet, as debates about end-of-life treatment intensify, many families are discovering that the reality can feel very different.
Disagreements between families and medical teams are common, especially near the end of life. Physicians and families often face heartbreaking situations in which aggressive treatment may prolong suffering rather than improve quality of life. These are complex decisions, and families depend on clinicians for honest guidance and expertise.
But guidance is not the same as control.
Ideally, treatment decisions using shared decision-making emerge from mutual respect and open dialogue. In practice, however, the language of shared decision-making sometimes masks a different reality: families feel pressured to accept what clinicians believe is the correct decision.
Patients are routinely reminded that they have the right to refuse aggressive treatment. But what happens when a patient or family chooses the opposite -- to continue treatment despite a grim prognosis? Too often, autonomy seems to disappear when a patient or family chooses care that physicians would not choose themselves. I knew conversations were happening in the background in an effort to sway our decision.
Decisions about feeding tubes in patients with advanced dementia are among the most ethically complex choices families and physicians face. Studies suggest feeding tubes rarely improve survival or quality of life in these patients, which is why clinicians often hesitate to recommend them. But difficult medical evidence does not eliminate the need for respectful dialogue. Families may consider the same information and reach different conclusions based on personal, cultural, or religious values. The options presented to my family were not presented in a neutral fashion, which is what I aim to do in my practice.
This wasn't the first time our family encountered this attitude.
On another occasion, my father developed a broken tooth that became infected and was causing him significant pain. My mother asked that it be extracted. Instead, the request triggered a family conference involving dentists, social workers, and medical residents. Ultimately, one dentist argued that the tooth should not be pulled and suggested allowing the infection to run its course given my father's condition.
Experiences like these make families wonder whether their loved one's values are truly being respected. I thought about residents I work with and their communication with families: do they do this? Having challenging discussions while being respectful and humble with regard to the family's experience is a difficult skill to master and teach.
Families bring deeply held values -- cultural, moral and religious -- to decisions about care. Those beliefs should not automatically be dismissed as ignorance or denial. When families misunderstand the prognosis, physicians should provide clear and compassionate education. But not every disagreement reflects a lack of understanding. Sometimes it simply reflects different priorities.
These situations create genuine ethical dilemmas. Physicians must balance professional judgment with respect for patient autonomy. But when the balance tips too far toward paternalism, the consequences are profound.
Trust begins to erode. Trust is the foundation of the physician-patient relationship. Without it, even the most technically excellent care becomes difficult for families to accept.
In my father's case, the feeding tube was ultimately placed after the hospital's patient advocacy office became involved. The intern's statement that the team could simply "refuse anything" raised more than a few eyebrows. The dentist involved in the earlier dispute was also removed from my father's care team. Yet, the damage was done. My family no longer trusts the medical team caring for my father, and that trust cannot be rebuilt.
Not every interaction was negative. An anesthesia resident showed remarkable kindness and respect toward my mother as she struggled with one of the most difficult decisions of her life. That moment served as a reminder of what medicine can look like at its best.
DeAnna M. Pollock, MD, is an anesthesiologist and the associate program director of the Anesthesiology Residency Program at Common Spirit St. Joseph's Medical Center in Stockton, California. She writes about medical ethics and patient advocacy.
CMS finalizes Medicare Advantage star ratings overhaul, sending billions of dollars more to insurers
The Trump administration has finalized a rule overhauling the Medicare Advantage star ratings system that’s expected to significantly boost insurers’ ratings — and the reimbursement that’s attached.
On Thursday, the CMS finalized a rule cutting measures that factor into the MA quality ratings and rolling back health equity initiatives that will funnel billions of dollars more to MA insurers.
Specifically, regulators eliminated 11 star ratings metrics measuring administrative processes on which plans perform similarly. The agency is also not implementing a new health equity award put in place by the Biden administration that was set to kick in next year, called the “health equity index.”
Instead, the CMS reinstated a bonus system that raises payments to payers with consistently high ratings.
The CMS argued that the changes refocus star ratings around clinical outcomes, instead of a system that prioritizes administrative functions that are similar between plans and don’t help beneficiaries shop for coverage.
“We are fundamentally shifting our approach to quality,” Medicare Director Chris Klomp said in a statement. “This isn’t just about adjusting measures; it’s about redefining success. We are moving away from a system that incentivizes administrative box-checking and are instead laser-focused on what truly matters: the clinical outcomes and health of our beneficiaries.”
However, the rule is also expected to increase star ratings for insurers, inflating the cost burden of MA at a time when regulators and legislators are increasingly alarmed about overpayments in the privatized Medicare program — including bonus payments based on stars.
The star ratings changes are expected to cost taxpayers more than $18 billion over the next decade, according to an analysis in the final rule. The CMS previously estimated the changes would cost about $13 billion when the rule was proposed in November.
The star ratings system grades MA plans on a scale from 1 to 5 based on a complex calculation of dozens of metrics measuring outcomes, patient experience and more. As part of the Trump administration’s focus on paring back what it views as overly onerous industry regulations, officials in the CMS proposed in November making the ratings simpler.
The goal was applauded by insurers eyeing the potential of higher scores, after stars fell coming out of the coronavirus pandemic, sparking a raft of lawsuits from the industry.
The metrics canceled by the CMS on Tuesday include one zeroing in on the performance of insurer’s call centers — the issue at the center of multiple suits from insurers, including MA giants UnitedHealthcare and Humana. Measures related to appeals and provider complaints were also cut.
The CMS had planned to nix a metric for eye exams for diabetic patients, but decided to keep it in after plans complained. Most of the changes take effect in the 2027 measurement period, and will inform star ratings in 2029.
MA groups applauded the final rule, saying they approved of changes to make star ratings simpler and more oriented towards clinical quality.
The Alliance of Community Health Plans, which represents nonprofit insurers, said it “strongly” supported CMS’ decision to eliminate the health equity index and restore the previous reward factor, noting it would better support rural communities.
Billions of dollars more in higher Medicare spending on star ratings bonuses is relatively nominal at the payer level, and when compared to the overall MA program — MA is expected to cost taxpayers more than $750 billion in 2028.
How much the rule benefits a plan also depends on their specific situation.
Beyond the impact on Medicare spending, “there may be effects on supplemental benefits, premiums, and plan profits. These impacts will likely vary significantly from plan to plan (or contract to contract) based on the business strategies and the competitive landscape for each plan and contract,” regulators wrote in the final rule.
But the rule is a boon nonetheless, especially for plans facing shrinking profit margins from a combination of stagnating government reimbursement and rising spending on members’ care. MA growth has slowed as major payers exit underperforming markets and trim benefits in a bid to resuscitate profits, though MA still covers 35 million seniors, more than half of all Medicare beneficiaries.
MA plans in particular are waiting anxiously for the CMS to finalize MA payment for 2027, and are crossing their fingers that final rates will be more generous than the flat update proposed earlier this year.
Regulators have until this coming Monday to publish the rate announcement.
The final rule also undoes key health equity changes to the MA program enacted by the Biden administration, as the Trump administration continues to target diversity, equity and inclusion initiatives.
MA plans’ quality improvement programs will no longer have to include activities designed to reduce health disparities, while their utilization management committees won’t have to include a health equity expert member, conduct annual health equity analyses or publicly post the result of those reviews, according to a fact sheet on the rule.
The CMS also finalized clarifications around MA plans’ supplemental benefits, which go above and beyond what can be provided in traditional Medicare.
Moving forward, debit cards used to administer supplemental benefits have to be linked electronically to the specific items and services covered by a plan, so that the plan can verify that a charge is eligible at the point of sale. Plans are not allowed to provide marijuana products as supplemental benefits for their chronically ill members, the CMS said.
Regulators rescinded a Biden-era requirement that MA plans notify their members of any unused supplemental benefits in the middle of the year. They also did not finalize a proposed ban on marketing the dollar value of supplemental benefits.
The CMS also declined to finalize a proposal creating a special enrollment period for enrollees affected by providers leaving their MA network to find a new plan. Regulators said they would consider the idea in future rulemaking, as contract disputes between MA plans and providers ramp up, affecting more beneficiaries.
https://www.healthcaredive.com/news/medicare-advantage-star-ratings-overhaul-cms-final-rule/816569/
Vericel new 10-year BARDA contract up to $197M for NexoBrid procurement, advanced development
- Contract spans procurement, inventory management and U.S. manufacturing design activities for NexoBrid
- BARDA funding also supports advanced development of NexoBrid, including potential new indications and formulations
Oruka Therapeutics (NASDAQ: ORKA) files $1B shelf to sell equity, warrants
IDF says it struck Iran's Quds Force site in Beirut
The Israel Defense Forces (IDF) announced on Saturday that its Israel Air Force (IAF) targeted yesterday command centers of Iran's Islamic Revolutionary Guard Corps' (IRGC) Quds Force operating in Lebanon's capital.
"Yesterday, the IAF completed a wave of attacks on the infrastructure of terrorist organizations throughout Lebanon, in which headquarters used by the Lebanese Quds Force were attacked," it was stated on X.
Moreover, the Israeli military also shared that it had hit two command centers belonging to the Palestinian Islamic Jihad, "which were utilized by the organization's senior officials for decision-making and coordination with Hezbollah."
https://breakingthenews.net/Article/IDF-says-it-struck-Iran's-Quds-Force-site-in-Beirut/66012490
IDF confirms striking Iran's petrochemical sites
The Israel Defense Forces (IDF) confirmed on Saturday that its troops targeted the Mahshahr Petrochemical Special Economic Zone in Iran's southern Khuzestan province earlier today.
The military also claimed that this infrastructure was used by the Iranian regime to produce materials for ballistic missiles, whereas the Israeli attacks halted the manufacture, and are expected to cause billions of dollars in financial damage.
https://breakingthenews.net/Article/IDF-confirms-striking-Iran's-petrochemical-sites/66012625