This Pandemic should prompt everyone, and especially older people, to think about how they want to die and how they want their financial assets and liabilities handled after they are gone from this world. I already have reviewed my will, trust documents and health care directive and decided that no changes were necessary other than updating contact information for my health care agents.[1]
I also recently have discovered another important document that an individual should review and decide whether it is appropriate for him or her or anyone in their family to fill out and sign before that individual ever goes into a hospital emergency room.
That document is the POLST or Provider Orders for Life-Sustaining Treatment, which was created “to advance care planning for patients who are considered to be at risk for a life-threatening clinical event because they have a serious life-limiting medical condition, which may include advanced frailty.”[2] The Minnesota form has the following sections with boxes to check the appropriate treatment:[3]
A. CARDIOPULMONARY RESUSCITATION (CPR) Patient has no pulse and is not breathing.
Attempt Resuscitation/ CPR (Note: selecting this requires selecting “Full Treatment” in Section B).
Do Not Attempt Resuscitation / DNR (Allow Natural Death). When not in cardiopulmonary arrest, follow orders in B.
B. MEDICAL TREATMENTSPatient has pulse and/or is breathing.
Full Treatment. Use intubation, advanced airway interventions, and mechanical ventilation as indicated. Transfer to hospital and/or intensive care unit if indicated. All patients will receive comfort-focused treatments. TREATMENT PLAN: Full treatment including life support measures in the intensive care unit.
Selective Treatment. Use medical treatment, antibiotics, IV fluids and cardiac monitor as indicated. No intubation, advanced airway interventions, or mechanical ventilation. May consider less invasive airway support (e.g. CPAP, BiPAP). Transfer to hospital if indicated. Generally avoid the intensive care unit. All patients will receive comfort-focused treatments. TREATMENT PLAN: Provide basic medical treatments aimed at treating new or reversible illness.
Comfort-Focused Treatment (Allow Natural Death). Relieve pain and suffering through the use of any medication by any route, positioning, wound care and other measures. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Patient prefers no transfer to hospital for life-sustaining treatments. Transfer if comfort needs cannot be met in current location. TREATMENT PLAN: Maximize comfort through symptom management.
E. ADDITIONAL PATIENT PREFERENCES (OPTIONAL)
ARTIFICIALLY ADMINISTERED NUTRITIONOffer food by mouth if feasible. Long-term artificial nutrition by tube. Defined trial period of artificial nutrition by tube. No artificial nutrition by tube.
ANTIBIOTICSUse IV/IM antibiotic treatment. Oral antibiotics only (no IV/IM). No antibiotics. Use other methods to relieve symptoms when possible.
ADDITIONAL PATIENT PREFERENCES (g. dialysis, duration of intubation)
POLST was started in the early 1990s by a group of Oregon medical ethicists, and then in September 2004 the National POLST Advisory Panel (later known as the National POLST Paradigm Task Force and now known as The National POLST Office) was convened to establish quality standards for POLST forms and programs and to assist states in developing POLST as a model process. [4]
On May 16, in Havana the U.S.-Cuba Bilateral Commission held its third meeting to review the status of the countries’ efforts to normalize relations. The U.S. delegation was headed by Ambassador Kristie Kenney, currently serving as Counselor of the Department of State, who was assisted by John S. Creamer, Deputy Assistant Secretary of State, Bureau of Western Hemisphere Affairs, U.S. Department of State; and by U.S. Ambassador Jeffrey DeLaurentis, Chargé d’Affaires, U.S. Embassy, Havana, Cuba. The Cuban delegation’s head was Josefina Vidal Ferreiro, the Director General of the Cuban Ministry of Foreign Affairs’ Department of the United States.[1]
Before the meeting the U.S. State Department said it “will provide an opportunity to review progress on a number of shared priorities since the last Bilateral Commission meeting in November 2015, including progress made during the President’s historic trip to Cuba in March. The United States and Cuba expect to plan continued engagements on environmental protection, agriculture, law enforcement, health, migration, civil aviation, direct mail, maritime and port security, educational and cultural exchanges, telecommunications, trafficking in persons, regulatory issues, human rights, and claims for the remainder of 2016.”
Director General Vidal’s Press Conference
At a press conference after the meeting, Director General Vidal said the meeting had been “productive” and conducted in a “professional climate of mutual respect.” (A photograph of Vidal at the press conference is on the left.) The parties agreed to hold the fourth meeting of the Bilateral Commission in September 2016 in Washington, D.C.
Vidal also said she had told the U.S. delegation that Cuba reiterates its “appreciation for the positive results from President Obama’s visit to Cuba” that had been mentioned by President Raúl Castro during Obama’s visit. Indeed, she said, Cuba believes this visit is “a further step in the process towards improving relations” between the two countries and “can serve as an impetus to further advance this process.”[2]
Vidal acknowledged that there has been an increase in official visits as well as technical meetings on topics of common interest resulting in nine bilateral agreements to expand beneficial cooperation.[3]
According to Vidal, both delegations agreed on steps that will improve relations, including conducting high-level visits and technical exchanges on environmental, hydrography, and implementation and enforcement of the law, including fighting trafficking in drugs and people, and immigration fraud. The two countries also are getting ready to conclude new agreements to cooperate in areas such as health, agriculture, meteorology, seismology, terrestrial protected areas, response to oil-spill pollution, fighting drug trafficking and search and rescue, among others. They also are ready to start a dialogue on intellectual property and continue those relating to climate change and regulations in force in the two countries in the economic and trade area.
However, Vidal said, progress has not been as fast in the economic area because “the blockade [embargo] remains in force” despite the positive measures taken by President Obama to loosen U.S. restrictions. There still are significant U.S. restrictions on U.S. exports to Cuba and imports from Cuba. In addition, U.S. investments in Cuba are not allowed except in telecommunications, and there are no normal banking relations between the two countries. Therefore, Cuba stressed again the priority of the “lifting the economic, commercial and financial blockade [embargo].”
More specifically Vidal said Cuba had told the U.S. representative that in the last six months two American companies and one French company had been fined by the U.S. for maintaining links with Cuba while Cuba has had problems with 13 international banks’ closing accounts, denying money transfers or suspending all operations with Cuba. In addition, six service providers have ceased providing services to Cuban embassies and consulates in third countries (Turkey, Austria, Namibia and Canada).
In addition, the Cuban delegation, said Vidal, had reaffirmed the need for the U.S. to return to Cuba the territory [allegedly] illegally occupied by the U.S. naval base in Guantanamo. It “is the only case of a military base in the world that is based in a territory leased in perpetuity, which is an anomaly from the point of view of international law.[4] There is no similar example in the world and is the only instance of a military base in a foreign country against the will of the government and people of that country.
Vidal also mentioned the following U.S. policies and actions that needed to be changed:
the U.S. preferential migration policies for Cuban citizens, expressed in the existence of the policy of dry feet/wet feet;
the U.S. Cuban Adjustment Act regarding those immigration policies;
the U.S. program of parole for Cuban health professionals;
the special U.S. radio and television broadcasts designed especially for Cuba (Radio and TV Marti); and
U.S. programs designed to bring about changes in the economic, political and social system of Cuba.[5]
These U.S. policies, according to Vidal, underscored “a huge contradiction” for the U.S. On the one hand, President Obama said in his speech in Cuba that the U.S. has neither the intention nor the ability to bring about change in Cuba and that in any case it was up to the people of Cuba to make their own decisions. On the other hand, the U.S. has programs with huge budgets ($20 million dollars every year) aimed at bringing about such change. If indeed there is neither the intention nor the ability to bring about change in Cuba, then there is no reason to have such programs.
Normalization, said Vidal, also needs to have protection of rights to trademarks and patents because there are Cuban companies owning well-known marks, which for reasons of the blockade and other reasons have been taken away from the Cubans.
Before the meeting, another Cuban Foreign Ministry official said that the parties previously had discussed, but not negotiated, with respect to Cuba’s claim for damages with respect to the U.S. embargo and the U.S. claims for compensation for property expropriated by the Cuban government. At the meeting itself, according to a Cuban statement, the Cubans had delivered a list of its most recent alleged damages from the blockade (embargo).
U.S. Embassy Statement
The U.S. Embassy in Havana after this Bilateral Commission meeting issued a shorter, but similar, statement about the “respectful and productive” discussions. “Both governments recognized significant steps made toward greater cooperation in environmental protection, civil aviation, direct mail, maritime and port security, health, agriculture, educational and cultural exchanges, and regulatory issues. The parties also discussed dialogues on human rights and claims, and the [U.S.] looks forward to holding these meetings in the near future.”
Conclusion
Since the actual meeting was conducted in secret, it is difficult to assess what was actually accomplished except through officials’ subsequent public comments.
On May 17, the two countries conducted their second Law Enforcement Dialogue, which will be discussed in a subsequent post.
[2] Vidal’s positive comment about Obama’s visit is in sharp contrast to the negative comments about the visit from Vidal’s superior, Foreign Minister Bruno Rodriguez at the recent Congress of the Communist Party of Cuba. (See Conclusion of Seventh Congress of Communist Party of Cuba, dwkcommentaries.com (April 20, 2016).)
[3] Beforehand an official of Cuba’s Foreign Ministry said that since the December 2014 announcement of détente the parties had signed nine agreements covering the environment, email, navigation safety, agriculture and travel. In addition, the Telecommunications Company of Cuba (ETECSA) had signed agreements with three U.S. companies for cellular roaming in Cuba; a U.S. company (Starwood) had an agreement to manage several Cuban hotels; and the Carnival cruise lines had made a maiden voyage to the island.
[4] The U.S., however, contends that the lease is not in perpetuity, but for so long as the U.S. uses it as a “naval station.” This is one of the potential issues to be resolved in an international arbitration as suggested in a previous post. (Does Cuba Have a Right To Terminate the U.S. Lease of Guantanamo Bay? dwkcommentaries.com (April 26, 2015).)
[5] Prior posts have concurred in the Cuban requests for ending all of these U.S. programs and policies. See Topical List of Posts—Cuba.
On September 11, in Havana, the U.S.-Cuba Bilateral Commission held its first meeting. It decided on an agenda for the future discussions and hoped-for resolution of remaining issues regarding normalization of relations. The commission agreed to meet again in November in Washington, D.C. to review progress in these areas and to chart areas of cooperation for 2016.[1]
The agenda has been divided into three tracks, with the first encompassing issues where there is significant agreement and the possibility of short-term progress. These include re-establishing regularly scheduled flights, environmental protection, natural disaster response, health and combatting drug trafficking. A second track includes more difficult topics such as human rights, human trafficking, climate change and epidemics. The third includes complex, longer-term issues like the return of the U.S. base at Guantanamo Bay, U.S. damage claims over properties nationalized in Cuba after the 1959 revolution and Cuba’s damage claims for more than $300 billion in alleged economic damages from the U.S. embargo and for what it says are other acts of aggression.
Cuba reiterated its opposition to the comprehensive U.S. economic embargo, the U.S. occupation of Guantanamo and anti-communist radio and television broadcasts beamed into Cuba, but did not seek to place them on the agenda because they were measures unilaterally imposed by the United States.
Both sides agreed the discussions were full and frank, extensive, and conducted in a courteous and respectful manner.
Cuba’s delegation was led by Josefina Vidal Ferreiro, the Foreign Ministry’s director general for the United States, The U.S.’ by Deputy Assistant Secretary of State for South America and Cuba, Edward Alex Lee, accompanied by the Director of the Secretary’s Policy Planning Staff, David McKean; and Charge d’affaires ad interim Jeffery DeLaurentis. Below to the left is a photograph of the Cuban delegation; below to the right is a photograph of the U.S. delegation.
Cuban delegationU.S. delegation
Vidal indicated that the both sides saw the start of the process as opening at least the possibility of an Obama visit to Cuba, saying that it is natural for countries with normal relations to receive visits from each other’s leaders.
