Death certificates were changed to an electronic format so it looks like automatically there is a loss in accountability because the old rules we learned about in the last post can’t be followed (in the same way at least). So that change is significant in itself. Under the old system, for instance, the death certificate accompanied the body to the funeral home.
So just getting back to this document (just noting additional points besides the fact that the deaths are considered “natural”):
It’s just a totally different process than what was represented in the 2010 training document:
What is the role of the LTC on-call physician or Nurse Practitioner?
•The LTC physician or NP does not need to attend the LTC home to pronounce death.
•The physician or NP will be required to provide guidance to the MRDR team in the LTC home as to the immediate and antecedent cause(s) of death, and other significant contributing conditions, which will be entered by the MRDR team on the template for submission to the OCC.
•The OCC team will complete the electronic MCOD [Medical Certificate of Death]
•The OCC team may follow up with the physician and MRDR team if further clarification is needed.
•As this process will continue 24/7, it is important that the on-call physician is available to assist the MRD team with informing these key pieces of information whenever a death occurs.
Compare this to the old-style death certificate process. The physician or NP (Nurse Practioner) does not have to be present. And they do not even enter the data into the template! The MRDR team enters the data and they submit it to the OCC (Office of the Chief Coroner). The remote office actually completes the electronic death certificate. Do we assume it is a person who is actually legally qualified to do that at the coroner’s office–actually the Chief Coroner? So many assumptions to make, so many weak links in all of this. That’s the way it looks to me.
Also the expression “will continue 24/7” reads like they were expecting a constant flow of bodies. What was the rate of death at LTC homes in past years and what was it in these last few months? Can we compare?
The MRDR acronym is very inappropriate and is repeated a lot in the document. The two terms are MRDT which is “Managing Resident Deaths Team” and MRDR stands for “Managing Resident Death(s) Report.”
The next topic in the document:
What about a death that requires a coroner investigation?
•The Institutional Patient Death Record (IPDR) will continue to be required and provided to the OCC as part of the Managing Resident Deaths process.
•The OCC Team will review the IPDR and proceed with contacting a coroner when required.
•Deaths that are secondary to COVID-19 should not be characterized as unexpected deaths in the IPDR
If a death requires a coroner investigation, do we leave the deceased resident in their room in the LTC facility?
•No. Regardless of whether a death requires a coroner investigation, the movement of the resident to the funeral home by the funeral service provider will proceed.
•When required, the OCC Team will contact a coroner who will connect with the funeral home.
I don’t know if this is a new procedure or not. Was the body normally left at the LTC home until the coroner investigated? I checked the training document and this page. There is also the Coroners Act to look up on this question.
If the death is characterized as a sudden or unexpected death and notification to Compliance is required what coroner name do you provide?
•Please indicate that the death was reported to the OCC team as part of the Managing Resident Deaths in Long Term Care process.
•When required, the OCC Team will contact a coroner who will connect with the funeral home if necessary.
Referring to the “OCC Team” as opposed to an individual who is named and accountable seems like shifting sand to me. Who says there is actually a coroner on the team and how would they know whether to contact them or not? Shouldn’t there be a clear line of communication between parties such as family members and an actual coroner who decides whether to investigate or not?
The next section explains that the “IPDR process” (I assume this refers to their standard process when there is a death at an LTC home) is “incorporated into the Managing Resident Death Report (MRDR)” “for the duration of this process.” It’s “part of the MDR process during the COVID-19 outbreak period.” And it’s electronic. IPDR stands for “Institutional Patient Death Record.”
This part seems to indicate there was an obstacle to doing all of this so quickly:
Question 9 of the Institutional Patient Death Record (IPDR) references Ministry of Health (MOH) Compliance or Critical Incident Findings.
a)What is the relevant time period?
b)How can these be accessed as they are often maintained separate from the resident’s health record?
•Please provide evaluate to determine if there have been MOHCompliance or critical incident findings within the year prior to the death of the resident
•Each LTC home Director of Care should identify a method to ensure timely access to this information to support timely completion of the MRDR
There is short time-frame:
How quickly should the MRDT complete the Managing Resident Deaths Report (MRDR)and IDPR send it to the OCC?
•This process should be completed within a few hours of the death.
•The MRDR can be sent to the OCC by one of the following methods:
. . . [email, secure web form or fax]
There isn’t much time given for this process. How could it have been done at night–was all the data available outside of working hours? Were the government offices staffed 24 hours for accessing the data? I wonder how many snags they have run into with this process, which I guess is still ongoing.
So this is where it gets rushed:
Who calls the funeral home?
•The family must call the funeral home to request their services and initiate transfer of the deceased resident.
•Ensure the family member who has the necessary legal authority contacts the funeral home immediately after providing the information to the MRDT.
•The MRDT should also call the funeral home to let them know that the family will be in contact, to expect their call, and to facilitate prompt transfer of the deceased resident.
Notice the short time pressure put on the family members. That is a key point of the main article.
They want the deceased removed quickly.
Continuing on page 4:
The funeral home will be informed of the specifics, etc. . .
Funeral service providers already knew about this:
•Funeral service providers have been working together with the Office of the Chief Coroner to prepare this approach
•They have been informed of and their role to promptly attend to transfer a deceased resident into their care
•They are aware that the medical certificate of death will not be transported with the body but sent electronically from the OCC directly to the funeral home [the old procedure replaced by the new one]. . ..
•The nurse or physician who was providing care should ensure there is an ID bracelet or other appropriate form of ID on the resident.
oID arm bands may be available as part of the home evacuation plan
•In addition, ID must be affixed securely to the outside of the body bag.
•In cases of suspected or confirmed COVID-19 deaths, you must label the body bag with “COVID-19”.
•Before the deceased resident is moved, the MRDT must ensure that the ID on the residentmatches the ID on the body bag. This is of critical importance [this point is underlined].
I think there is concern about the ID especially because a physical death certificate no longer accompanies the body.
Then there are some points about body bags.
LTC staff will be required to transfer the deceased resident into the body bag as the funeral service providers will not be entering into the LTC home, to prevent any inadvertent transmission of COVID-19
Then there are points about preparation of the body, e.g.:
Tubes, catheters and lines should be left in place on the deceased resident unless these impede with placement in and closure of the body bag.
The reason given is concern about movement of fluids and transmission of infection.
Depending on the family’s wishes, jewellery and personal effects are supposed to be either left with the body or removed from the resident’s room and disinfected before giving them to the family.
Similarly with clothing.
They don’t want a blanket placed over the body bag:
While recognizing the desirability of this practice any object placed over the body bag on the stretcher increases the risk of contamination and should not occur
So one of the signals and assumptions with all of these rules is that this particular virus is very contagious. I wonder if this procedure and all of these concerns about contamination had existed in previous situations with Legionnaire’s Disease, etc.
The body bag is supposed to contain the infection, including the shroud, and the external surface is supposed to be disinfected for the same reason.
The next points include:
It recommended that staff do not wash the body to avoid any additional risk of transmission of the virus
So I wonder if this is very unusual–to avoid washing the body? Is that normally done? Is this a major change? What are the percentages of current deaths that are being designated as COVID-19 and are following all these rules? Is it the same with hospitals? What about those who officially died from other causes? What about other infectious illnesses? Is there a change that affects every deceased person? Wouldn’t everyone be inclined to just follow the same rules for every death? There are a series of questions that call for understanding from those who are experienced with these things. Maybe some journalists could do some investigation also.
The labeling procedure is emphasized
The MRDT must ensure that the body bag is properly labelled, preferably with an indelible ink marker, i.e. Sharpie, and ensuring that it matches the ID on the deceased resident. This is of critical importance [underlined in the document].
•Clear, legible labeling on the body bag is extremely important.
•The most effective way to do so is label the bag prior to disinfecting the bag in the room
•The following information must be clearly labeled on the bag:
oFull name of the resident
oDate of birth
oIn cases of suspected or confirmed COVID-19 deaths, the bag must be labelled “COVID-19”
•While a peel and stick label can be used, ensure that it will not come off during the disinfecting process
•It is important to remember that the body bag must be disinfected after the deceased resident is placed inside
It seems significant to me that there would end up two different categories of deceased, those who are labeled with “COVID-19” and those who aren’t. How many–coming from care homes–and what percentage were labelled as such and how many were not as each month goes by with these procedures? And the same question could be asked about hospital deaths, or at-home deaths? I guess these numbers are available.
Page 6, 7:
The next part is about washing the body bag after the body is placed inside.
Has this amount of care been taken with other infectious illnesses in the past?
The funeral service providers do not enter:
. . . The funeral service providers will remain outside of the facility at the designated release area. •The funeral home will provide the MRDT with a stretcher at the door.
•The MRDT will move the deceased resident and wash the body bag on the funeral home stretcher.
•The stretcher will be transferred to the funeral service provider outside the door of the designated release area.
If there is no family:
•At times, deceased residents may not have any available or involved family:
oThe person may have indicated this during life to LTC staff
oThe Office of the Public Guardian and Trustee may be acting as their decision maker in the absence of next of kin
•If there is no family known to be involved, please complete the No NOK [No Next Of Kin] section on the MRDR
•At the time of sending the MRDR, please contact the OCC Team who will assist with prompt disposition planning. . . .
The family members are rushed into deciding on a funeral home (apparently based on the belief that they were not going to have room for all the bodies otherwise)
Advise that the selection of a funeral home must be done promptly, given exceptional circumstances.
•The MRDT can use the Funeral Home Finder-Dynamic Tool to provide the list of nearby funeral homes to the family to assist with their decision.
•Advise that if unable to choose, the MRDT will proceed with choosing a funeral home that family members will be required to work with.
So either the government genuinely believed there was going to be a large flow of bodies [check when the official death numbers peaked] or else this creates the impression and expectation that there was or was going to be an emergency so great that they would not have room or time to keep the bodies at the care home. I really doubt that rushing people made it easy for anyone to follow procedures correctly–and I also think that these rules would have scared much of the staff into not being present, which apparently happened in some places (if not in Ontario)?
So this is a very important section:
What if the family wishes to exercise religious or cultural practices for the deceased resident in the LTC facility?
•It is recognized that families may have specific religious beliefs or practices they wish to follow at the end of life.
•If the family belongs to a particular place of worship, encourage the family to contact them as soon as possible to make any necessary arrangements.
•The family may also discuss any personal, faith based or cultural practices with their funeral services provider.
•Advise that family will be unable to wash or touch the deceased resident while in the LTC home.
•Given the strict restrictions on visitor entry into LTC homes outside clergy should not attend the home
In practice, have they been allowed the time to exercise these practices? What if they had to travel some distance–and say it took 6 hours–would that have been too short a time? What actually happened?
So I notice that these are major changes. Somehow I don’t think that these are being brought in temporarily and only for “COVID-19” deceased. It seems to me that it standardizes death procedures in such a way as to shift the religious and cultural practices to the funeral service business. To remove these practices from care homes [or from hospitals at some point??] is a major shift in our society away from respect for religion–away from seniors homes and possibly other types of facilities. Again, if this turns out to be temporary, that’s one thing. If it’s permanent, then I think I’m on the right track with how I look at it.
And these rules remind us that there have been STRICT RULES ON WHO COULD VISIT–and that included clergy. People should try to guage for themselves how revolutionary that is in our society–clergy not being allowed into “care” homes. What is the current status on rules for visiting care homes? Families? Clergy?
So you can read about the seniors’ homes in Brave New World and make comparisons and observe if there seems to be a shift during the twentieth century and twenty-first centuries as to how familes think of death and the elderly and where they live when they’re at the end of their life. Notice how shocked people are about the concept of death during COVID-19–because they aren’t aware of the hundreds of deaths occurring every day in Canada–deaths that happen normally (or for other reasons besides a virus). For a family in a natural type of society, death is part of life–and it should be part of the experience for everyone in the family. Depending on strangers to look after our family members has consequences.
As we’ve seen with the Kissinger population report on its recommended policies for the world as a whole, how many people are dying alone without grown children to contact them/ This is by design according to that report that wanted the State to look after the elderly so that they would have less incentive to have children–that’s what the Kissinger-sponsored report on population in the 1970s said–along with the many other recommendations.
Another major difference. Again, how long does this rule stay in place, or has it been removed:
Can we practice ceremony such as honour guards?
•During the MRD process in the COVID-19 outbreak period ceremonies such as honour guards should not occur.
•While this is unfortunate and challenging it is important to ensure all steps are taken to reduce any potential risk of transmission to other residents staff.
•We acknowledge that all deceased residents were a cherished member of their families and communities and encourage other virtual methods of honouring the loss of a dearly loved community and family member.
Presumably these gatherings would be too large–regardless of where they were held supposedly–it wouldn’t have just been a restriction for the care home. And that would have nothing to do with the body–because the body could be completely contained. It’s to do with the emergency orders to ban gatherings–in violation of freedom of assembly.
Notice the marketing language to soften the dictates.
Notice the agenda is repeated which we have heard elsewhere that people are supposed to accept VIRTUAL life – via the Internet–these are things that never existed 30 years ago. And now these are supposed to SUBSTITUTE and solve these sudden problems we are presented wit. This is social engineering on an unprecedented scale.
These restrictions would be CRIMINAL if it turns out that this COVID-19 was contrived–and I don’t have any problem saying that. I can see where all this is leading. And that’s what people are doing. They are presenting evidence that this was contrived.
Count them up, may have forgotten some:
1) Restrictions on visitors, including clergy.
2) No honor guards etc.
3) Try to move the religious ceremonies to the funeral home.
4) Rush the family to choose a funeral home.
Can the family accompany the deceased resident to the LTC release area?
•This is advised against: Family members will not be permitted to accompany the deceased resident through the LTC facility release area, due to the increased risk of transmission for family members, care providers and funeral service providers.
•The family may be able to see the deceased resident at the funeral home.
So, was that ever a rule in place for other infectious illnesses in the past? It does seem to encourage the idea that families should be separated from the death process, from their loved ones–unless the disease is as dangerous as they say–but that’s the issue. So it’s not right if it’s not true–if the caution is not scientifically justified for this infection. If this is just social engineering, then it’s wrong. I think this is death standardization. If these rules disappear in future, fine. Let’s see what happens. Nothing to worry about. Otherwise it’s possibly an abusive power to have, to separate families from their loved one arbitrarily. I doubt this has happened much before and when it has, there were extreme circumstances. And this is what many of us are questioning with good reasons.
The Medical Certificate of Death will be securely sent electronically to the funeral service provider by the OCC; it will not be sent to the institution where the death occurred.
•For LTC homes, a copy of the IPDR and MRDR should be added to the resident’s health record.
LTC homes in hospitals follow the same rules:
LTC homes that are within hospital settings should follow the Managing Resident Deaths in Long-Term Care process
Does this MDR process apply to retirement homes?
•No. This process applies to LTC homes only
•The Office of the Chief Coroner is working with the retirement home operators and regulator to develop an approach to support this sector.
Do we need to follow all the steps outlined in the process if the home is not on outbreak and has no COVID-19 infections
. . .
*The placement of deceased residents into body bags, labelling, disinfecting the external surface, maintaining FH staff outside the home and transfer using the FH stretcher will be followed for all deaths whether the home is in outbreak or not.
*Completing the MRDR process in a timely manner must occur . . . .
*Other after care decisions must be carefully considered in the context of potential transmission of the virus,i.e. need for complete assurance of no infections in residents and no risk with entry of visitors into the home.
So, at least certain procedures listed become a convention for all deaths in the LTC homes, and we would have to check what the later policies said about retirement homes, etc. or other deaths in general. So the tendency to standardization is built in to these types of things. Crises are used to change the way people do things.
Have they relaxed rules about visitors? Are we still in the COVID outbreak period officially?
So getting back to the article, remember that there were these incidents with large numbers of residents dying:
Taken together [the documents about interpreting symptoms and the other documents and statements by officials], this may explain what the daughter of a woman who died along with dozens of others, during a COVID-19 outbreak at an Ontario care home experienced. The daughter granted the author an exclusive interview on May 13. (Under a pseudonym to shield her from possible repercussions.)
Diane Plaxton said in the interview that on April 1 she received a shocking and unexpected phone call from her mother’s care home.
“Your mother’s declining. She’s been having loose bowels and lots of diarrhea. There’s a DNR on her chart. And we’re not sending anyone to the hospital. [Likely because of ‘Condition Set Two,’ below] We’re going to have to put her on palliative care,” Plaxton recalls the head nurse telling her in a cold, uncaring voice. . ..
Plaxton told the head nurse that her mother was on bowel-cleansing meds and asked her to rehydrate her.
. . . The nurse refused, saying it would “just prolong the inevitable.”
The author posits:
. . . the nurse could well have been complying fully with the new rules by diagnosing Plaxton’s mother with a novel-coronavirus infection based on her having diarrhea alone . . .
Furthermore, since transfer to a hospital was not an option (as per ‘Condition Set Two’) and since COVID-19 is deemed to be very frequently fatal in the elderly, this may be why the head nurse pushed Plaxton so hard to consent to palliative care for her mother.
The second nurse agreed that “palliative care was not appropriate” and “agreed instead to allow her to not take the bowel-cleaning meds, and to coax her to eat and drink to recover her fluids and strength. She also said she’d keep an eye on the slight fever Plaxton’s mother had.”
April 10 she got a call from another nurse, who was panicking. She told Plaxton her mom was struggling to breathe and “going fast.”
The nurse said the care home couldn’t transfer her to the hospital. She asked Plaxton’s permission for the doctor to give her mother “a shot to ease her passing.”
She didn’t say what the shot was, but “it very likely was morphine, which is routinely used to relieve severe pain. A high enough dose of morphine slows people’s breathing and hastens their death.”
The family decided to give consent, and their mother died.
CONDITION SET TWO: HOSPITAL-CARE RATIONING GUIDELINES
So we’ve discussed the article’s CONDITION SET ONE sources, which referred to “Broad Definitions of Novel-coronavirus Infections and Outbreaks”
I’m just going to list the documents and summarize the main points. Then I’ll do the same with the last section “CONDITION SET THREE: New Rules Surrounding Death Certificates and Removal and Disposition of Bodies” which we’ve covered a lot of already.
(1) UK’s National Institute for Clinical Excellence COVID-19 rapid guideline: critical care
The acronym for this British organization is NICE!
It expects physicians to take the recommendations into account but it is not mandatory to apply them.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. . .
So then I notice points that are standard in the corporate & government world now about avoiding discrimination and about concern for the environment. Already I have posted the Ontario media story about how they were going to ration the use of medical equipment–in other words to discriminate against those who were elderly (link). And as far as the environment, well, extremists believe that humans are bad for the environment. That has been the indoctrination (link to Gates 2010 talk).
Page 2 mentions the frailty scale.
The first step in that chart after admission to hospital is to “assess frailty”. If you are considered “more frail”, then they start you down a different branch of the decision tree to decide whether you are going to be given critical care or not. If it’s not considered appropriate, and your condition deteriorates, then you get “End-of-life care.”
In the text, point 2.4, for example, is:
Sensitively discuss a possible ‘do not attempt cardiopulmonary resuscitation’ decision with all adults with capacity and an assessment suggestive of increased frailty (for example, a CFS score of 5 or more) . . . .
The Faculty of Intensive Care Medicine have produced a guide to best practice and decision-making in critical care at the end of life,for patients, relatives and the public on care at the end of life.
Key questions to consider are:
•How will critical care treatments help the person in the short and long term?
•Could critical care treatments offer a quality of life that is acceptable to the person?
•Could critical care treatments help achieve a patient’s goals for a good life?
•Are there non-critical-care treatments that may help the person and be more comfortable for them?
ICNARC data on outcomes for pneumonia
ICNARC (the Intensive Care National Audit and Research Centre) has mortality data . . .
It has three charts of probabilities.
Note: the data below is for all-cause pneumonia, not COVID-19.
Overall mortality data
Age (years) Critical care unit mortality Acute hospital mortality
It has mortality rates for each age range. Then it has another chart for patients with a cardiovascular co-morbidity and the third for a respiratory co-morbidity.
So that document was for the UK
2) The author refers to this link.
The article in question is
Fair Allocation of Scarce Medical Resources in the Time of Covid-19
Emanuel EJ, Persad G, Upshur R, et al. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. N Engl J Med. 2020;382(21):2049-2055. doi:10.1056/NEJMsb2005114
That’s the New England Journal of Medicine.
[I notice there was a competing article that came up in the search that helps explain what that one is about, but it has a different point of view:
The Future of Bioethics: It Shouldn’t Take a Pandemic
Larry R Churchill, Nancy M P King, Gail E Henderson
PMID: 32596911 DOI: 10.1002/hast.1133
The Covid-19 pandemic has concentrated bioethics attention on the “lifeboat ethics” of rationing and fair allocation of scarce medical resources, such as testing, intensive care unit beds, and ventilators. This focus drives ethics resources away from . . . .
I’m just quoting that explain what this is all about.]
Rosemary Frei’s article on care homes points out some details about the authorship of the life-boat ethics article:
(Interestingly, the paper’s lead author, Ezekiel Emmanuel, MD, PhD, is an oncologist, bioethicist and senior fellow at the Center for American Progress. The centre is secretive about its funders but according to a 2011 investigation in The Nation its supporters included dozens of giant corporations ranging from Boeing to Walmart. Today, retired general Wesley Clark and executive VP of global investment firm Blackstone [Hamilton] James are among the organization’s trustee advisory board members.)
Ezekiel Emmanuel, according to Wikipedia.org, is part of a very influential family:
His two younger brothers are former Chicago mayor Rahm Emanuel and Hollywood-based talent agent Ari Emanuel . . .
He is an
American oncologist, bioethicist and senior fellow at the Center for American Progress.
In his book The Ends of Human Life Emanuel used the AIDS patient “Andrew” as an example of moral medical dilemmas. Andrew talked to a local support group and signed a living will asking that life sustaining procedures be withdrawn if there is no reasonable expectation of recovery.
The article explains that he was caught up in the “Death Panel” controversy–which was the media’s way of ridiculing the concerns people have about what bioethicists are up to–could they really be engaged in advocating less resources be spent on elderly patients for example? Well, actually, we know the general trend.
I think the way the Wikipedia article twists and turns is something else to behold, but it refers to his article and clear statements here:
Why I Hope to Die at 75 by Ezekiel J. Emmanuel | October 2014
To me, I don’t feel comfortable even quoting this statement:
. . . living too long is also a loss. It renders many of us, if not disabled, then faltering and declining, a state that may not be worse than death but is nonetheless deprived. It robs us of our creativity and ability to contribute to work, society, the world. It transforms how people experience us, relate to us, and, most important, remember us. We are no longer remembered as vibrant and engaged but as feeble, ineffectual, even pathetic.
. . . Once I have lived to 75, my approach to my health care will completely change. I won’t actively end my life. But I won’t try to prolong it, either. . . .
. . .I will accept only palliative—not curative—treatments if I am suffering pain or other disability.
These statements go hand in hand with the culture of death. This attitude has been sold to people through media, Hollywood films such as Million Dollar Baby.
The more and more people experience illness and the failure of the medical system to treat illness, and suppress the vast amount of information available about nutrition and other methods of treatment available, the more overwhelmed people are with the ocean of propaganda and fear generated by those who run our society, the more inclined they are to adopt these beliefs that devalue themselves and others–the more inclined they are to give up!
So, in Canada, euthanasia has been completely legalized–a whole elaborate system–sold to people as something good. And a couple of years later, we have COVID-19 events.
But what if someone could just prolong their life by using some affordable information about nutrition? And why shouldn’t people of all ages try to insist on better treatments regardless of what age they are? We need to do something about the monopoly system of medicine–to insist that other forms of medicine are no longer suppressed.
So during the COVID-19 events, we see the full culmination of this, and we have the move towards a command-and-control, centralized, surveillance-oriented medical system all over the world whether government-run or not. Because if it isn’t a government controlling the policies for medicine, it’s a big corporation.
So we had these articles representing government policies appear in the media. This one is from March 29, 2020:
The provincial government has developed a “triage protocol” for doctors who may soon be forced to make ethically fraught decisions over how to ration critical care beds and ventilators — a policy document that will shape life-or-death choices over which patients to prioritize if hospitals become overwhelmed by the COVID-19 outbreak.
And this was a fictional scenario! It never happened. In Canada, the hospitals were half empty, there were thousands of unoccupied beds and thousands of delayed surgeries.
But the point of the article is to lead people into accepting a new type of world–of austerity–a new low carbon, “sustainable” world of rationing resources–of the Great Reset! A Brave New World of shuffling off a little faster when you’re “too old.” Some people want you to think you have nothing important to do anymore but maybe you do have some important things to do with the rest of your life–some wisdom to share, or gain, or some things you need to do. Of course.
The article about the Center for American Progress:
Corporate Influence at the Center for American Progress? | May 20, 2013
Numerous corporations appear on all four lists. They include . . . .
Last week, I sought comment for this story from Purse; Neera Tanden, CAP’s president; and John Podesta, CAP’s chair and counselor