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A Fresh Look at End-of-Life Care

Joe Cantlupe, for HealthLeaders Media, September 13, 2013
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This article appears in the September issue of HealthLeaders magazine.

Muna Salman, MD, a palliative care hospitalist at the 220-bed Rush Copley Medical Center in Aurora, Ill., recalls listening as an elderly, gravely ill patient talked about her dream of being free of pain, even as her family talked of complicated procedures that held no promise of giving her more days. "No more," the patient said, hopeful that she could simply spend her remaining time at home. Salman walked out of the room and teared up, filled with humility over the patient's resolve and a sense of professional satisfaction in knowing, "We helped her on her path."

Mohana Karlekar, MD, medical director of the palliative care program at the 832-bed Vanderbilt University Medical Center in Nashville, recalls a 90-year-old patient who had "terrible heart failure" and was interested in transitioning to a comfort-based approach. The patient was anxious to begin this conversation but afraid to get bad news. He wasn't ready for any in-depth conversations just yet. "Providing too much information when a patient is not ready can result in moral distress. One needs to communicate information in a way that's sensitive to his needs," says Karlekar. "Some may be willing to engage. Some may not."

Timothy G. Ihrig, MD, MA, medical director for palliative medicine at the 132-bed UnityPoint Health-Trinity Medical Center in Fort Dodge, Iowa, recalls treating a 43-year-old woman who had ovarian cancer and was later diagnosed with breast cancer. She was extremely depressed. Ihrig talked with her about a complicated treatment plan. In a sense, "I walked a journey with her, framed it in a real-world perspective." She pursued her treatment plan vigorously. After a series of procedures and treatments, she's now "traveling the world, a new person," he says.

Turmoil, uncertainty, calmness, and serenity are wrapped around the medical mission in end-of-life care. The physicians' experiences reflect those of countless others and are illustrative of the uncertainty in the complicated area of healthcare involving critical conditions and those patients nearing death. Physicians and hospitals struggle over the question of care: Should another test be done? Should there be another surgery? It's never an easy decision, involving a complex mix of medical considerations, the desires of patients and families, and ethical concerns.

"We don't always deal with the issues of death and dying very effectively in our culture," says Kathleen Potempa, PhD, RN, FAAN, dean of the University of Michigan School of Nursing. "When you have a very seriously ill person, a physician is trained to do everything to save a life and the family may be hoping that one more thing will be the magic bullet, but that isn't the reality.

"We don't step back and think of it from a humanistic perspective—we are trained healers, and we forget that dying is a natural part of the human experience," she says. Too often, "we're not letting the person align with the spiritual side of letting go, physically, emotionally, and psychologically, which is important for a peaceful death."

Although hospitals, health systems, and physicians have been struggling with initiating significant conversations with patients and families about chronic illness and end-of-life care, that is changing. At some organizations, clinicians, encouraged by executives, are holding end-of-life conversation more openly and more often. Others say there's a long way to go. As far as healthcare leaders are concerned, the conversations couldn't happen any sooner.

Cost factors

By 2030, the number of people in the United States over the age of 85 is expected to double to 8.5 million. Hospitals are filling rapidly with seriously ill and frail patients. These patients, many with chronic conditions, are bouncing back and forth between nursing homes and acute care hospitals, which shows the need for better coordination and discharge planning.

A 2009 New England Journal of Medicine study found that Medicare payments for unplanned rehospitalizations totaled $17.4 billion in 2004, and that one in five Medicare patients was rehospitalized within 30 days of discharge. A 20% decline in potentially preventable readmissions (from 12.3% to 9.8%) would reduce readmission spending by more than $2.5 billion, according to the Medicare Payment Advisory Commission's March 2013 report to Congress.

As more healthcare facilities seek to know a patient's wishes for end-of-life care, that emotional path also is being made against the cool backdrop of the highest healthcare costs: Care for chronically ill and gravely sick patients is inexorably linked to expensive procedures or expensive stays in the intensive care unit. While hospitals have begun making inroads in controlling spending on end-of-life care, they still fall short in holding back expenses, according to the Dartmouth Atlas Project, which studies variations in health spending.

From 2007 to 2010, the use of hospital services in the last six months of life "fell significantly," with a 9.5% decrease in hospital days per patient and an 11% decrease in deaths. However, Medicare spending per patient in the last two years of life rose from $60,694 to $69,947, a 15.2% increase during a period when the consumer price index rose only 5.3%, the project notes.

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