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A Fresh Look at End-of-Life Care

Joe Cantlupe, for HealthLeaders Media, September 16, 2013

It's imperative that healthcare providers team with patients to determine the ultimate medical mission.

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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1 comments on "A Fresh Look at End-of-Life Care"


Carol J. Eblen (9/20/2013 at 8:32 PM)
In 1991, The Congress, at the request Of Medicare, passed the Patient Self Determination Act (PSDA) which together with the 1986 Hospice/Palliative Entitlement, was intended to solve or stem the problems of overtreatment of the elderly that produced the fiscal problem of expensive end-of-life care in the nation's ICUs and CCUs that was covered by Medicare and private insurance. Elderly patients might spend weeks in ICU and finally die [INVALID]or survive to go home, or to a nursing home [INVALID]-and then return to ICU to die in the last year of their lives. It was envisioned that The PSDA would permit elderly patients to elect to shorten their lives to shorten their suffering, even if the refused life-saving or life-extending treatments weren't deemed "medically futile" by the physician/hospital. Unfortunately, the AMA lobbied against physicians/clinics being placed under the mandate of the 1991 PSDA. While Congress and Medicare [INVALID]d two distinct standards of care that would be reimbursed by Medicare/Hospice, the physicians (primarily the specialists) didn't want the legal burden and expense of SEEKING INFORMED CONSENT from their elderly patients for one standard of care as opposed to the other. Because the for-profit incorporated clinics and physicians' specialist practices were not covered under the PSDA, and because clinics/physicians (the specialists) were reimbursed up to the Diagnosis Group Cap for treatment of life threatening cancers/diseases no matter the age and co-morbidities of the elderly patients (because of the Age Discrimination Statute) they had/have no incentive or legal duty to discuss the other legal standard of care [INVALID]d and reimbursed by Medicare, i.e. Hospice/palliative care, with their elderly patients with life threatening diseases/cancers. (In the past few years, some of the states have passed new laws that do impose a legal obligation on the physicians to inform their elderly (and all) patients about Palliative Care/transition to Hospice. Unfortunately, there has been no clarification of the PSDA at the federal level, even though there has been much "noise" and a few proposed bills concerning end-of-life conversations and treatments. In this age of specialization, the Primary Physicians, in keeping with their oaths, refer their very ill and threatened patients to specialists. The primary physicians didn't think it was their responsibility to talk to the specialists' patients about the two different standards of care. Elderly patients on Tricare-for-Life and other Insurance can self-refer to specialists, etc., and bypass their primary physicians. When both the specialist and the primary physician rejected any responsibility to have these end-of-life conversations, the Acute Care Hospitals then were put in the position of promoting hospitalists/palliative care teams, etc. who would consult within the hospital with inpatients with life-threatening diseases about end-of-life choices and the two standards of care. Even this, however, was not terribly successful because physicians were still over treating with chemo and radiation in the outpatient setting. Patients were not referred to palliative care/transition to Hospice in a timely manner and were often unaware that the treatment they were getting was merely palliative and that, in reality, there was no chance of cure. (We see lately that the Department of Justice is moving against Oncologists who have been over treating for profit) Palliative care which has become a board certified specialty (outside of pain clinics) since the 1991 PSDA was passed into law is practiced within the hospital inpatient setting. The hospitals have to contribute as much as 50% (more or less) of the operating expenses of in-house palliative teams and do so with the view that the palliative teams will refer more patients to Hospice earlier in the course of their diseases/cancers. It was envisioned that the Palliative Teams within hospitals would produce earlier voluntary entrance by patients into Hospice but, of course, the requirement of physician certification of 6 months or less to live worked against this vision. NOW, we see that a TRIAL is planned by Medicare wherein elderly/disabled and all patients will be entitled to be on BOTH the Medicare and the Hospice entitlement at the same time. With Obama Care, over treatment of the elderly/disabled on Medicare/Medicaid will be a problem of the past because already and for the past ten years or more, under both political parties, CMS and its private partners in BIG Insurance have NOT been reimbursing physicians/hospitals for over treatment, mistake, error, and the complications thereof, and the hospitals have had to eat these costs. This has produced a very hostile environment for the elderly/disabled who have exceeded DRG caps or who are the victims of over treatment, or mistakes/errors, and the complications thereof. Unilateral DNRs are being misused to shorten the lives of elderly patients without their informed consent when Hospitals/physicians KNOW that there will be no further reimbursement from CMS and the private insurers. It appears, however, that the solution [INVALID]-if Hospice Care, after the trials, will no longer be a separate entitlement where curative care is abandoned and merely part of Medicare, etc. [INVALID]-that the specialists will still not have to SEEK informed consent from elderly Medicare/Medicaid patients for curative treatment, as opposed to doing nothing and accepting palliative care and transition to Hospice. What do you think?