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Protocols Needed For Palliative Care at End of Life

Cheryl Clark, for HealthLeaders Media, July 7, 2010

"Unfortunately, your husband has end-stage renal disease. He has a 'Do Not Resuscitate order in his chart. And now he is on a downhill trajectory that will lead to death within days or weeks. Should we continue his treatment?"

Or...

"Our medical team has done everything we can, but your wife has dementia, and is not responding to our treatment. It's time to make a decision. We can stop now, and make her comfortable. We can turn off her pacemaker."

These are the types of conversations that should be happening more often in hospitals when patients are near the end. But in at least one hospital, they are not happening anywhere near as promptly or as much as they should.

That's according to a report in the Archives of Internal Medicine. Researchers at Ronald Reagan UCLA Medical Center and RAND Corp. examined medical records of nearly 500 terminally ill patients to see if they were appropriately advised with a conversation that would lead to better palliative care.

"These data suggest that patient goals for medical care and careful weighing of the burdens and benefits of treatments in light of clinical realities may not always drive the care that seriously ill hospitalized patients receive," wrote the authors, Anne M. Walling, MD and Neil S. Wenger, MD.

"However, there has not been a systematic, clinically detailed measurement of the quality of care planning, palliation and symptom management among dying inpatients," the report said.

In a nutshell, they said, hospitals don't have standard process tools that trigger these kinds of discussions in a timely way. "Palliative care and ethics consultations, and — to a degree — family meetings occurred relatively infrequently given the vulnerable patient population," they wrote.

While the researchers said in an interview that they don't think hospitals are deliberately avoiding these conversations to continue ramping up charges, they acknowledge there is a lot of money at stake.

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