Wednesday, August 26, 2009

End of Life and Palliative Care in the News

With all the attention focused on various health care reform bills, there has been a lot more discussion in recent weeks about the end of life and palliative care in the media. Here are a few articles:
  • Dr. Pauline W. Chen writes about the importance of talking about end of life often in her Doctor and Patient column in the New York Times.
    While the timing and appropriateness of these discussions should be considered in each individual case, talking about end-of-life care “doesn’t inhibit or prohibit patient choices. Instead patients will be more likely to make better informed decisions and to get the kind of care they want. And physicians will have an idea of their patients’ preferences, regardless of what those preferences are.”

    “At this point,” Dr. Prigerson reflected, “the studies show that patients and families benefit. Even if they are not told, patients who are dying probably suspect that something isn’t right. They appreciate the honesty of these conversations, which in turn enhances their trust in and the therapeutic alliance with their doctors.

    “If patients remain silent, their voices won’t be heard. And the effect on patients and surviving family members can be significant and enduring.”

  • While giving information on end of life options is important, a study appearing in the American Journal of Respiratory and Critical Care Medicine showed that over 40% of caregivers preferred that physicians do not express personal views about end-of-life care.
    "Our findings reveal that surrogates' views are heterogeneous, with a substantial minority preferring not to receive a recommendation from physicians," the authors concluded.

    "To best meet surrogates' needs, we recommend that physicians ask surrogates whether they would like to hear the physician's recommendation and view the recommendation as a starting point for shared deliberations about how to act for the good of the patient."

    Randall Curtis, MD, of Harborview Medical Center in Seattle and president of the American Thoracic Society, predicted the study would have a practice-changing impact on physicians.

    "I had previously assumed that almost all families would want physicians' recommendations, but these findings indicate that there is no such consensus among surrogates," Curtis said in a statement.

    "I suspect that physicians can do more harm by withholding a recommendation that is desired than by providing a recommendation that is not desired, but this study suggests we should ask rather than assume."

  • U.S. News & World Report discusses facts about palliative care in their Living Well column.
    Hospice care, a type of palliative care, does not always spell the end. Hospice also tends to a person's comfort and emotional and spiritual well-being, but without the treatments to prolong life or aggressively treat disease when illness is considered terminal and death seems inevitably near. The Medicare Hospice Benefit, which provides the vast majority of hospice coverage—though private insurers and Medicaid do, too—requires two doctors to certify that, to the best of their knowledge, the patient is not likely to live six months. About 90 percent of people in hospice choose to die at home, explains Shumacher, where care is usually given by family with the support of social workers, nurses, physicians, home health aides, bereavement counselors, spiritual counselors, and volunteers.

    But some patients' health stabilizes, or even improves, in hospice. One misconception, says Meier, is that "hospice is a one-way ticket out of town—it's not." She has had a number of patients who've done better under the coordinated care of hospice and whom she has taken "off benefit" in order to get them, say, a new heart failure protocol to treat the disease. Should her patient take another turn for the worse, hospice becomes available again. "You need a doctor who knows how to work the system on your behalf," says Meier.

  • At the New York Times, Anemona Hartocollis wrote a feature on palliative care. Following a palliative care doctor at Montefiore Medical Center, this piece examines the conversations between patients, family members, and their physicians at the end of life. Hartocollis points out that New York teaching hospitals rank lower on utilization of hospice care compared to the rest of the nation.
    At Montefiore, only 12 percent of dying patients from 2001 to 2005 entered hospice care, for an average of 4.9 days, during their last six months of life, according to the latest data from the Dartmouth Atlas of Health Care.

    At Mount Sinai, it was 14 percent of patients for 4.6 days; at NewYork-Presbyterian, 15 percent for 5.2 days; and at New York University Medical Center, 20 percent for 6.7 days, according to the Dartmouth data.

    Nationally, nearly 32 percent of dying patients had hospice care during the same period, for an average of 11.6 days.

    In New York, hospice is “brink-of-death care,” said Dr. Ira Byock, the director of palliative medicine at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., and the author of “Dying Well.”

    While treatments that try to extend lives produce more fees for doctors and hospitals, they may be given for reasons besides money. “Many clinicians don’t want to send the message that they’re giving up on their patients,” said Dr. David Goodman, a co-author of the Dartmouth Atlas. “They see palliative care as diminishing hope.”