Sunday, February 28, 2010

Palliative Care - 1996 and 2010

More than 13 years ago, Philadephia Inquirer reporter Michael Vitez wrote a series about end-of-life care which won a Pulitzer Prize - see here for the first installment of that five-part series.

Some excerpts from that piece:

"Medicine has gotten so good at keeping people alive that Americans increasingly must decide how and when they will die. They must choose if death will come in a hospital room with beeping machines and blinking monitors or if it will come at home, with hospice workers blunting the fear and pain that so often accompany the final hours."
"The intensive-care unit offers a hope for recovery, but the price can be a miserable death. Deciding when to surrender can be a torture all its own."
"Advocates for change believe doctors are too optimistic, too sparing in what they tell patients. They say that families would be more willing to accept death earlier if doctors were more honest, more realistic. Reformers want to make sure that patients get the care they need, but not unnecessary or unwanted treatment. The key to humane and cost-effective intensive care is to treat those who will benefit, but not squander precious resources and impose futile treatments on those who will not. But often it is impossible to know who will live and who won't."

In today's Philadelphia Inquirer appears an article by Michael Vitez (read here), as part one of an occasional series on the dilemmas facing today's hospitals. The subject is how hospitals are addressing end-of-care issues, and in his article Mr. Vitez follows the work of the palliative care team, led by palliative medicine physician Dr. Diane Dietzen, at Abington Memorial Hospital, a large, suburban Philadelphia hospital. An insightful article, one that lays out in very personal stories the challenges faced by families and providers alike. In Mr. Vitez' words: "My goal is to spend a year at Abington, writing stories that show how one hospital deals with the biggest issues in health care today and also the changes that are coming fast and furious - regardless of what Congress and the President do - to hospitals and health care.
This first story looks at how the palliative care movement is medicine's response to the dismal way people have died. I try to show, up close, how the team works, the agony that families feel, the immense costs involved. "

Has much changed around end-of-life care in those 13 years? Surely, a patient in an ICU with a poor prognosis is more likely today than 1996 to be consulted by a palliative medicine physician such as Dr. Dietzen. But how much more likely, and if a consult is requested, is the timing appropriate? Just as surely, large variations in late-life care continue to persist among hospitals and communities, still raising questions about the appropriate role for acute hospital care in the management of patients with advanced illnesses.

As one of the doctors in the 1997 article stated ," America wants to offer the most advanced technology and treatments to everyone, yet keep health-care costs down."
How to balance those desires, the doctor added, "is a discussion nobody wants to have." Thirteen years later, when one considers the discussions taking place in the name of health reform, one must wonder how far have we advanced.

Monday, February 22, 2010

Rational Discussion, or Discussion about Rationing?

In a recent post on the Health Beat blog, Naomi Freundlich comments that although life-expectancy is increasing, so is the incidence of multiple medical problems and chronic disease in the elderly. Which, once again, raises the question of how Medicare costs could possibly be tamed?

The author goes on to say that "we also face a more personal, moral challenge as life expectancy continues its relentless march forward: We must begin to separate new treatments that will help older people age better—avoiding long-term disability, dementia and frailty—from those that merely extend life at any cost. We can only do this by having honest conversations about end-of-life issues; in medical schools, among families and between doctors and patients. "

The Urban Institute, a nonpartisan research center, found in a 2009 report that the government could save $90.8 billion over 10 years by better managing end-of-life care. And, the Institute further concluded that much end-of-life spending isn’t sought by patients and goes against their families’ expressed preferences.

$90 BILLION dollars. Makes me wonder who would be receiving that money if it were spent. Surely, much of it would go to hospitals. And some of it to physicians. Makes me wonder also if this subject can be discussed rationally, rather than it being a discussion about rationing.

Can Hospice and Palliative Care Escape the R Word?

The question Why are Referrals to Hospice Slowing? seems to be making the rounds these days.
Misconceptions about hospice and palliative care have abounded well before the latest efforts to refrom the health care system. How else to explain the persistent and continuing reticence to refer to, and accept hospice services, in most US communities. What's different today is that the skeptics of hospice and palliative medicine are more vitriolic than their predecessors, and their talking points (arguments) are more vivid - "death panels, socialized medicine".
I served as the chief executive of a hospice affiliated with a highly-regarded academic health center in the 90s, and the reasons then were abundant for the low referral rate to hospice: patients were referred to academic health centers because they wanted to avail themselves of the most sophisticated medical care for cure; the attending physicians were providing palliative care; the patients' religious/cultural beliefs made them unready for hospice, etc. We've all heard them before, and we still hear these reasons now.
It's just that now, in the context of health reform, palliative care, for some, is considered 'rationing."
And it gains credence because there is so much money in late-life care.

Sunday, February 21, 2010

Why Organizational Delivery Models Matter to Effective Palliative Care

There are multiple examples of health systems -- President Obama and health policy makers have cited Mayo, Geisinger, Cleveland Clinic, and others as models for health-care reform -- that consistently and reliably achieve similar results: providing good care at low cost, with high patient satisfaction. Bassett Healthcare, serving the Cooperstown, New York region, is among those others. What these systems have in common, we're advised, is that they are integrated systems that employ their physicians, emphasizing patient-centered care, better outcomes, and prudent stewardship of health-care resources, with accountability for results.

We've looked closer into these hospitals and communities to understand better if this model also produces desirable results around late-life care. We've learned previously that Geisinger has seen exemplay results in its late-life care practices. So we took at look through the Dartmouth Medical Atlas at the formerly named Mary Imogene Bassett Hospital, now known simply as Bassett Medical Center. The Hospital's results in the seven DAI Palliative Outcome Measures earned it an exemplary grade. Patients loyal to Bassett were 20% less likely to die in the hospital, spent almost 40% fewer days than state average in a hospital during the last six months of life , and were more likely to have been under hospice/palliative care. Yet perhaps the most telling is that in their final months, 30% fewer patients were seen more than ten physicians during late- life care. You read this correctly, TEN is the benchmark.

Thus, we find that in another community a tightly integrated health system produces desirable outcomes in late-life care. What remains unclear is what attributes of a tightly integrated health system are most responsible for these results. With that knowledge, these attributes might be replicated elsewhere (as in an Accountable Palliative Care Organization).

I'm curious to learn your experiences and thoughts.

Thursday, February 4, 2010

Palliative Care Grand Rounds, February MMX

February's Palliative Care Grand Rounds is up (see here for an interesting collection of blog posts from the previous month, gathered by Jared Porter, blogger for Alive Hospice).