End-of-life care

You are currently browsing articles tagged End-of-life care.

Maximizing utility for end-of-life care

June 20, 2011 in Hospitals, Nursing Homes | 1 comment

Hospitals in Sacramento were concerned about the large number of nusring home transfers to its facility.  Were many of these tranfers unnecessary? Did patients with little chance of recovery benefit from these hospital stays?

To reduce end-of-life tranfers to hospitals from nursing homes, 3 Sacramento-area hospital systems and 18 nursing homes instuted the Preparing Residents for End-of-Life Plans and Respecting Endof-Life Decisions (PREPARED) project.  In the project, the hospital systems provided clinician educators with expertise in end-of-life care to work part of their time each week in nursing homes. The PREPARED intervention included provided advance care planning (ACP) education to patients as well as nursing home staff and administrators.

The study found that the initiative decreased hospitalization rates, increased nursing home as the the site of death, and improved perceptions of quality of care by family members.

How do family members perceive quality of care? The study shows that family members prefer the more intimate setting of a nursing home to a hospital, but this preference is likely conditional on a fixed death date.  By this I mean that if a family knew there loved one would die with certainty on a given date, the nursing home would be the preferred setting. If hospital care could extend the patient’s life, however, (i.e., more realistically not conditioning on death date) then family members may prefer to send their loved one to the hospital even though it is a less intimate setting.  A lot of these preferences may have to do with provider education. Providers who tell family members that their loved one has a chance (albiet small) of recover may be more likely to go the hospital route than those whose providers tell them there is basically no chance of recovery.

Further, most people would rather commit an error of commission than omission.  For instance, by not sending a loved one to the hospital, family members may feel guilt that they didn’t do all they could to save the patient.  However, sending the loved one to the hospital has its own risks (hospital acquired infections, complications, medical errors), but it seems that generally family members feel less guilty about death due hospital-related care.

Thus, although the study shows that family members are more satisfied when their loved one dies in a nursing home compared to a hospital, I do not believe that this is strong evidence of a long-term trend towards less hospitalization of terminally ill patients.

Source: Kathy Glasmire and Kathleen Kerr. Be Prepared: Reducing Nursing Home Transfers Near End of Life. CHCF, March 2011.

Tags: , , ,

Atul Gawande’s Latest Article

July 30, 2010 in Nursing Homes, Supply of Medical Services | 2 comments

Atul Gawande has written yet another excellent article in the New Yorker.  This one about end of life care.  In the debate surrounding health reform, many politicians hijacked the serious discussion of end-of-life decisions and decisions to use non-invasive medical treatment were termed death panels.  But end-of-life decisions merit further investigation.  Not only can giving patients end-of-life treatment options lower cost, but it can also improve the patient remaining quality of life.  For instance:

“Coping with Cancer project published a study showing that terminally ill cancer patients who were put on a mechanical ventilator, given electrical defibrillation or chest compressions, or admitted, near death, to intensive care had a substantially worse quality of life in their last week than those who received no such interventions. And, six months after their death, their caregivers were three times as likely to suffer major depression.”

One reason that palliative care has not been adopted by more patients is that most hospice facilities compel patients to agree to forego more intensive services.  One innovative program convinced more terminal patients to use hospice facilities by allowing access to more intensive treatment while in hospice care.

“In late 2004, executives at Aetna, the insurance company, started an experiment. They knew that only a small percentage of the terminally ill ever halted efforts at curative treatment and enrolled in hospice, and that, when they did, it was usually not until the very end. So Aetna decided to let a group of policyholders with a life expectancy of less than a year receive hospice serviceswithout forgoing other treatments…A two-year study of this “concurrent care” program found that enrolled patients were much more likely to use hospice: the figure leaped from twenty-six per cent to seventy per cent. That was no surprise, since they weren’t forced to give up anything. The surprising result was that they did give up things. They visited the emergency room almost half as often as the control patients did. Their use of hospitals and I.C.U.s dropped by more than two-thirds. Over-all costs fell by almost a quarter.”

NPR’s Fresh Air also has an interview with Dr. Gawande.

Tags: , ,

Medical Conservatism and End-of-life Decisions

June 20, 2010 in Medicare, Supply of Medical Services | 3 comments

The New York Times Magazine discusses two pressing issues: 1) what type of treatment to the elderly really wish to receive at the end of their life and 2) how does economic incentives affect how physicians advise these patients.  Much of my own research has dealt with (2) [see here].  The following two excerpts are revealing.

“According to an analysis by the Dartmouth Atlas medical-research group, patients are far more likely than their doctors to reject aggressive treatments when fully informed of pros, cons and alternatives — information, one study suggests, that nearly half of patients say they don’t get. And although many doctors assume that people want to extend their lives, many do not. In a 1997 study in The Journal of the American Geriatrics Society, 30 percent of seriously ill people surveyed in a hospital said they would ‘rather die’ than live permanently in a nursing home. In a 2008 study in The Journal of the American College of Cardiology, 28 percent of patients with advanced heart failure said they would trade one day of excellent health for another two years in their current state.”

“It was a case study in what primary-care doctors have long bemoaned: that Medicare rewards doctors far better for doing procedures than for assessing whether they should be done at all. The incentives for overtreatment continue, said Dr. Ted Epperly, the board chairman of the American Academy of Family Physicians, because those who profit from them — specialists, hospitals, drug companies and the medical-device manufacturers — spend money lobbying Congress and the public to keep it that way.“

Tags: , ,