Philly Inquirer Article on End of Life Care.

Lyle Fettig at PalliMed writes about the recent Philadelphia Inquirer article that examines "death panels" and debunks the fear that opponents of health care reform have tried to cause about them. The article, he says:

accurately portrays the reality of life and death in the American healthcare system as well as the potential of palliative care. The article describes the experiences of Mary Tole, a 74 year-old woman who spent 67 days in the hospital at Abington Memorial Hospital last fall (10 in the ICU and 57 on a ward). The palliative care team's crucial interactions with the patient and her family are detailed.

You can read the Philadelphia Inquirer article here.

Fettig reserves the second part of his post for a critique of the Keith Olbermann "special comment" from last week that debunks "death panels" and calls for greater use of advance directives. Fettig writes that while advance directives are important, they alone won't solve the end of life care challenges that our medical system and patients are experiencing. He writes:

But is advance care planning really the issue here? ACP often has a limited impact on what actually happens once someone becomes ill. Olbermann seems to suggest that he had those tough talks with his father before his current illness, and it sounds like his father still retained at least some capacity to make decisions up until very recently anyway. Yet his father still wound up having interminable suffering.

I look at advance care planning as sorta like an immunization. If you give 100,000 people the flu shot, some will be protected from having any symptoms of the flu, many will still get mild symptoms, and some will still have a severe case of the flu inspite of the shot. What does advance care planning immunize people against? Hopefully, unwanted intervention in the face of a poor prognosis, for one. But more importantly, it probably immunizes loved ones against "second guessing" or "thirtieth guessing" (as Olbermann puts it). It's not going to stop the second guessing altogether, though. Second guessing is part of any difficult decision, especially important decisions that you rarely make. ACP seems most helpful to me in those circumstances when the patient's poor prognosis is REALLY clear (either they are very likely to die soon regardless of what is done or they aren't likely to recover some important function, like severe anoxic brain injury). Patients who have completed living wills usually have those types of circumstances in mind when they completed the documents. But oh, the paths that you can take to reach your death and how often the prognosis (and even diagnosis) remains unclear up until death or resolution of the illness! (As in Mrs. Tole's case.) ACP seems much less helpful in those circumstances, and leaves more room for "thirtieth guessing."

And Fettig lays out the changes that should be made to our current "care pathway":

So here's the "care pathway" that needs to change:
1) Man gets really sick, goes through torturing procedure after procedure.
2) Man gets to the point where he can't take it anymore.
3) Man pleads with his son (presumably before his doctors?) to RELIEVE and RELEASE!
4) His son thinks the man's docs will look askance on this request (indicating that the doctors have never had a goals of care conversation with the son previously).
5) Only at that point does any communication seem to occur about relief of suffering and the possibility that life-prolongation should no longer be the goal.

In other words, just as when someone requires intensive care for the flu in spite of an immunization, when the living will or previous discussions don't necessarily apply to the present serious illness (or ACP hasn't taken place), you need someone who can provide intensive communication care: someone who can get to the bottom of how the illness fits into the patient's life-narrative and someone that can blend this narrative with the medical narrative in a way that makes sense to the patient's family.

As discussed previously on Pallimed, the current Medicare reimbursement scheme DOES reimburse physicians to have these difficult conversations. You can bill for time spent counseling, and there's no limit to the number of these sessions. Why don't they happen?

1) Inadequate training of most physicians to conduct these types of conversations.
2) Disproportionate reimbursement for procedures compared to "cognitive-based" tasks.
3) Inadequate availability and utilization of palliative care teams.

You can read more analysis of the Philly article by Tim Cousounis at Palliative Care Success here.