Too many physicians lack the skills to discuss end-of-life wishes with patients. It is awkward for the doctors to even bring up the topic in certain circumstances. Doctors are trained to save peoples’ lives, not to give up on them. But physicians need to change their mindset.
Editor's Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Lori E. Rousche, MD, a family physician in Souderton, Pennsylvania. She is also the hospice medical director for Grand View Health in Sellersville, Pennsylvania. The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica.
Dr. RouscheIn today’s healthcare environment, the push is on to save money and provide better quality of care.
Insurance companies are grading doctors on the quality of care, and paying more money to physicians that perform better. There are many metrics tied to doctors’ pay. For instance, asking about falls, screening for depression, addressing abnormal body mass index, keeping blood pressures below a certain level, managing diabetes correctly and many others are used as a scorecard to determine bonuses for doctors and inspire them to improve quality.
One of the more recent quality metrics that is being studied is whether a hospice care consultation was done in a timely manner.
Hospice is a wonderful service that enhances end-of-life care and improves patient and family satisfaction with the dying process, however, it is very much underused.
Most hospice consults are performed very late in the game, and some patients end up on the hospice service for less than 12 hours before death. This is very unfortunate, because there is so much to be gained from having hospice involved. The question to be asked is: “Is it ethical to reward doctors for consulting hospice, which in the long run saves the insurance companies more money?” By taking away the option of ongoing treatments in a terminal cancer patient, especially very costly experimental treatments, the insurance companies will see significant savings.
In addition, by keeping the chronic heart failure patient at home with hospice and out of the emergency room and ICU will save money and the insurance companies will reap the rewards. But will the patients? In some cases, that is a definite yes.
Over 50% of patients screened wished they had opted for hospice earlier in their illness. End of life is a difficult time, but it can also be a time of dignity and grace. Suffering can be lessened with palliative services. Enhanced quality of time left is often preferred by patients to an increased quantity of time, if that remaining time is spent with an increased burden of illness from chemotherapy or other drugs.
Patients in hospice often have better family interaction during end of life, because the focus is on comfort care and providing the patient with peace, not continued admissions and treatments with more fatigue and side effects. A chaplain, a social worker and a nurse are always involved with any given hospice patient and this dynamic allows patients to express any last desires or misgivings.
Next: "A disservice to terminal patients"
The hospice team works hard to bring fulfillment to dying patients. They work to repair broken families if that is the patient’s wish. They bring in harpists or horses or whatever the patient thinks will help them with the dying process.
Too many physicians lack the skills to discuss end-of-life wishes with patients. It is awkward for the doctors to even bring up the topic in certain circumstances. Doctors are trained to save peoples’ lives, not to give up on them. But physicians need to change their mindset. Hospice is not “no care,” but comfort care.
A doctor is not giving up by consulting hospice. The doctor is just acknowledging that no one lives forever and sometimes the medicines available just can’t save people. Most patients, especially those that are terminal, are so grateful when a physician finally broaches the topic of end of life. Patients should be asked how they want to spend their last days or months on Earth. Many patients have a set idea in their head of how they want to go out of this world, and most of the time it does not involve a hospital room and lots of drugs.
It is actually a disservice to terminal patients not to consult hospice. Dying patients, whether they have cancer, COPD, CHF, Alzheimer’s or dementia, should have the option of stopping the fight.
Ending the repeated hospital admissions with the polypharmacy accompanying it, should be a terminal patient’s right, or choice. Doctors need to understand that death by hospice is much better than death without it.
That said, the question remains: Should hospice consultation be a quality metric? Doctors don’t have much say in what is considered quality by the insurance companies. They may not agree that asking about falls or screening for depression is “quality” medicine, but they have to comply or risk not making enough money to maintain their staff and office.
Given the lack of understanding about hospice and end of life by most physicians, it may very well be a good thing to require a hospice consult. The patients can always say no. And the patients that say yes, will be very richly rewarded.