Daily Briefing Blog

Death isn't failure: Teaching doctors when to prescribe hospice


Clare Rizer, The Daily Briefing

The single most important predictor of whether you enroll in hospice care?

Your physician.

That's based on study data from more than 200,000 patient records, Ziad Obermeyer writes in Health Affairs. (Obermeyer's a physician researcher at Brigham and Women's Hospital and assistant professor at Harvard Medical School.)

Alternate factors, including the patient's race, gender, or a geographic location, did not even come close to a doctor's level of influence with regard to end-of-life care, the Boston Globe's Kay Lazar points out.

And that's a lot of power—and a lot of responsibility—for one physician.

"For so many patients, no one has ever sat down with them and talked with them about hospice care, instead of being on a ventilator or in a nursing home," Obermeyer tells the Boston Globe. "As physicians, we need to have these conversations earlier."

But some experts warn hospitals aren't designed to encourage the transition to palliative or hospice care, partly because insurers are more likely to cover treatments than conversations. And many doctors don't feel comfortable discussing palliative or hospice care with their patients, says Advisory Board consultant Natalie Dawe.

Physicians may even go so far as to issue more tests or prescribe additional medication simply to avoid an uncomfortable conversation, says Lachlan Forrow, director of ethics and palliative care programs at Beth Israel Deaconess Medical Center.

How comprehensive is your palliative care program?

How to deal with the discomfort

Dawe tells the Daily Briefing that simple strategies can prepare physicians to have these conversations. For example, she says hospitals should:

  • Train a range of providers (especially those outside of the hospital, including ambulatory and post-acute care providers) on how to talk with patients about advance care options;
  • Conduct education and community outreach efforts at places like senior activity centers and retirement communities to teach people about advance care planning and to dispel common myths; and
  • Make advance care planning a routine part of patient care (for example, building it into annual wellness visits or upon patient hospital admission)

Dawe also says physicians and patients should discuss end-of-life care preferences early on in a patient's advanced illness. Specifically, she recommends that doctors ask their patients questions like, "Have you discussed who will make medical decisions for you if you can no longer make them for yourself" and "Have you considered when you want to continue certain treatments versus when you'd prefer to stop aggressive treatment?"

How to start a conversation you're dreading

To ease into those conversations, Dawe suggests that doctors feel out patients' palliative care preferences—which she calls "a great entry point into hospice care"—to reduce discomfort during treatment.

According to Advisory Board research, simply defining palliative care for a patient and addressing misperceptions about it prompted 63% of seniors to say they were "very likely" to consider such care.

Having these discussions early and often also could alleviate some of the exorbitant health costs associated with terminally ill seniors. In 2011 nearly 25% of Medicare spending was used to cover patients during their last six months of life, according to the Medicare NewsGroup, Lazar reports.

Changing the physician perspective

Experts also called for a structural shift in how payers and providers approach palliative and hospice care.

A key first step is to get insurers to stop blindly paying for treatment that a patient may not actually want, Forrow noted in the Globe.

"In the future, any medical care for a patient with a serious advancing illness should only be paid for if it is based on the patient's preferences, and there is documentation that [the patient] knew about hospice options," Forrow says.

And Obermeyer says that doctors need to rethink the purpose of treatment—they need to stop believing that "death is failure," he says.

"Doctors, from the time we take organic chemistry forward, we don't like to fail," Obermeyer tells the Globe. But "death is not the greatest failure," he contends. "Not giving patients the care they want is failure." 

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The best palliative care programs don't just provide a better experience for terminally ill patients—they also yield longer survival rates, lower costs, and improved quality.

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