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 Susan Tolle, director of the Center for Ethics in Health Care at the
Oregon Health and Science University, is one of three physicians
responding to the NEJM’s most recent “Clinical Decisions” case
feature, detailing a woman undergoing treatment for metastatic
breast cancer. However, her advance directive has not been reviewed
in close to a decade.
The two other physicians who responded with their opinions – Dr.
Anthony L. Back from the University of Washington, Fred Hutchinson
Cancer Research Center in Seattle and Dr. Diane E. Meier from the
Center to Advance Palliative Care at the Icahn School of Medicine at
Mount Sinai in New York City - claim an oncologist or palliative
specialist should initiate the conversation about the patient’s
goals. But Tolle says it is the primary care physician’s obligation
to lead this difficult discussion and myriad others nationwide.
“Primary care has to get a sense that it should own this, and we
should be providing this continuity of support,” she said.
Tolle developed the Physician Orders for Life-Sustaining Treatment (POLST)
paradigm, designed to turn treatment wishes of seriously ill
patients into actionable medical orders. While having a POLST form
filled out is strongly associated with receiving desired levels of
treatment, Tolle maintains that without widespread intervention of
primary providers, patients will be less likely to ensure their end
of life wishes are honored.
NEJM editors say they selected this case as part of a larger
dialogue about end of life care, now reaching from hospital hallways
to American living rooms as the PBS Frontline documentary, “Being
Mortal,” which debuted Tuesday. The report is based on Dr. Atul
Gawande’s best-selling book about the need for doctors to talk with
patients about death.
“We’re trying to engender discussion,” said Jonathan Adler, NEJM
clinical strategy editor and Massachusetts General Hospital
emergency physician. “Not infrequently do I see patients for whom
this discussion should have taken place but didn’t, and something
catastrophic happens. People are rushing to make these decisions and
different family members with different perspectives are talking
about what they think the patient’s wishes were.”
Tolle points out that dialogue regarding goals of care earlier in an
illness impacts patient satisfaction and choices. According to the
Institute of Medicine’s recent Dying in America report, more than a
quarter of adults have given little or no thought to end of life
wishes. Fewer have communicated wishes in writing or through
conversation. These statistics are ones that Tolle encourages her
primary care colleagues to work to reverse.
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Leaders within the American College of Physicians, an organization
representing internists, agree. “Somebody has to step up,” said
Robert Centor, Chair of the ACP Board of Regents. “If you’re a
primary care physician, it’s incumbent on you to have the discussion
with patients before and especially after they get sick about goals.
If we don’t know a patient’s goals, they can’t get the best possible
care.”
End of life planning, however, is not a billable Medicare service,
and often takes much of what Centor calls the primary care
physician’s most important commodity: time. “The system discourages
us from spending enough time,” he said. “But we have a moral and
ethical responsibility to give patients the time they deserve.”
Tolle applauds insurance programs that task nurse case managers with
calling seriously ill policy holders to help decision-making. In
place for close to a decade, Aetna’s Compassionate Care Program has
resulted in an 86 percent reduction of patient days in intensive
care.
“In the current state of medical practice, we are not seeing this
type of engagement offered to people with advanced illness,” said
Randall Krakauer, Aetna’s director for medical strategy. “They are
not getting the advice, assistance and support that we think is most
appropriate.”
Certainly, Krakauer acknowledged, the program has had huge
cost-savings; however, he said, finances did not drive its
implementation. “We were not at all clear when we began that it was
going to save money,” he said.
Tolle said Aetna and other insurers are performing a service that
should be done and hopes will be more routinely provided by primary
physicians.“We should be able to offer more coordinated care from
inside the health system than from the outside.”
SOURCE: http://bit.ly/199kOhp New England Journal of Medicine,
February 11, 2015.
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