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 Researchers in the Netherlands found that end-of-life discussions
are rarely a subject of direct, interprofessional communication.
Although the study, published in the journal Family Practice,
reflects European realities, its findings likely resonate across the
siloed American health system, too.
“Most patients in the U.S. have many doctors, and if each is doing
their own little thing, no wonder patients are confused,” said
University of Washington professor and oncologist Dr. Tony Back, who
was not involved with the study. “The primary care doctor says, ‘I
think I should talk about end-of-life care with this patient,’ and
the oncologist says, ‘We have another treatment to try.’ The patient
is saddled with sorting that out, and it’s not fair.”
The research team, led by Dr. John J Oosterink at VU University
Medical Center in Amsterdam, interviewed 16 general practitioners
and 14 cancer specialists about the last discussion they had with a
patient about end-of-life issues. Oncologists were asked whether
they knew what their patients’ general practitioner discussed, and
general practitioners were asked the same about oncologists’
involvement.
The study investigators did not respond to a request for comment.
While general practitioners and oncologists all recognized the
importance of timely end-of-life discussions, most believed general
practitioners - due to longstanding patient relationships - were in
the most appropriate role to facilitate them.
General practitioners who spoke about end-of-life issues emphasized
patients’ wishes and concerns. Oncologists focused on incurability
and non-treatment orders.
Some American oncologists don’t expect primary care physicians to be
involved in end-of-life planning at all.
“That relationship gets lost in a cancer diagnosis, and most of my
patients stop seeing the internist,” said Virginia Kaklamani, a
professor of medicine and leader of the breast oncology program at
the University of Texas Health Science Center in San Antonio who
wasn't involved in the study. “The person closest to the patient
should initiate an end of life discussion, and that person ends up
being the oncologist.”
Kaklamani told Reuters Health that after an initial phone call
following a new patient appointment, talks with primary care
physicians are rare. “If everything was done right, it would be
extremely helpful for communication to be better. But for impact,
the internist would need to have a relationship with the patient and
continue to follow the patient. That’s not happening.”
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According to internist Dr. Cheryl Wilkes, a clinical practice
director at Northwestern University’s Feinberg School of Medicine in
Chicago, the primary care doctor’s communication with oncologists is
often limited to what is written in the electronic medical record.
“I get a copy of their note, and it’s on me to look at it,” Wilkes
told Reuters Health. “I’ll have a feel for how the cancer is
progressing, but as an internist, I don’t know the exact
implications of what that means for their time frame.”
Wilkes does initiate these essential talks herself. Medicare’s new
coverage of advance care planning as part of the “Welcome to
Medicare” visit and annual wellness visits that follow encourages
her to start this conversation more frequently. “I love it that once
a year, I am enabled to do it,” said Wilkes, who also was not
involved in the study.
Back says that efforts like Wilkes’ are essential to prepare
patients for the end of life and ensure they receive the same
message from each physician they see. Challenges arise when
internists initiate end of life dialogue, but oncologists tell
patients that such discussions are premature. Back is one of the
co-founders of the non-profit Vital Talk, which develops
communication courses to foster better connections between patients
and clinicians - particularly surrounding end-of-life care.
“What is happening in our system is the internist, who maybe knows
the patient well and is better at drawing out that patient’s values,
doesn’t have a very clear place at the table,” Back said. “They can
bring something very important to this situation.”
SOURCE: http://bit.ly/2cGmh5n Family Practice, online September 1,
2016.
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