Physicians shouldn't fear death talk with patients

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 Lisa Price, MD, board certified in internal medicine and geriatrics and has expertise in managed care, electronic health records, quality improvement and geriatrics. The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica.

Lisa Price, MDThe advance directive. The words instill a sense of foreboding, a finality not many are prepared to face.

As a geriatrician, I have discussed advance directives countless times throughout my career with older adults and their families. This conversation can be challenging because people often don’t want to think or talk about their death or the death of loved one. Physicians also can feel trepidation anticipating this conversation. A recent survey of 735 physicians by the John A Hartford Foundation, the California Health Care Foundation and the Cambia Health Foundation reported that 46% felt unsure of what to say.  

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This same study reported 29% of physicians reported they received no formal training on discussing end of life, 29% reported their practice had no formal system for assessing a patients end of life wishes, and 24% report their electronic health record did not have a place to indicate a patient had an advanced care plan. In 2009, the discussion of end-of-life care was linked to a politically-charged term of “death panel,” and providers were not reimbursed for having these often complex discussions.

Having the Talk

Despite the barriers, physicians overwhelmingly (99%) recognized the importance of having these conversations with their patients. As America’s population ages—10,000 people turn 65 each day—improving our comfort with, and skill at, discussing end-of-life care will become increasingly important.

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In January, the Centers for Medicare and Medicaid Services (CMS) began reimbursing health providers at a rate of $80 for a minimum 30-minute conversation with patients regarding advanced directives. Hopefully, the fact that CMS recognizes the importance of this service will lead to more people having these conversations with their doctors.

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CMS isn’t the only one who finds these conversations important: patients value and want to have them, as well. The Centers for Disease Control and Prevention found that 60% of people reported it was “extremely important” that their families not be burdened by difficult decisions at the end of their lives.

The presence of advance directives has been associated with greater use of hospice care and fewer  communications problems with providers. There are resources available to help providers start the conversation and improve their skills. One is The Conversation Project (http://theconversationproject.org), which contains tool kits for starting the conversation. These tool kits are general or disease-specific, and intended for both providers and the community. Another is the Physicians Order for Life Sustaining Treatment Paradigm (POLST). POLST has a website (http://www.polst.org/) containing information, tools and training resources for providers, patients and families.

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Providers must overcome the challenges inherent in having this often difficult, uncomfortable conversation for the good of older patients. Physicians agree nearly universally about the importance of having advance directive conversations as a way to honor their older patients’ end-of-life wishes. Providers must be the ones to start the conversation with families, caregivers and older adults. By opening the dialogue everyone involved will benefit from “the talk.” 

Lisa Price, M.D. is chief mMedical officer at Denver-based InnovAge, a provider of health and wellness services for older adults in California, Colorado and New Mexico. She was a private practice geriatrician for 11 years, and then attended on the Acute Care of the Elderly (ACE) service and taught Quality Improvement at the University of Colorado. Price is board certified in internal medicine and geriatrics, and has expertise in managed care, electronic health records and quality improvement. http://MyInnovAge.org.

Citations

http://content.healthaffairs.org/content/20/4/188.full.html

http://www.jhartfound.org/blog/end-of-life-and-serious-illness-a-john-a-hartford-foundation-change-agents-issue-brief/

http://www.jhartfound.org/advance-care-planning-poll

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3979710/

http://www.ncbi.nlm.nih.gov/pubmed/14959592

https://stacks.cdc.gov/view/cdc/5871/