Preparing internists for end-of-life discussions

Janet L. Abrahm, MDIt makes sense for internists to start “difficult conversations” with their patients who have life-limiting illnesses when they still have years left to live.

That’s according to Janet L. Abrahm, MD, a palliative care expert at the Dana-Farber Cancer Institute in Boston and professor of medicine at Harvard Medical School. Internists play an important role in having what she calls “goals of care” or “values” discussions with their patients.

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“It’s really part of the whole active prevention package that internists are so good at,” says Abrahm, an oncologist by training. “Internists look ahead at the likely consequences of asymptomatic but treatable conditions like hypertension or hypercholesterolemia and they make plans with the patient to prevent those consequences.”

Abrahm will be a presenter at this year’s American College of Physicians Internal Medicine Meeting in Washington, D.C.  Her session, “Palliative and End-of-Life Care” is scheduled for Friday, May 6.

She recently spoke to Medical Economics about internists’ unique position to form relationships with their patients and bridge the discussion to these difficult decisions later in life.

Medical Economics: What do you see as internists’ role in preparing for future discussions with patients about possible palliative or end-of-life issues?

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Abrahm: We rely on our internists to be the primary care physicians caring for a patient over a period of years. They are in the best position to understand clearly the patient’s hopes and fears should they develop a serious disease or should they simply age. A lot of our internists are caring for an aging population. So with a patient with a potentially life-limiting illness over the age of 65, with parents that are aging, it wouldn’t be unrealistic at all to start talking about looking ahead and asking them to reflect not just on their parents’ wishes, but on their own hopes and fears, their own values and what medical treatments may or may not be in concert with who they want to be even if they later become debilitated.

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As the internist becomes more comfortable with that conversation, it becomes part of the overall care of the patient, getting to know the patient, knowing the things that would make life valuable, where they get their strength from: religion, family, etc. It’s really getting a 3D picture of this person …

There are guides, like the Serious Illness Conversation Guides being developed by Dr. Susan Block and her colleagues at Ariadne Labs. They’ve developed questions using patient-tested language that can help an internist to start with the conversation.

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ME: What can you advise the hesitant internist to do about discussing palliative care / initiating discussions about patients’ goals and values?

Abrahm: Start by understanding that palliative care goes along with life-prolonging care; that’s the whole point−to improve the quality of the patient’s life at the same time the life-prolonging care is going on, a so-called extra layer of support. Palliative care clinicians can help internists to manage refractory symptoms and with difficult conversations.  I think that one of the easy ways to identify which patients would benefit from the conversation is to go through your panel of patients with your staff and ask: “Who are the people who we wouldn’t be surprised if we heard they died in the next year?” Maybe there are 10 of those patients out of 1,000 … maybe 20. Certainly, those would be the patients you’d want to start having the conversations with.  You would feel horrible if they were hospitalized in the ICU, intubated and you never had a chance to talk with them about whether this was want they were willing to undergo. You know them best, you’ve been following them and their family for years. Palliative care clinicians can join internists to help with the conversation, or they can use the conversation guides. There is also The Conversation Project that has a lot of resources for families who want to start thinking about their choices.

There’s now a billing code for having these discussions, so that [physicians can code] 99497 for first 30 minutes; 99498 for next 30 minutes, and that’s in addition to what you’d charge for the visit anyway.  So if you look through your panel … you can book extra 15 minutes to 20 minutes to start that discussion, maybe to give materials and maybe two or three months later, have them bring them back for another discussion.  You can bill for these discussion and you don’t even need to complete any documents like healthcare proxy forms, just indicate you’ve had the discussion.

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ME: Do you think this move by The U.S. Centers for Medicare & Medicaid Services will aid these dialogues or are they already happening in physicians’ offices?

Abrahm: What I’m hoping is that for some of the large, full-risk healthcare systems, it might change practice. Kaiser, for example, is [in an accountable care organization (ACO) model in which it assumes] full-risk for its patients. The leadership might decide, “OK, we can create a trigger for which patients would benefit from having that conversation (e.g. with a life-limiting illness, at a certain age or certain number of comorbidities) and we can encourage our clinicians to have these discussions with those patients and to bill this code.”

Next: Even more tips

I like systemic fixes like this, where the incentives are aligned: the ACO prospers and so does the patient. This way, if there were a number of internists in a large practice who were interested in having these conversations, but the system only allowed 15 minutes for follow-up visits, they could advocate for scheduling advance care planning conversations, emphasizing both the reimbursement for the visit itself and the downstream savings such conversations are likely to deliver to the system. Patients and their families would in turn benefit from the planning their physicians would help them do.  A systemic change could happen in the whole organization, aligning the patient’s wishes with the financial incentives.

ME: What other tips do you have for physicians when it comes to end-of-life discussions?

Abrahm: I’ve found the more I have these discussions, the easier it gets. It is a lot easier for me to talk about this now than people’s sex lives, to be perfectly honest. When you’re first starting, use a conversation guide and make the questions your own as you get used to what works for you and what doesn’t. Using patient-tested questions that are very likely to result in helpful answers is a great way to start having difficult conversations.

Asking about people’s hopes and fears and where they get their strengths from and what they are willing to go through to get more time, how much does your family know about your wishes–that’s a new skill for most internists to learn.  I certainly never had a course in residency or in specialty training on how to do this.  And [patients] expect [the physicians] to bring it up. When you do, you’re clearly stating, “I’m here for the long run. I care for you as a whole person. Now that you have a life-limiting illness, I need to know more than I knew before so that I can help you and your family make decisions going forward, as we walk this road together.”