In shocks heard around the world, the Journal of Clinical Oncology is reporting a dramatic change in position from the American Society of Clinical Oncology for initiating end of life discussion choices with patients.
How do I summarize their position? Patients with advanced cancer should be presented with an end of life care discussion before they are dead. I think it's a start. Baby steps I say. The alternative scenario is displayed here in hospitalist vs oncologist.
End of life ethical issues are a constant presence for hospitalists. As the inpatient doctor of default for many patients, we are often asked to provide care for patients who are struggling to survive. These are patients who are actively in the dying process. These are patients who are on the last leg of their journey, delayed only by days, weeks, or months by the heroic actions of their doctors in shining armor swooping in to save the day.
I will be the first to admit that palliative care teams provide a phenomenal service, not for me, but for my patients. I can't even begin to offer my patients the level of discussion my patients deserve when they are stricken with advanced stages of chronic progressive disease. In fact, very few of my requests for palliative care consults come for cancer patients.
Most of the time, I am asking for help to change full code status in 85 years olds to DNR. I don't care how healthy you are. If you are 85 years old, intubating you and performing CPR (CPT 92950) is ludicrous. It borders on assault.
Most of my requests for palliative care or end of life care discussions come for patients with chronic progressive single or multi organ failure for whom no doctor in the world will ever fix, delay or reverse. These are patients with heart failure, renal failure, lung failure, brain failure. These are patients for whom life has failed them.
The Medicare-Merry-Go-Round is filled with a whole lot of suffering for selfish reasons. Families are selfish and often in extreme guilt and denial. Patients are selfish, not because they want to live for themselves, but rather live for their loved ones. Doctors are selfish because they think they are much better at what they do than they actually are.
We can't end that suffering until we admit that we are a major part of the denial process. We are great at offering therapy options to patients because that's what we do. We treat. Physicians are absolutely horrible at offering prognosis of disease. There is no formal medical school education training in prognosis. It is a catastrophic failure of the medical education process.
Why? Because prognosis is not about the disease. It's about the person. There are a whole lot of factors that go into survival, morbidity and mortality for the individual case. Doctors treat the disease. Palliative care teams treat the person. That's the difference between what we do and what they do. This will always be the case. We have to admit that and move on from there.
As physicians, we do a great job of causing unnecessary pain and suffering, which we will readily deny, because we are treating disease, not life. If the bloodless surgery or the stent or the scope or the medication fixed the problem, we take credit for success because it worked. We are treating the disease but the suffering goes on. But we still succeeded because we treat disease, not life.
The lack of systems processes in place to help facilitate end of life and palliative care discussions are a catastrophic failure of magnificent proportions. The delivery of health care is in autopilot because nobody wants to take responsibility for this process, which often is the most important treatment we can offer. And I hate to say it, but I would suspect a big part of this failure has to do with how hospitals get paid by Medicare and how doctors get paid.
Starting in 2013, the Medicare National Bank will start taking money back from hospitals that have a higher than acceptable readmission rate for three primary diagnosis related groups
- heart failure
- acute myocardial infarction
- pneumonia
I guarantee to you as sure as I am that The Happy Hospitalist is all that is whole and pure that hospitals everywhere will be integrating palliative care systemic processes into their hospital admission process to guarantee that they will not suffer under declining Medicare payment proposals going forward. Taking the payment process one step forward, I guarantee that bundled payments and gain sharing agreements between hospitals and physicians will generate lots of physician interest in palliative care for their patients. Unfortunately, I think, that's what it's going to take. But it's WIN-WIN. The Medicare death squads are coming. They're just coming out of necessity because hospitals and physicians will push them just to survive.
How ironic. In order for hospitals and physicians to survive, they will have to present the treatment option of allowing natural death. It changes everything.
Nobody gets admitted to the hospital onto a palliative care service, but they should, because often times that is the most appropriate treatment available. In fact, it should often lead the decision making process. I for one commend palliative care for often times providing the only quality medical care in the hospital.
Why so many doctors are against admitting that their patient is in the dying process and should be spoken with frankly and honestly about the lack of treatment options to make them feel better, is beyond me. Having an end of life care discussion should always happen before the patient is dead.
