Transcript Slide 1
FACT VERSUS FICTION:
KEY ISSUES IN HEALTH
REFORM
August 20, 2009
National Press Club
Christine Cassel, MD
President
American Board of Internal Medicine
Patient Centered?
What Do Patients with Serious
Illness Want?
Pain and symptom control
Avoid painful prolongation of the dying
process
Achieve a sense of control and dignity
Relieve burdens on family
Strengthen relationships with loved ones
Singer et al. JAMA 1999;281(2):163-168.
And What They Get: Suffering in U.S. Hospitals
National Data on the Experience of Advanced
Illness
in 5 Tertiary Care Teaching Hospitals
9,000 patients with life-threatening illness, 50% died within
six months of entry
Half of patients had moderate-severe pain >50% of last
three days of life.
38% of those who died spent >10 days in ICU, in coma, or
on a ventilator.
JAMA 1995;274:1591-98
Patient Centered?
What Do Family Caregivers Want?
Study of 475 family members 1-2 years
after bereavement
•Loved one’s wishes honored
•Inclusion in decision processes
•Support/assistance at home
•Practical help (transportation, medicines, equipment)
•Personal care needs (bathing, feeding, toileting)
•Honest information
•24/7 access
•To be listened to
•Privacy
•To be remembered and contacted after the death
Tolle et al. Oregon report card.1999 www.ohsu.edu/ethics
And What They Get: Family
Satisfaction with Hospitals as the Last
Place of Care
2000 Mortality follow-back survey,
n=1578 decedents
•Not enough contact with MD: 78%
•Not enough emotional support (patient): 51%
•Not enough information about what to expect with the the
dying process: 50%
•Not enough emotional support (family): 38%
•Not enough help with pain: 19%
Teno et al. JAMA 2004;291:88-93.
Medicare Spending by Sector in
Last Two Years of Life
Source: The Dartmouth Atlas of Health Care 2008
Available at: http://www.dartmouthatlas.org/atlases/2008_Chronic_Care_Atlas.pdf
Association between cost and quality of death in
the final week of life (adjusted P = .006)
Zhang, B. et al. Arch Intern Med 2009;169:480-488.
Copyright restrictions may apply.
Advance Directive
Advance health care directives, also known as
advance directives or advance decisions, are
instructions given by individuals specifying what actions
should be taken for their health in the event that they are
no longer able to make decisions due to illness or
incapacity.
A living will is one form of advance directive, leaving
instructions for treatment. Another form authorizes a
specific type of power of attorney or health care proxy,
where someone is appointed by the individual to make
decisions on their behalf when they are incapacitated.
People may also have a combination of both.
-- Wikipedia
Medical Care Received in the Last
Week of Life
by End-of-Life Discussion
Copyright restrictions may apply.
Wright, A. A. et al. JAMA 2008;300:1665-1673.
Policy – House Tri-Committee Bill
Provides Medicare coverage for voluntary
Advance Care Planning Consultations at least
every five years.
Requires quality measures in PQRI on end-oflife care and advanced care planning.
Other legislative proposals not included are
related to education, workforce, quality and
research.
Diane E. Meier, MD
Director, Center to Advance Palliative
Care
Mount Sinai School of Medicine
A Tale of Two Patients:
Elaine G. and Judy F.
Diane E. Meier, MD
Professor
Mount Sinai School of Medicine
August 20, 2009
Elaine G., 82 year old nursing
home resident with dementia and
recurrent pneumonia
Business as usual
Multiple admissions for recurrent pneumonia
No prior evidence of her wishes
Prolonged critical care
Hospital complications
Pain
Angry, guilty adult son
Judy F., 65 year old with
metastatic lung cancer seeking
guidance
Diagnosed age 59
No smoking history
Given prognosis of 6-12 months
With expert oncologist, lived 6 years
Sought palliative care as symptoms worsened
for pain, insomnia, fatigue, questions about the
future and what to expect
Received simultaneous palliative and cancer
care for a year
When cancer Rx no longer helpful, referred to
hospice for 3 weeks, died peacefully at home
surrounded by family
Conceptual Shift for Palliative Care
Life Prolonging Care
Life Prolonging
Care
Medicare
Hospice
Benefit
Hospice Care
Palliative Care
Dx
Death
Old
New
Implications and Lessons: Match
the Care to the Patient’s Needs
We don’t know who is at the end of life until
weeks-days before death
Advance care planning necessary from point of
diagnosis of advanced progressive illness
regardless of prognosis- not at “end of life”
Non hospice palliative care appropriate whenever
symptom, function, and family burden regardless
of prognosis, and in combination with all other
appropriate life prolonging treatment
Hospice when life prolonging treatment no longer
effective or burden>benefit.
Result is genuinely patient-centered care,
markedly lower costs
Art Buchwald, Whose Humor Poked the
Powerful, Dies at 81
By RICHARD SEVERO
Published: January 19, 2007, New York Times
As he continued to write his column, he found
material in his own survival. “So far things are
going my way,” he wrote in March. “I am known in
the hospice as The Man Who Wouldn’t Die. How
long they allow me to stay here is another
problem. I don’t know where I’d go now, or if
people would still want to see me if I weren’t in a
hospice. But in case you’re wondering, I’m having
a swell time — the best time of my life.”
Life is pleasant. Death is
peaceful. It's the transition that's
troublesome.
Isaac Asimov
US science fiction novelist & scholar (1920 - 1992)
Although the world is full of
suffering, it is also full of the
overcoming of it.
Helen Keller
Optimism, 1903
In loving memory
Jerald Winakur, MD
Center for Medical Humanities and
Ethics
University of Texas Health Science
Center at San Antonio
MEMORY LESSONS:
A GERIATRICIAN’S TALE
JERALD WINAKUR, M.D., F.A.C.P., C.M.D.
The Center for Medical Humanities and Ethics
The University of Texas Health Science Center
at San Antonio
AMERICA’S AGING
SOCIETY
--Over 65: 72 million people, 20% of our
populace in the next 23 years
--Over 85: 18 million by 2050
--Only 20% are fully mobile
--50% have some degree of dementia
The “State of Collapse” in
America’s Primary Care/Geriatric
Workforce
--50% decline in students choosing primary care as a
career since the late nineties
--20% decline in the number of certified geriatricians
practicing in the last 10 years
--7000 geriatricians in America today
The “State of Collapse” in
America’s Primary
Care/Geriatric Workforce
--300 new geriatricians entering the workforce yearly
does not replace those retiring
--Only 2% of residents in training choose Geriatrics as a
career
--2008: only one geriatrician per 8000 patients
--Current deficit of 14,000 geriatricians will grow to
34,000 by 2030
A HELPFUL WEBSITE:
texaslivingwills.org
by Craig Klugman, PhD
Health Affairs gratefully acknowledges the
generosity
of the following organizations
for support of this conference:
The End