A New Model for End-of-Life Care
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Conversations about palliative care and hospice should be started slowly, during the course of a serious illness, and must involve everyone from the patient and his or her physician to family and community services. “By starting [the process] earlier, the transition [to hospice] is much more smooth and seamless,” said physician Barry M. Kinzbrunner, executive vice president and chief medical officer for VITAS, one of the nation’s largest hospice care providers.
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Panelists (L-R) Barry M. Kinzbrunner, MD, Executive
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Physicians and religious studies experts also weighed in during the panel session, titled “Care Models, Economics and Ethics of End-of-Life Decision Making,” presenting a clear and unified vision for the future of both palliative and hospice care. Both take a holistic approach to a patient’s wellbeing, with a focus on managing pain and symptoms. But hospice care is provided near the end of life, typically the last six months, while palliative care may include management of chronic disease processes and may include treatment aimed at curing illness.
Hospice care providers face many challenges, noted both Kinzbrunner and VITAS CEO Tim O’Toole, who moderated the panel. Such care requires a team approach and includes everything from pain and symptom management to emotional and spiritual support. The work is labor-intensive, as well, with care administered at all hours of the day and in a variety of places.
“We have to give the full gamut of care to these patients,” said Kinzbrunner, whose company sponsored the session. “Care is tailored to the wishes and needs of the patients and their families, and that’s key. It’s not about what we think, it’s about what the patient thinks and wants and needs.”
But hospice care should not be restricted to patients’ last six months of life (which is when they typically become eligible), argued oncologist Amy Abernethy, an associate professor of medicine at the Duke University School of Medicine and director of the Duke Cancer Research Program. She advocated that palliative and hospice care be seamlessly blended, and physicians should begin addressing symptoms and patient comfort during treatment.
“Why do we let the artifacts of a reimbursement system get in our way in figuring out how we’re going to take the best care of people who are potentially suffering from their illness, irrespective of their current length of life?” she asked. “Because frankly, it’s really hard to figure out how long people are going to live.”
In addition to doing whatever they can to cure a disease, Abernethy said, in this “evolving model” for end-of-life-care physicians should place greater emphasis on pain and symptom management and quality of life. She also provided an outline for what she called “a handshake model,” in which oncologists and other physicians work hand-in-hand with hospitals, community organizations and finally hospice providers to ensure quality care throughout the patient’s experience. She cited data from the New England Journal of Medicine showing that early palliative care not only improved patient survival but also provided a better quality of life and used fewer hospital resources.
The proposed model of care — whether palliative or hospice — means that the team of professionals providing it must include the patient’s own doctors, Kinzbrunner added. It’s a role that more and more physicians find themselves drawn into, yet are often unprepared for.
“We need to be able to transform, in many ways, the way we think about educating the workforce of physicians, social workers, nurses and chaplains to provide better holistic care,” said panel member Richard Payne, a professor of medicine and divinity at Duke University. He cited a number of trends in health care that make end-of-life care more difficult, including an emphasis in excellence in trauma care, the overmedicalization of the process of dying and the move toward specialization, which often obscures more comprehensive care.
Payne cited statistics from a 10-year-old survey of 65 academic medical centers in the U.S. that found that fewer than 20 percent of students and residents at that time received any formal education on end-of-life issues, and that 39 percent felt unprepared to address patient and family fears about dealing with advanced illness. He also showed the audience a survey illustrating that 10 years ago 72 percent of surgery textbooks had no content addressing end-of-life issues, nor did 47 percent of geriatrics textbooks.
“These kinds of data were so embarrassing … that there has been a concentrated effort to reverse this. But again, we still have a ways to go,” said Payne, who applauded models such as the Harvard Medical School Center for Palliative Care as well as other educational programs aimed at both medical students and practicing physicians.
Patients, too, can help make the end-of-life experience a little bit less stressful for their families, their health care providers and themselves, noted UM Religious Studies Professor Stephen Sapp. He discussed living wills, health care surrogates and do-not-resuscitate orders. “If we do some advanced planning at this point in our lives, our families won’t have to guess, at some later point in our lives, what we would want,” he said.
By Andrea Carneiro
