August 20, 2009National Press Club

FACT VERSUS FICTION: KEY ISSUES IN HEALTH

REFORM

FACT VERSUS FICTION: KEY ISSUES IN HEALTH

REFORM

Christine Cassel, MDPresident

American Board of Internal Medicine

Patient Centered? What Do Patients with Serious Illness Want?

Pain and symptom controlAvoid painful prolongation of the dying

processAchieve a sense of control and dignity

Relieve burdens on familyStrengthen relationships with loved

onesSinger 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 Care2000 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 2008Available at: http://www.dartmouthatlas.org/atlases/2008_Chronic_Care_Atlas.pdf

Copyright restrictions may apply.Zhang, B. et al. Arch Intern Med 2009;169:480-488.

Association between cost and quality of death in the final week of life (adjusted P =

.006)

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

Copyright restrictions may apply. Wright, A. A. et al. JAMA 2008;300:1665-1673.

Medical Care Received in the Last Week of Life

by End-of-Life Discussion

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-of-life care and advanced care planning.

Other legislative proposals not included are related to education, workforce,

quality and research.

Diane E. Meier, MDDirector, Center to Advance

Palliative CareMount Sinai School of Medicine

A Tale of Two Patients:Elaine G. and Judy F.

Diane E. Meier, MDProfessor

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 wishesProlonged critical careHospital complications

PainAngry, guilty adult son

Judy F., 65 year old with metastatic lung cancer

seeking guidanceDiagnosed age 59No smoking history

Given prognosis of 6-12 monthsWith expert oncologist, lived 6 yearsSought palliative care as symptoms

worsened for pain, insomnia, fatigue, questions about the future and what to

expectReceived simultaneous palliative and cancer

care for a yearWhen cancer Rx no longer helpful, referred to hospice for 3 weeks, died peacefully at

home surrounded by family

Conceptual Shift for Palliative Care

Medicare Medicare Hospice Hospice BenefitBenefit

Life Prolonging CareLife Prolonging Care OldOld

Palliative CarePalliative Care

Bereavement

Hospice CareHospice CareLife ProlongingLife Prolonging

CareCareNewNew

Dx Death

Implications and Lessons: Match the Care to the

Patient’s NeedsWe 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 AsimovUS science fiction novelist & scholar (1920 - 1992)

Although the world is full of suffering, it is also full of

the overcoming of it.

Helen KellerOptimism, 1903

In loving memory

Jerald Winakur, MDCenter for Medical Humanities and

EthicsUniversity of Texas Health Science

Center at San Antonio

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

MEMORY LESSONS: A GERIATRICIAN’S TALE

--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

AMERICA’S AGING SOCIETY

--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

The “State of Collapse” in America’s Primary

Care/Geriatric Workforce

A HELPFUL WEBSITE:

texaslivingwills.orgby Craig Klugman, PhD

Health Affairs gratefully acknowledges the generosity of the following organizations for support of this conference:

The End