ResistanceIt’s not just for patients…..

MAPP Workshop

4/27/2012Janis B. Petzel, M.D., DFAPA

Why Do Doctors Resist

Death, Documents and Data?

Death

• Self-selection and training• Military model “death warrior”• Reaction to our own helplessness?• Fear?

Documents

• Informed Consent• Advance Directives

Source of Resistance?

• Surface:– Time-sucking– Don’t help but hurt if done wrong

• Less Obvious:– Forced on us by legal system– Make us confront our mistakes and limitations

• Ideas?

Data

• Historic• Numerous examples

– PSA– Failure to monitor for metabolic syndrome in

patients on antipsychotic medication– Improved longevity on with palliative care, but

low referral rates

Why?

• Many times, data is not “stable” over time• Aging out of current knowledge?• Clinical experience does not match data?

– We believe ourselves more than we believe data?• Economics?• “Don’t just do something, stand there” has been

trained out of us?

• Ideas?

Feeding Tubes in Dementia

Hand feeding takes time,Poorly reimbursed

Is it all about money?

Utilization of Nasogastric Feeding Tubes in a Group of Chronically Ill, Elderly Patients in a Community Hospital

Timothy E. Quill, MD

Arch Intern Med. 1989;149(9):1937-1941.

Results:• 2/51 had informed consent

documented• 1/7 surrogates consulted

took patient wishes into account

• 35/55 died in hospital, including 90% who had asked for comfort-oriented treatment

• 53% restraints

Conclusions:• Not effective: only 2% NG

removed due to patient improvement

• 8:1 ratio of biomedical reason for insertion rather than quality of life

Tube Feedings in Elderly Patients Indications, Benefits, and Complications Jerry O. Ciocon, MD; Felix A. Silverstone, MD; L. Michael Graver, MD; Cornelius J.

Foley, MD Arch Intern Med. 1988;148(2):429-433.

Outline of study:• 11 months• 70 patients• 65-95 years old• 69 patients initially had NG,

of these, 15 later got G Tube

Reason for Tube Feeding:• 50% Refusal to swallow

• 47% Dysphagia, no obstruction

• 3% Esophageal Obstruction

Tube Feedings in Elderly Patients Indications, Benefits, and Complications Arch Intern Med. 1988;148(2):429-433.

NG Tube Group• Early Complications

– 67% agitation/extubation– 43% aspiration pneumonia

• Late Complications– 44% aspiration pneumonia– 39% agitation/extubation

G Tube Group• Early Complications

– 56%aspiration pneumonia– 50% tube dysfunction– 49% agitation/extubation

• Late Complications– 56%agitation/extubation– 38% tube dysfunction

40% Mortality

From blog: “he received no support when he requested a feeding tube” for his wife

Why?

• Money?• Feel we have to do something?• Trying to please family?• Force of habit?

• Ideas?

Tube Feeding in Dementia: How Incentives Undermine Health Care Quality and Patient Safety. Finucane et al. doi:10.10161 j.jamda.2007.01.007

•Nursing Home—fears of getting “ding-ed” for patient weight loss, negligence•Money

– “reduced physical function”=hand feeding, takes 35+minutes/patient

– “special care”=tube feeding reimbursed under Medicare

Perfect Storm?

• Reimbursement• Regulations• Tort

Clinical Correlates•Low referral rates to hospice•Futile care in CCU•Poor ability to switch from acute care to palliative•Poor ability to discuss prognosis accurately•?Poor ability to recognize our own needs

Discussion: