Advance care planning vital to true patient-centered care

A report issued by the Dartmouth Atlas Project this year found that as people age, many continue to receive care that does not align with their own preferences.

This is especially true at the end stages of serious illnesses.

While many patients tend to prefer comfort measures over further medical interventions, the Dartmouth team reported that patients are spending more days on average undergoing aggressive treatments in the intensive-care unit, despite concerns over the value of such care.

Although excellent pain relief services are available for patients in need, the report also found that late hospice referrals occur too frequently—adversely affecting not only the quality of care delivered, but also the experience and satisfaction of patients and their families. Rather than rushing through a process of providing pain medications in these situations, hospice professionals need more time to get to know patients and families, building trust so they may truly address their needs.

In too many cases, efforts to prolong life can result in drawn-out, uncomfortable and even painful final days. While not an easy topic for anyone, the report sheds much-needed light on the fact that physicians must be comfortable discussing end-of-life care planning with patients. We owe it to them to respectfully open this dialogue and ensure their care decisions, goals and wishes are honored.

Although the CMS announced last year that it would begin providing reimbursement for end-of-life discussions with patients, they can still be incredibly difficult on a personal level for a clinician to initiate. As physicians, we are conditioned to develop meaningful, long-standing relationships to ensure our patients' health, making end-of-life issues so hard to broach. Patients are also often uncomfortable proactively sharing their feelings on the topic. But these conversations are essential. From an organizational standpoint, it can be challenging to implement practices that help physicians have these discussions, and to document their patients' wishes so they are available when needed.

Despite these obstacles, the ability of a healthcare system to honor its patients' care preferences at the end of life is essential to providing patient-centered, quality care. Establishing an internal support system, which includes comprehensive training, is an effective way to help physicians learn how to respectfully begin these conversations as part of routine care.

At Atrius Health, those with extensive expertise in advance care planning serve as mentors for their colleagues, using video presentations, interactive sessions and role playing as various means of strengthening competencies among clinicians in initiating conversations with patients about end-of-life care and documenting patient wishes.

These responsibilities should not rest with physicians alone. Patient-centered care is a team endeavor, so all who serve patients should be well-versed in end-of-life care. While it is important that physicians consider these conversations with patients of all ages, such care planning and documentation is especially vital for geriatric or critically ill patients.

In collaboration with a patient's primary-care physician, multidisciplinary palliative-care teams are critical in meeting the needs of patients and their families. This coordinated approach allows specially trained physicians and advance-practice clinicians, case managers, home care nurses, chaplaincy and social work disciplines to treat symptoms and facilitate advance care planning, while also providing psychosocial support through family meetings, bereavement care and referral to hospice when appropriate.

The cultural shift necessary for clinicians to responsibly and compassionately approach end-of-life care will not happen on its own. Just as we are accountable for honoring our patients' wishes, we have an obligation to support our colleagues through these difficult discussions. We owe it to each other to provide this assistance. More importantly, we owe it to our patients to make sure we do it right.