AMA end-of-life efforts could bolster hospice
AMA end-of-life efforts could bolster hospice
Dispel some of the myths about palliative careA new initiative by the American Medical Association (AMA) in Chicago to emphasize the physician’s need to improve the quality of end-of-life care for patients could be the beginning of the recognition hospice leaders have sought for 25 years — or it could be just another vehicle to bypass you.
"I’ve heard palliative care presentations without the holistic approach," that hospices provide, says Ronald Coffin, Mdiv, PhD, executive director and founder of Hospice of the Comforter in Colorado Springs, CO. "Doctors sometimes see palliative care as separate from hospice."
The AMA’s new program, expected to be funded late last month at $1.3 million by the Robert Wood Johnson Foundation in Princeton, NJ, is a direct turn away from the curative approach that has doctors spending millions to save the unsaveable. "We began this initiative because of the SUPPORT [Study to Understand Programs and preferences for Outcomes and Risks of Treatments] study that had fairly broad criticisms that doctors simply weren’t doing what was required of them," says Jeff Munson, AMA staff associate who helped formulate the initiatives. That study, also funded by the Robert Wood Johnson Foundation, analyzed the cases of 4,301 patients and found that most suffered painful and prolonged deaths, even when they had asked to avoid all aggressive, life-threatening measures.1
Munson says the two-pronged approach of the new program is designed to encourage physicians to emphasize advance care planning at every stage of health care, including yearly well checkups, and to train them in palliative care techniques. "We want to . . . dispel some of the myths about palliative care, so that they can promise patients a more comfortable way of dying, something we haven’t been doing," he says.
The AMA will directly teach 10% of all physicians in high-profile positions and provide educational material to others dealing directly with patients.
Along the way, Munson says he hopes the AMA will teach physicians about hospice. "There’s some pretty serious misconceptions about what hospice goals are. We would hope to be able to train them that [hospice] is one of their principal options which patients should know about," he acknowledges.
Despite the kind words, it is unclear whether hospice will be an equal partner in this new push. And because of the feeling that hospice may be regarded as an evil stepsister, hospice officials express mild suspicion about physicians’ new interest in end-of-life improvement. "There are competing interests in the health care system, and it would be naive to overlook that," says Coffin. "The interest in health care follows the money."
With the implementation of the new ICD-9 CM Medicare code last year that allows reimbursement for palliative care, hospice administrators worry that physicians will see palliative care as "another reimbursement issue, another revenue stream," says Coffin.
If that were to happen, Coffin says he fears there will be even more resistance to hospice and the palliative care provided in its holistic approach. "When I talk to doctors here, there’s a lot of misperception about pain control. They believe if you give them morphine, you are going to kill [the patients]. . . . We don’t curtail life here; we’re not substituting for Dr. Kevorkian."
Even administrators of hospices that have good relationships with physicians acknowledge the difficulty of getting doctors to refer patients at all or soon enough to make a difference in the patients’ lives.
"Our community may be fairly unusual. We’re a very old hospice, very stable, and very involved in the medical community. People do think of us," says Gretchen Brown, MSW, president and CEO of Hospice of the Bluegrass in Lexington, KY. She adds, "They do sometimes think of us too late, though."
Late referrals continue to be one of hospice’s main problems. "We still so often get all our patients in the last few days, when there is just not enough time for us to do [our best job] with them or their families [and meet their needs]. . . . Three months is optimal, six months is good but not realistic," says Jeanne M. Brenneis, Mdiv, STM, director of the Center for Bioethics and chaplain at the Hospice of Northern Virginia in Arlington, VA.
Munson acknowledges the obvious: "A lot of time physicians refer to hospice because they don’t know where to put the patient. [Physicians] need to understand that hospice is not just a place to put them to get them out of the hospital, that it’s a place to facilitate the healthy dying process."
Will this year’s AMA initiatives actually change a physician’s mind about hospices? In the end, says Dale Smith, executive director of the American Academy of Hospice and Palliative Medicine in Gainesville, FL, that is not really the issue.
"Our position would be that anything that allows a greater number of patients to get better palliative care, then that is what should be done, whatever the setting," he says, noting that the academy itself recently certified 126 physicians in palliative care. "I view all this positively because two years ago we would not have even been having this discussion. The word palliative’ would not have been known.
"We’re just tickled pink that organizations like the AMA are beginning to be interested in palliative care."
Reference
1. "A Controlled Trial to Improve Care for Seriously Ill Hospitalized Patients," JAMA 1995; 274:1,591-1,597.
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