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Posted by Dr. Lachlan Forrow February 11, 2013 12:37 PM
Consistency in who your caregivers are is often crucial to excellence in care near the end of life. Most transitions from one facility to another are intensely disruptive -- the patient is suddenly in a completely different environment, where s/he and loved ones need to start over again in building relationships with caregiving staff (not to mention the stresses of finding the new facility, figuring out parking, etc. etc.).
And for professional caregivers to be effective in delivering personalized care, even the most skilled and humane staff need time to get the know the patient as a unique human being, and to get to know key family members as individuals.
Minimizing the number of transitions between facilities in the last phase of life is thus an obvious priority for achieving excellence in care. Unfortunately, a disturbing article last week in the Journal of the American Medical Association shows that we are moving in exactly the wrong direction.
As Dr. Joan M. Teno and her colleagues show, for Medicare beneficiaries who died over the past decade (from 2000 to 2009), the average number of "health care transitions" -- i.e. changes in location of care -- in the last 90 days of life increased by 50%, from an average of 2.1 transitions per person to 3.1.
This is not a patient-centered health care system.
Part of the problem, as Dr. Teno explains in a news@JAMA interview, is driven by money -- hospital-level care is expensive but reimbursed relatively well, and nursing homes have financial incentives to transfer sick patients to acute care hospitals. But acute care hospitals then have financial incentives to discharge patients back as soon as the immediate problem has stabilized. For a growing number of patients (14.2% in 2009, up from 10.3% in 2000), their place of care changes even in the last 3 days of life. This isn't just disruptive at a human level, at a time when patients and families should be able to focus all of their energy on each other. As Dr. Teno explains, when a patient is transferred from a hospital to a nursing home "the nursing home has to represcribe all the patient's medications. There is often a delay in getting medicine to the patient."
Doing better requires proactive, patient-centered planning by everyone involved. But our current fee-for-service system does not reward clinicians for spending time talking with patients and families about goals of care, including the crucial issue of where the patient would want to be in the last phase of life. Dr. Teno expresses hope that moving away from fee-for-service, into "accountable care organizations" using "global" or "bundled" payment mechanisms will help.
Whatever the payment mechanisms, the first question about any proposed transition needs to be: "Is this change in location good for the patient (and family)?" Sometimes, as when the change is to fulfill a patient's deep desire to be home at the very end, the answer is "Yes." But much more often, especially when it is predictable that death is likely to take place within a small number of days, the answer is an obvious "No."
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About the authorLachlan Forrow, MD is Director of Ethics Programs and Director of Palliative Care Programs at Boston's Beth Israel Deaconess Medical Center and Associate Professor of Medicine at Harvard Medical School. More »
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