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Posted by Dr. Lachlan Forrow August 20, 2013 07:55 AM
Your doctor obviously can only take care of you the way you would want if s/he talks to you about your preferences. And then the results of this conversation need to be documented in your medical record, so that your wishes are known and readily available to any other doctor who might need to make decisions -- especially if there's a sudden crisis and you have arrived at a hospital, unable to speak for yourself.
We know that these conversations with your doctor happen too rarely (for patients with a serious illness, anything less than always is "too rarely"). And even when they do happen, they are too rarely documented in a way that is available when and where the information is needed.
But we also all "know" how complicated and difficult this can be, even (or maybe especially) when you are sick enough that you are in the hospital. We "know" that patients in the hospital are often so focused on the immediate problem, on getting better and getting back home, that they may not want to have "The Conversation" about what they would want if things get worse. And we "know" that doctors in the hospital are so busy that it's hard to find time before you are discharged to sit down and have "the conversation" with you, much less take the time to write down what they talked about with you, and what you said you would (and wouldn't) want if you got sicker and had to come back. And if, during this hospitalization, you are now getting better, then everyone has breathed a sigh of relief -- "the conversation" doesn't have to happen right now, it can wait.
And then it often simply doesn't happen at all.
But maybe what we all "know" is wrong.
A provocative new article in JAMA Internal Medicine, titled "Incentivizing Residents to Document Inpatient Advance Care Planning", shows that doing better may not be so complicated after all.
The authors report on the results of a "Housestaff Incentive Program" involving internal medicine residents at the University of California at San Francisco (UCSF). In this program, medicine residents choose a "quality improvement" project with specific, measurable goals, and if those goals are met then the medical residents each receive a financial reward. For 2011-2012, the residents chose the goal of "improving documentation of advance care planning discussions", because they recognized that "inconsistent documentation was a barrier to honoring patients' wishes."
In a nice summary of the study by Paula Span in her NY Times blog, she explains that:
The researchers came up with a standard form, which was inserted in patients’ electronic health records. It asked just a few questions: Does the patient have any “expressed wishes” about how much care he wants or doesn’t? Where are those preferences recorded — in a living will, a durable power of attorney, a P.O.L.S.T. form (which would be scanned into the record). Or are they expressed orally?
The researchers’ form requests a brief summary: He doesn’t want to be resuscitated or intubated? She wants a feeding tube but not a ventilator? Or she wants “all available care?” Does he have a designated decision maker? What is that person’s name and phone number, and what language does he or she speak?
If residents recorded this information for at least 75 percent of discharged patients, for three of the four quarters in the academic year, they each got a $400 bonus. If not, they didn’t.
The results were dramatic.
From a baseline of 22% "completed fields" at the start of the project (July 2011), rates of completion rose rapidly, to over 90% by October, a level sustained through the end of the project (May 2012). By comparison, for patients discharged by attending physicians without involvement of medical residents, the average rate of "completed fields" during the year was only 11.7%.
Of course, the project was not just about "money" -- the residents also used many of the basic tools of any "quality improvement" project. They created simple, easy-to-use fields in the discharge summary where information could be recorded. They conducted educational sessions about how to use those fields. Every two weeks they emailed simple charts to all residents providing "feedback data" on how well they were doing.
And of course many questions still remain -- were the dramatic improvements sustained after the project (and the financial incentives) ended? Did having this information available in the discharge summary help ensure that subsequent care was reliably anchored in the patient's expressed wishes? Is it possible to achieve similar results without the financial incentives?
I think it would be a tragic misunderstanding, and deeply unfair to the medical residents at UCSF, to conclude from their project that "at the end of the day, for doctors, it's all about the money". It was not money that led the UCSF residents to choose this project over the countless other quality improvement projects they could have done. It was not money that led them to do all the work involved in creating the user-friendly systems that made documenting patients' wishes so much easier. It was not money that led them to do all of the educational outreach, and provide the concrete "feedback data" to their fellow residents about how they were doing.
The UCSF residents were clearly troubled by finding themselves working in a health care system that is not designed to ensure that each patient's wishes are known and respected. So they decided to change that, and very quickly achieved dramatic improvements. Yes, they used financial incentives as part of the motivation for their colleagues. But "at the end of the day", I suspect their greatest reward was not the money at all -- it was knowing that they had helped improve the care of their patients, and made it easier for other doctors to do the same.
But let's find out -- all we will need is another group of energetic and motivated medical residents at another medical center, who try to replicate the UCSF success, but without a year-end cash payment being the reward. I'm willing to bet (a cup of coffee, not money) that some group of medical residents will soon try that, and succeed.
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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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