End-of-life care done properly requires more than just a conversation between a physician and patient.

Even though it is a big step for the federal Medicare program to recommend that physicians be compensated for advanced care planning, such as end-of-life care, an expert at the Institute for Healthcare Improvement says that hospitals need to do more than talk.

"It's not just having the conversation," said Kelly McCutcheon Adams, a director for IHI. "It's not one and done."

Providers also need to understand such things as when and how often to have conversations, how to use over time what is learned in the conversations and the mechanics of how the information is recorded and presented in the electronic health record, said McCutcheon Adams, who is lead author of a recent IHI white paper called "Conversation Ready: A Framework for Improving End-of-Life Care."

Fortunately, she said, an argument for improved management of advance care wishes is a strong one in the current health care environment.

"This is one of those fantastic issues in health care where everything flies in the same direction," McCutcheon Adams said. "This effort, to me, aligns with every other priority that hospital executives have to pay attention to."

She pointed to such things as the effort to reduce readmissions and accountable care models as having incredible alignment with end-of-life care discussions and use of those discussions.

For those interested in getting started, IHI suggests a qualitative chart review of the last 20 patients to die in the hospital, looking for whether what happened with the patient matches his or her wishes, if those wishes were known.

"That process can be eye-opening" in identifying the strengths and weaknesses of a hospital's end-of-life care management," she adds.

IHI outlines five principles for creating a framework for a hospital to be ready to have conversations with their patients about end-of-life care.

    1. Engage with patients and families to understand what matters most to them at the end of life.

    2. Steward information about each patient's end-of-life care wishes as reliably as one would allergy information.

    3. Respect people's wishes for care at the end of life by partnering to develop a patient-centered plan of care.

    4. Exemplify the work in our own lives, so that caregivers fully understand the benefits and challenges.

    5. Connect in a manner that is culturally and individually respectful of each patient.

"There is surprising power in simply asking patients, 'What matters to you?' " McCutcheon Adams said. "This is so much about patient-centered care."