It was not long ago that hospitals replaced homes as the place where life began ... and ended. Not only did hospitals bring the most advanced technology to bear in prolonging life, be it for a preemie struggling for breath or an advanced cancer patient whose organ systems were progressively failing, but the health system also spared families from the untidiness of death.
From the hospital’s perspective, meeting all the needs of its patients was like an annuity. It would pay consistent returns throughout the patient’s lifetime, with a kicker at the end as the patient’s utilization often soared. Savvy health care marketers picked up quickly on the opportunity to position their organizations as “cradle to grave” providers.
At the time, few consumers or providers saw any harm in such thinking; after all, it was simply a demonstration of how the fruits of science could be harvested for the benefit of society. But in the early 1970s, things began to change: A handful of physicians, nurses and educators began to question whether the health care field was properly managing end-of-life issues. Chief among these provocateurs were Elisabeth Kübler-Ross, M.D., and Florence Wald, dean of the Yale School of Nursing.
They raised difficult questions about the types of interventions that were appropriate for terminal patients, particularly those suffering from advanced cancer. They also asked where such patients would best be served — in a hospital or in their home surrounded by loved ones.
Other physicians pushed back, suggesting it was medicine’s moral obligation to do everything possible to rescue patients from the abyss of death. And so, a dynamic tension arose between those who sought to heal the body and those whose definition of healing was not simply biological but included concepts such as quality of life, finding meaning and purpose at life’s end, holding on to hope and achieving closure. It is a tension that continues today despite significant changes in end-of-life care.
As the number of Americans approaching end of life swells, health care leaders bear a tremendous moral obligation to advance not merely the thinking relative to end-of-life care but also the implementation of care and the care standards that address the gestalt of patient and family needs.
Pre-eminent organizations — from the Institute of Medicine to innumerable foundations — have acknowledged this need through research grants, white papers, books and advocacy. It is still not enough. Transformational change in end-of-life care is going to require every hospital administrator and chief of staff to roll up his or her sleeves and get to work.
Not long ago, the goal was simply to increase enrollment in hospice care while decreasing the number of deaths in hospitals. According to a study conducted by Joan M. Teno et al. and published in the Feb. 6, 2013, edition of the Journal of the American Medical Association, the percentage of deaths occurring in hospitals decreased from 32.6 percent in 2000 to 24.6 percent in 2009. Teno further revealed that hospice use at the time of death increased over this same period from 21.6 percent to 42.2 percent. But what appeared to be a major success was, in a reality, an indication that the measures needed to be recast.
Rather than being a cause for celebration, the research results raise difficult questions, including:
- Are hospice patients experiencing an optimal length of stay based on their clinical condition, personal values and other factors, or are they being transitioned into hospice care only after potentially unnecessary, ineffective or inappropriate interventions have failed?
- What important knowledge can be gleaned regarding the current state of end-of-life care by examining intensive care unit admissions, emergency department admissions and other types of health care utilization during the last six months of life? Was such utilization beneficial to the patient if measured against quality of life and other factors?
- Are there financial motivations that appear to be affecting end-of-life decisions rather than a solitary focus on what is in the best interest of the patients? Who within the hospital is empowered to raise and examine this issue?
- Are physicians and other members of the care team appropriately trained to engage patients and their families in constructive dialogue about end-of-life care? If not, what efforts are being put in place to change this deficit?
- Are the medical staff using palliative care to meet the needs of patients? If not, is it due to a deficit in training about the basics of palliative care, a lack of specialists for integration into the care team or both? How is this issue being addressed?
- Are there appropriate quality measures being established to monitor and encourage the improvement of end-of-life care in our hospitals?
Health care delivery is an evolving science. One need look no further for proof than our flawed reimbursement system and the myriad attempts to fix it. So, it is not surprising that course corrections are needed if hospitals are to deliver optimally effective and empathetic end-of-life care. Those course corrections will require time and conviction — two commodities that can be in short supply among hospital senior executives and physicians who are besieged with many other concerns.
Yet, just as it is sacred to protect life by employing the potent tools of medicine, it is equally sacred to facilitate the transition from life — with great respect for the needs of the patient as well as family members. The efforts made by health care leaders to improve end-of-life care have the power to speak volumes about the moral imperatives of hospitals and their stewards. Gains will be realized only if improving end-of-life care becomes one of a handful of strategic initiatives guiding your institution through the difficult times ahead.
John Leifer is the CEO of the Leifer Group, a health care strategy firm in Leawood, Kan. He is also the author of The Myths of Modern Medicine: The Alarming Truth About American Health Care and After You Hear It’s Cancer: A Guide to Surviving the Difficult Journey Ahead.