We are all Palliative Physicians

70% of us say we prefer not to die in a hospital. Yet, 70% of us die in hospitals, too often tied to a ventilator, on vasopressors, either unconscious or in distress.  

Last week, over one hundred physicians, nurses, and other health professionals gathered at the Feinstein Institute for a day-long learning session on Advanced Illness.  Some conferences add to what you know.  Once in a while, as in this case, a conference changes the way you think. 

Some of the take-aways are obvious.  Conversations about end-of-life care need to happen long before the patient arrives in our ED or in the ICU.  So we need to engage our community partners.  These encounters are hard to have in the office (with or without federal funding) and hard to have in the hospital, because they are emotionally stressful, because they take time we don't always have, and because we need better skills.  Additionally, advance directives don’t solve the problem.  Identifying a healthcare Agent is a good idea.  But what good is it, really, if the physician and his team lack the skills to guide the individual, respectfully and empathetically, through the difficult choices to be made, honoring the patient’s autonomy while providing clear professional advice?  And Living Wills are of little help, with their boiler-plate language which rarely squares with clinical reality: “I want to forego X, Y and Z…in the event that there is no reasonable hope of my recovery…”

Here’s the real crux of the issue.  Too often we fail to grasp the essential question.  And so, with the best of intentions, we ask meaningless, or even harmful questions:  “Do you want us to do everything?”…or this variant… “If your heart were to stop, what measures would you like us to take?”  At their core, questions like these ask “which do you prefer, Mr. Smith, life or death?”  This question and its variants, often asked in a vacuum, are unhelpful, confusing and distressing to patients and families.

How, as a medical community, can we do better? First, we must listen closely, and that includes listening to ourselves.  If we were the patient, would we sound like we care? And like we were making sense?   Second, we need helpful guidelines for end-of-life discussions.  I have excerpted below a standard reference in the field of Palliative medicine.  Not every discussion will be a fully formed family meeting.  But there are steps that must precede any discussion about the plan of care when cure is no longer a realistic goal.  (A training program for practitioners is just now getting underway at our Center for Learning and Innovation.)


Ultimately, we need to learn to move beyond harmful questions -- “Do you want everything done?” -- to dialogue.  What is most important to the patient?  Is it comfort?  Is it the ability to interact with others? Is it independence? Or is it another day or week of life, until a relative arrives or an anniversary happens or just because the person’s values are such that prolonging life even a little trumps all other considerations?  Given that death is not optional, the ultimate question is “from what you know, what kind of death would mom have wanted?” The answers simply can’t be obtained from a check-the-box kind of interaction.  They require conversation. The key point is that as health professionals, we don’t advocate death, and we don’t help patients chose death.  However, as death draws nearer, we have an obligation to learn what patients and families understand about the situation, fill in the gaps, engage the family about what matters to the patient, and then make clear recommendations about how to move from curative measures that wont work to comfort measures that will.    

Ms. Smith, I have conferred with our team of physicians.  It is clear that your dad’s heart, lungs and kidneys are failing and he is not going to get better.  Basically, we have three choices.  We could admit him to the ICU.  He may need a breathing tube and then probably a feeding tube.  When his heart stops, we could do “CPR,” which means pressing very hard on his chest and shocking his heart.  Sometimes ribs break when we do this, especially in frail elderly people like your father.  The odds are less than 1/20 that CPR would work at all, and even less that he would ever be conscious after that.  Almost certainly, he would die in the ICU with the tubes.  A different option is to elect “Comfort care” at this time, which means that we would focus on pain relief and medications to keep him from the discomfort of feeling short of breath.    There is a third choice, and that is to provide medical care that will not tie him to a machine, while treating what problems we can, without invasive measures.  It is still uncomfortable to be in a hospital bed, but not as distressing as the ICU.  This care could include fluids, antibiotics and other medications, as well as pain relief and attention to his comfort.  As doctors, we aren’t perfect at predicting exactly when death will happen.  It is possible that the ICU could prolong dad’s death by a number of days, or maybe not at all.  Based on what you have told us about his wishes, our recommendation is that we avoid the most invasive care.  I suggest that as he declines we protect him from CPR and from ICU care.  I don’t think either one is in his best interest.  I know these are never easy decisions. We are here for you and for your dad. How does this plan sound to you right now? 


Once a plan of care is established, it should not be disrupted casually, because a consultant has a different point of view, or accidentally, because the care team has not communicated the family’s wishes internally, or because multiple hand-offs have thrown a wrench into our efforts to provide well-coordinated care.  As patients decline and the end draws nearer it becomes more important than ever that we function not so much as a team of experts, but as an expert team.

We know that as physicians it is our role to help - this is our motivation and our defining characteristic.  This is also the principle of beneficence, and it stands arm-in-arm with the reciprocal obligation to avoid harm ("non-maleficence").  What this means, practically speaking, is that we should never feel compelled to offer interventions that in our judgment will not help, and most especially we should avoid these when they add to suffering.  Sometimes the pursuit of these principles will put us at odds with a family.  But there are those around you who can help, including our colleagues in the Palliative Medicine program, the Bioethics consultation service, and, finally, clinical leadership.

There is tremendous opportunity here.  I look forward to working with many of you - our exceptionally committed and talented physicians -  to spread information, skills and a new culture of caring that does credit to our institution and does right by the patients and families who depend on us.
  

Communicating about Withholding or Withdrawing Therapies and 

Shifting Goals from Cure toward Comfort, Dignity and Quality of Life

1. Establish the Setting
Review relevant information.	Patient's prognosis Outcome of therapy in question in this patient
Make sure the right people are there.	Patient's or surrogate's loved ones Staff
Find a comfortable, quiet location.	Places for everyone to sit Seclusion from others Ability of everyone to see and hear each other
Introduce the topic for discussion.	“I was hoping we could talk about the next steps in your care.”
2. Review the Patient's Situation
Elicit the patient's or surrogate's understanding.	“Can you tell me your understanding of what is going on with your medical situation?” “What have the other doctors told you about your dad's medical situation?”
Educate as needed.	“That's right, the cancer has spread. What that means is that although there are treatments to control the symptoms, we can't cure the cancer.”
3. Review Overall Goals of Care
Elicit goals from the patient or surrogate.	“Did you talk with Dr. Smith about what the goal of your treatments should be?”
Summarize to confirm.	“So it sounds like the most important thing is to make sure your father is comfortable.”
4. Relate Your Recommendation for Withholding or Withdrawing Treatment
Introduce the specific treatment to be discussed.	“Today I wanted to talk about what we should do if your breathing gets worse, including whether we should use a breathing machine.”
Ask about previous experience with the intervention in question.	“Has anyone ever asked you about being on a breathing machine?”
Describe the intervention in question and its benefits and burdens for this patient.	“Based on what we’ve talked about—the fact that this cancer isn't curable—the chance of being able to come off the breathing machine would be very low.”
State your recommendation.	“I recommend that if your breathing gets worse we don't put you on a breathing machine.”
Describe how you feel your plans are consistent with the patient's overall goals.	“The reason I think we shouldn't is that you said you wouldn't want your life to be prolonged if there wasn't a good chance of recovering to where you are now.”
Describe what treatments will be provided.	“We will use medicines to improve your breathing and comfort.”
5. Respond to Patient or Surrogate Reaction
Acknowledge emotions.	“It's hard getting to this point, isn't it?”
Is the recommendation consistent with patient's values and goals?	“How does that plan sound to you?”
Answer questions.	“I’ll be around if you think of things you want to ask me later, but are there questions can  I answer now?”
6. Summarize and Establish Follow-Up
Summarize.	“Good. So we’ll keep the antibiotics going and give you medicines if the breathing gets worse, but we won't put you on a breathing machine.”
Explain the next steps in treatment.	“We’ll plan on keeping you here in the hospital for the next few days and see how things go.”
Arrange for the next meeting.	“I’ll see you tomorrow on rounds. Please have your nurse page me if you need anything before then."

An open letter to our new class of residents

Dear Colleagues,

Welcome to a new chapter in your professional life!  In some important ways, it is the first chapter. Everything leading up to this -- your college career, medical school and much else -- was no more than Prologue.  For the first time, you will (correctly) be introduced as "Doctor."  What can you expect next?  Given the pace of change in healthcare, I won't even try to make predictions about anything beyond Chapter 1.

First, some bad news.  For those of you who came to Medicine to "make a killing (financially)" I'm truly sorry.  That era has mostly passed.  (You should be comfortable enough, but there is certainly more money in Finance, commercial real estate or home improvement.) The same goes for "professional autonomy," if by that you mean the privilege to do pretty much what you want in practicing Medicine, or if you mean going it alone, or if you are referring to doing what you do without external scrutiny.  That train has also left.  Contemporary healthcare is team-oriented, quality- and value-driven, and consequently more closely regulated and scrutinized that any other profession or industry anywhere.

A little more bad news.  I mentioned that you won't be able to make a killing.  Of course, that is only partly true.  A defining characteristic of the healing professions is the risk of inadvertently doing harm - including the ultimate harm of killing a patient.  There is no way out of this.  There are three doors from which to choose. First door: if the possibility of harming a patient doesn't concern you, then we have made a grave error in accepting you into our training program.  I sincerely doubt, however, that this is the case. Behind the second door is another uncomfortable possibility - that we fail to provide you with any real responsibility during the next three years, relegating you to the role of "tourist" in our hospitals, with other physicians making all the decisions and thereby protecting you (and patients) from any risk at all.  Unfortunately, that would leave you wholly unprepared to practice independently at the completion of your training.

It is my fervent hope that you arrive at door number three.  Behind this is a scene in which you are an integral part of the care team, supervised but not to the point of exclusion from the process. Your mentors manage Risk, but do not seek to abolish it.  This pathway leads to growth, but at the expense of some sleep.  I refer not to the sleep lost from a night on-call, but rather to the experience of staring at the ceiling at 2:00 am, wondering whether you followed up on the electrolytes, or ordered the repeat chest film or remembered to tell the attending about that CT result.  These moments of nocturnal anxiety are ubiquitous among real physicians, during training and, hopefully, for the rest of our lives. They are part and parcel of what it means to be a physician - one who accepts the awesome responsibility for the wellbeing of other persons.

Why should you want to do this work?  Why would any of us?  And why would so many of us make the claim that we could never imagine doing anything else?  Some of the answer comes from our patients and families, especially those who make clear statements of appreciation.  And by the way, these tend to correlate very poorly with the brilliance of our diagnoses or our meticulous attention to clinical practice guidelines (not that these things aren't critical)!  Mostly it is about the way you waited patiently to hear a wife ask all her questions, and then answered each in simple language, the way you sat down at the bedside, and in short the ways you communicated, with and without words, that you care.  There are also the rewards that come from our colleagues.  To be called "the physician's physician," to be held in high regard for your knowledge, skills and judgment, for your generosity of spirit and your professionalism - receiving expressions of this kind can make a day or much more.

Finally, however, what motivates and inspires us most must come from within. Caring for patients ultimately reminds us of our own mortality, and the fact that we have a finite number of days to make a mark in our world.  How do we want to do that?  How do we want to spend that precious time?  Wise physicians will remind us that the practice of our profession should not be the only part of a life well lived. Attention to our loved ones and to ourselves is vitally important.  But our professional lives comprise a great deal of our allotted time and the opportunity to use our minds and our hearts in an activity that beckons us toward ongoing efforts to master the craft, knowing that we can always improve and never find an end to learning or growth, and where our aim is the betterment of the situation of fellow human beings, this is unique to Medicine.  Welcome and good luck.

ICD 10 - What did you mean by that?

Physicians across our health system, and for that matter across the country, are busy making preparations to adapt their chart documentation to the International Classification of Diseases and Related Health Problems, 10th Edition, or ICD-10, which comes into national use on October 1, 2015. How did this change come about? What does it accomplish?  How does it affect my hospital, my patients…and me?

Those who are convinced that money makes the world go round will be skeptical of the following claim:  the ICD system did not start out as a methodology for billing healthcare services.   Its roots go all the way back to Francois Bossier de Lacroix (1706 - 1777), also known as Sauvages, who was a contemporary of the great taxonomist Linnaeus.  Sauvages was interested in making epidemiological studies of infant and child mortality and he used the reported causes of death (including such labels as "thrush," "rickets" and "overlaid") for these early efforts at public health investigation.

Modern efforts are traceable to a committee of the International Statistical Institute which was charged in 1891 with creating a listing of causes of death.  This effort was successfully completed by 1893 under the leadership of Jacque Bertillon and was adopted internationally over the next several years as the International Classification of Causes of Death.  A conference in 1900 was convened with representatives of 26 countries to carry out the first revision of the Bertillon classification.

Those who are interested at the progress of this work over the 20th century, including work in the US and internationally that lead to the more expansive goal of an International Classification of Diseases may find this article of interest (http://www.who.int/classifications/icd/en/HistoryOfICD.pdf).

The 9th revision of the ICD system was completed in 1986.  Within six years, however, it was clear that ICD-9 would not support scientific and medical advances in the understanding and classification of disease entities and a replacement was sought.  Again, the principle need was for a classification system that would support research at the clinical and epidemiological level.  A final report of the federal committee to create ICD-10 was submitted to HCFA (now the federal Center for Medicare and Medicaid Services or CMS) in December of 1998.

Over 100 countries have adopted ICD-10, and after several false starts and postponements, it looks like the most recent October 1st deadline for US adoption will actually stick.  Here at NSLIJ, efforts are being made to ensure that we are prepared for this coding change, which has potential implications for both publicly reported quality metrics, like risk-adjusted mortality rates, and for collecting third party reimbursement.

What do we physicians need to do?  First, take part in our system-wide education. AMA Category 1 CME will be awarded for taking the online modules posted in HealthPort under I-Learn.  As this education is rolling out in three "Waves" you will receive department-specific information about when you can find your modules. Second,  expect queries from the nurses who do chart audits for Clinical Documentation Improvement (or "CDI") - they will ask us to clarify items to ensure that the record contains enough detail to all coding in the new system.

Common issues will include laterality and the characterization of certain diseases.  For example, patients with asthma will need to be described with attention to the NIH guidelines.  Is this intermittent or persistent disease?  Mild, moderate or severe? 

Your medical leaders are acutely aware of the many burdens that the regulatory environment places on us as physicians, and the list just seems to keep growing. Writing informative notes, however, is good medico-legal practice.  And ultimately, insofar as the chart is a critical communication tool, it is good for our patients. Thoughts on the matter?  Feedback?  Recommendations? Let me know!

    

What Matters in the End

Some patients come to our hospital to have their condition treated.  They are the individuals seeking joint replacement or bariatric surgery, or they have arrived in diabetic ketoacidosis, or they were the victim of multi-trauma.  For scores of such patients every week we provide a high-tech, expertly delivered and durable fix.

Others, however, come back to us again and again.  It is not just that they have chronic conditions like  heart failure, or COPD, or diabetes.  Rather, it is that they have combinations of these and other conditions and that these life-limiting disorders have already devastated their bodies.  These persons are riding the rim of a maelstrom.   We may rescue them from each crisis, albeit briefly, but they are left weaker and ever more vulnerable to yet another hospital admission, or worse.

When we discuss these patients, I find myself asking time and again, "have we asked our Palliative Care team to get involved?"  And time and again, the answer comes - from nurses, from physicians, from Case Managers, from all of us - "no, the patient (or the daughter, or the son) isn't ready for that." This is a baffling and disturbing statement.  Let me explain my thinking.

Last week I finished Atul Gawande's brilliant exposition on America and the problem of death, entitled "Being Mortal -- Medicine and What Matters in the End."  Much of the book is an exploration of the insights that comprise the field of Palliative Medicine, from the notion that the relief of suffering really matters (and is much more than an asterisk applied to the science of curing) to the idea that our role as health professionals must include efforts to identify what matters to patients and families as the progression of chronic disease comes to define their life stories.

The essential questions are the same.  What are your goals and your expectations?  Is it your wish to fight death with every last weapon in our arsenal, regardless the human cost?  For some, the answer is exactly and unambiguously "Yes!" and it is best that the patient be provided the information necessary to understand this choice.  And it is best that we know the choice so that we can tailor our care accordingly.

At other times, the patient is looking for a plan - to paraphrase Gawande - that is less George Custer and more Robert E Lee.  Fight the battles that can be won, but understand the battlefield, and when victory cannot be obtained, determine a course of action that limits harm and preserves essential human dignity.  This is why I am so frustrated to hear "the patient isn't ready for that."

The statement makes no sense.  What is it the patient isn't ready for?  Not ready to be asked whether we are effectively relieving their suffering?  Not ready to know what lies ahead?  Not ready to have their present and future choices explained?

When the answer is that "the patient isn't ready for that," I fear that we have failed twice over.  The first failure resulted in the need for Palliative specialists in the first place.  As though having honest and sensitive conversations with patients involves a procedure for which only a few physicians are qualified.  And then the second failure, which involves turning Palliative Medicine teams into caricatures of themselves, or of what right wingers like to call "death panels."  Much is implied when we say "the patient isn't ready" - not so much about the patient or her family, but about us.  

We can do better.  The first thing we need to do is to resist the temptation to trivialize the heart-wrenching decisions that patients and families need to make as the end draws near.  Respect the process.  The second is never to forget that even though Palliative Medicine consultations sometimes lead to a movement away from curative treatment and toward comfort care, this is NOT the goal.  The reality is more complex.  The aim of these teams is really no different than that of every physician and nurse - to understand the patient and in doing so learn how to give the care that the person wants and needs.  It is nothing less than a perversion of our mission if we view every instance where life extending care is withdrawn a "success" and every one where it is not a "failure."

Finally, we need to figure out how to deliver "care" -- and not just treatment.  This means inviting questions, promoting dialogue early and often, and giving patients that which has become scarcer and more valuable than almost anything else in healthcare, by which of course I mean our time.

The New York State "No Surprise" Medical Billing Law - To Avoid Being Surprised, Read This

On March 31, 2015, the new "Emergency Medical Services and Surprise Billing" Act goes into effect, with implications for insurers, hospitals, physicians and patients across the state.  The intent of the Act is to protect patients from (sometimes catastrophic) financial responsibility for out-of-network emergency care and to ensure that prior to elective care there is adequate disclosure of the patient's potential out-of-network responsibility.  

Here is what physicians and other healthcare providers will need to do to comply with this legislation, according to attorneys at Nixon Peabody, a NY healthcare firm:

• Prior to providing non-emergency services, providers must disclose to patients their right to know what will be billed for the procedure and, if the patient requests, they must disclose the anticipated cost, warning patients that costs could go up if unanticipated complications occur.
• Providers must provide patients with their network and hospital affiliations in writing or online.
• When patients make appointments, providers must indicate whether they participate in a patient’s network.
• If other professionals will be involved in a patient’s care, the patient must be advised of who it might include and how to learn how much the network will cover for those doctors.

But the most important provisions of the law place significant limits on the physician's ability to seek out-of-network payment for emergency services. The Surprise Bill Law provides new protections for consumers from “surprise” bills for emergency medical services. For example, consumers who receive emergency services will not have to pay more than their usual in-network cost sharing and/or copayments, regardless of the network status of the providers. 

This means, for example, that a plastic surgeon who repairs a laceration in the ED will be prohibited from billing the patient for the difference between the patient's out-of-network benefit and the surgeon's usual charges.  Instead, the practitioner will have the choice of accepting the insurer's rate or submitting the matter to an independent review process that is outlined in the law.

Finally, consumers who receive other out-of-network medical services when there were no in-network providers available or when they did not receive the disclosures required by this new law can assign their claims to the out-of-network providers and pay only their usual in-network cost-sharing. In both of these situations, the medical bill is negotiated by and between the provider and the health plan. 

There are additional implications for payers, hospitals and patients.  If you are interested in reading more, go to…

http://www.nixonpeabody.com/files/169463_Health_Alert_3JUNE2014.pdf

NSLIJ HealthPort will update guidance for physicians in the near future.

Let's meet in the Doctors' Lounge

In September of last year, we participated in a System-wide survey of you and your fellow physicians --  community-based voluntary staff, full-time staff, the young as well as old timers like me.  This was called an "engagement" survey, and it was about how good a job hospital leaders are doing at making YOUR hospital a very positive part of your professional life.

Some of what you told us was reassuring.  A very high percentage of you felt that the hospital "cared about its patients" and about "providing high quality care."  You gave very high marks to our Nursing staff, Radiology services and the Laboratory.

Other areas were not as positive.  Many felt that the "climate of trust" was not what it should, that your input into matters that affect your practice was insufficient and that leadership up and down the organization could do a better job communicating with you.

Which brings us to The Doctors' Lounge.  These days, sustaining communication among ourselves as physicians is more challenging than ever before.  Which means, to my mind, that we need to find each other everywhere we can - on the floors, in the ED, at old-fashioned live meetings (if we can find the time to get there), via email and other electronic media -- like this blog, intended as a place for us to get together and exchange ideas.

I'll tell you what.  Don't meet me half way.  Just 1/10th of the way will do it!  I'll maintain the blog site and set up the posts, and monitor the Comments.  What I'd like you to is to commit to going onto the blog once in a while, just for the two minutes it takes to read what's there.  If you're inspired, perturbed or otherwise motivated to say something, please do so!   Challenge us, so that we can work together to create and sustain an environment that helps you take care of patients, helps you with your educational needs and maybe even enriches your professional life.  Meet me in the Doctors' Lounge.