Aligning Patient Preferences and Patient Care at the End of Life

Abstract

S tudies have shown that patients' priorities for quality care during advanced illness and at the end of life include consistent and reliable medical information, expert pain and symptom management, avoiding inappropriate prolongation of the dying process, relieving burdens on loved ones, and being prepared for death. [1][2][3][4] Despite patients' focus on quality of life issues, the majority of current Medicare spending is allocated towards hospital care, 1 and a significant proportion of this expenditure goes towards costly "cure-driven" interventions at the end of life. In an effort to deliver treatment plans that are concordant with patients' priorities, identification of patients' goals of care and alignment with medical delivery is critical.Mounting evidence suggests that addressing goals of care is directly linked with higher quality. A recent study, for example, revealed that a lack of "end-of-life" discussions in the hospital setting was associated with escalations in care in the last weeks of life and worse overall rated quality of care 4 . In this issue of JGIM, Yuen and colleagues 5 describe existing barriers and propose methods to facilitate earlier and more efficient discussions of cardiopulmonary resuscitation preferences in the inpatient setting.To ensure high quality care during advanced illness and at the end of life, educational initiatives and assessment methods focused on improving communication skills coupled with system changes need to be implemented.Guidelines for addressing cardiopulmonary resuscitation preferences with patients and surrogate decision makers have been formulated by experts in the field of palliative care. [6][7][8] The recommended steps include discussing and clarifying any misconceptions about the current medical condition and prognosis, eliciting goals and values for care, and discussing code status in a manner that adheres to the criteria for informed consent and if necessary making a physician recommendation. Yet this strategy is rarely followed in practice 9,10 . While core measures for the management of common medical conditions, such as aspirin administration after a myocardial infarction, have improved standards of care, delineating the required key elements in this communication process would be an important step for accrediting bodies and hospitals.Educating trainees will be essential in ensuring that these communication guidelines are utilized in patient encounters. Despite the fact that housestaff frequently address code status, these conversations are often brief, and do not elicit the patient's understanding of their prognosis or explore the patient's goals and values. Additionally, they rarely meet criteria for informed consent 9 . This deficiency is not limited to trainees. A study of attending hospitalists showed a similar poor performance 10 . Data further reveal that inadequate training leads to discomfort on the part of interns and residents when discussing these very important issues 11 . Mandatory formal curricula addressing this important skill se...

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General Practitioner Residents and Patients End-of Life: Involvement and Consequences

“…Lack of practice seems to be the main cause for communication di culties. The absence of speci c training in end of life communication is associated with physician discomfort and unease feelings (33)(34)(35). In consequence it is also a risk factor for burn-out (14).…”