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August 20, 2009National Press Club
FACT VERSUS FICTION: KEY ISSUES IN HEALTH
REFORM
FACT VERSUS FICTION: KEY ISSUES IN HEALTH
REFORM
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Christine Cassel, MDPresident
American Board of Internal Medicine
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Patient Centered? What Do Patients with Serious Illness Want?
Pain and symptom controlAvoid painful prolongation of the dying
processAchieve a sense of control and dignity
Relieve burdens on familyStrengthen relationships with loved
onesSinger et al. JAMA 1999;281(2):163-168.
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And What They Get: Suffering in U.S. Hospitals
National Data on the Experience of Advanced Illness
in 5 Tertiary Care Teaching Hospitals
9,000 patients with life-threatening illness, 50% died within six months of entry
Half of patients had moderate-severe pain >50% of last three days of life.
38% of those who died spent >10 days in ICU, in coma, or on a ventilator.
JAMA 1995;274:1591-98
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Patient Centered?What Do Family Caregivers
Want?Study of 475 family members 1-2 years
after bereavement
•Loved one’s wishes honored•Inclusion in decision processes•Support/assistance at home•Practical help (transportation, medicines, equipment)•Personal care needs (bathing, feeding, toileting)•Honest information•24/7 access•To be listened to•Privacy•To be remembered and contacted after the death
Tolle et al. Oregon report card.1999 www.ohsu.edu/ethics
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And What They Get: Family Satisfaction with Hospitals as the
Last Place of Care2000 Mortality follow-back survey,
n=1578 decedents•Not enough contact with MD: 78%•Not enough emotional support (patient): 51%•Not enough information about what to expect with the the
dying process: 50%•Not enough emotional support (family): 38%•Not enough help with pain: 19%
Teno et al. JAMA 2004;291:88-93.
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Medicare Spending by Sector in Last Two Years of Life
Source: The Dartmouth Atlas of Health Care 2008Available at: http://www.dartmouthatlas.org/atlases/2008_Chronic_Care_Atlas.pdf
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Copyright restrictions may apply.Zhang, B. et al. Arch Intern Med 2009;169:480-488.
Association between cost and quality of death in the final week of life (adjusted P =
.006)
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Advance Directive
Advance health care directives, also known as advance directives or advance decisions, are instructions given by individuals specifying what
actions should be taken for their health in the event that they are no longer able to make decisions due
to illness or incapacity.
A living will is one form of advance directive, leaving instructions for treatment. Another form authorizes a specific type of power of attorney or health care
proxy, where someone is appointed by the individual to make decisions on their behalf when they are incapacitated. People may also have a
combination of both. -- Wikipedia
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Copyright restrictions may apply. Wright, A. A. et al. JAMA 2008;300:1665-1673.
Medical Care Received in the Last Week of Life
by End-of-Life Discussion
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Policy – House Tri-Committee
Bill Provides Medicare coverage for voluntary Advance Care Planning Consultations at
least every five years.
Requires quality measures in PQRI on end-of-life care and advanced care planning.
Other legislative proposals not included are related to education, workforce,
quality and research.
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Diane E. Meier, MDDirector, Center to Advance
Palliative CareMount Sinai School of Medicine
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A Tale of Two Patients:Elaine G. and Judy F.
Diane E. Meier, MDProfessor
Mount Sinai School of Medicine
August 20, 2009
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Elaine G., 82 year old nursing home resident with dementia
and recurrent pneumonia Business as usual
Multiple admissions for recurrent pneumonia
No prior evidence of her wishesProlonged critical careHospital complications
PainAngry, guilty adult son
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Judy F., 65 year old with metastatic lung cancer
seeking guidanceDiagnosed age 59No smoking history
Given prognosis of 6-12 monthsWith expert oncologist, lived 6 yearsSought palliative care as symptoms
worsened for pain, insomnia, fatigue, questions about the future and what to
expectReceived simultaneous palliative and cancer
care for a yearWhen cancer Rx no longer helpful, referred to hospice for 3 weeks, died peacefully at
home surrounded by family
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Conceptual Shift for Palliative Care
Medicare Medicare Hospice Hospice BenefitBenefit
Life Prolonging CareLife Prolonging Care OldOld
Palliative CarePalliative Care
Bereavement
Hospice CareHospice CareLife ProlongingLife Prolonging
CareCareNewNew
Dx Death
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Implications and Lessons: Match the Care to the
Patient’s NeedsWe don’t know who is at the end of life until weeks-days before death
Advance care planning necessary from point of diagnosis of advanced progressive illness regardless of prognosis- not at “end of life”
Non hospice palliative care appropriate whenever symptom, function, and family burden regardless of prognosis, and in
combination with all other appropriate life prolonging treatment
Hospice when life prolonging treatment no longer effective or burden>benefit.
Result is genuinely patient-centered care, markedly lower costs
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Art Buchwald, Whose Humor Poked the Powerful, Dies at 81 By RICHARD SEVERO
Published: January 19, 2007, New York Times
As he continued to write his column, he found material in his own survival. “So far things
are going my way,” he wrote in March. “I am known in the hospice as The Man Who
Wouldn’t Die. How long they allow me to stay here is another problem. I don’t know where
I’d go now, or if people would still want to see me if I weren’t in a hospice. But in case
you’re wondering, I’m having a swell time — the best time of my life.”
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Life is pleasant. Death is peaceful. It's the transition
that's troublesome.
Isaac AsimovUS science fiction novelist & scholar (1920 - 1992)
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Although the world is full of suffering, it is also full of
the overcoming of it.
Helen KellerOptimism, 1903
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In loving memory
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Jerald Winakur, MDCenter for Medical Humanities and
EthicsUniversity of Texas Health Science
Center at San Antonio
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JERALD WINAKUR, M.D., F.A.C.P., C.M.D.
The Center for Medical Humanities and Ethics
The University of Texas Health Science Center at San Antonio
MEMORY LESSONS: A GERIATRICIAN’S TALE
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--Over 65: 72 million people, 20% of our populace in the next 23 years
--Over 85: 18 million by 2050
--Only 20% are fully mobile
--50% have some degree of dementia
AMERICA’S AGING SOCIETY
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--50% decline in students choosing primary care as a career since the late nineties
--20% decline in the number of certified geriatricians practicing in the last 10 years
--7000 geriatricians in America today
The “State of Collapse” in America’s Primary
Care/Geriatric Workforce
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--300 new geriatricians entering the workforce yearly does not replace those retiring
--Only 2% of residents in training choose Geriatrics as a career
--2008: only one geriatrician per 8000 patients
--Current deficit of 14,000 geriatricians will grow to 34,000 by 2030
The “State of Collapse” in America’s Primary
Care/Geriatric Workforce
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A HELPFUL WEBSITE:
texaslivingwills.orgby Craig Klugman, PhD
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Health Affairs gratefully acknowledges the generosity of the following organizations for support of this conference:
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The End