Note: The Bioethics Program blog will be moving to its new home on April 1, 2015. Be sure to change your bookmarks to http://bioethics.uniongraduatecollege.edu/blog/
by Richard Koo, Bioethics Program Alum (MSBioethics 2011) and Adjunct Faculty
About four years ago, Susan D. Block, M.D. posted a blog on Harvard Business Review’s website as part of a series of writings focusing on innovation in health care. In her blog, she bemoaned the “lousy job” doctors do in communicating with patients when it becomes apparent that additional treatment and technology will fail to stave off death. Among several other proposals, she suggested that standards for appropriate documentation of end of life discussions should be developed, promulgated, and used as reportable indicators of quality care. To carry out that innovation, she proposed that “all electronic medical record systems would be expected to support documentation of the patient’s health care proxy, values and goals” and “a broadly-agreed-upon definition of populations for whom these discussions and documentation are appropriate would be developed.”
Dr. Block is no stranger to the subject of end of life communications between doctors and patients. She participated in a number of panels and has authored articles on the subject since the 1990s. She also did not wait for the medical profession to follow through on her proposals. As Director of the Serious Illness Program at Ariadne Labs, Dr. Block spearheaded the development of a system (the “System”) to assure that doctors caring for seriously ill patients can develop competency in communicating with their patients so that the patients “can live with their serious illness and into the last stage of life with dignity, control and a sense of peace.” The System aims to train physicians in identifying appropriate patients for such communication, determining the right time to initiate the serious illness conversation, engaging in serious illness planning, helping patients discuss their end-of life preferences with their families, and documenting those plans and preferences in the patient’s electronic health record.
Presently, Ariadne Labs is evaluating the outcomes of the System through a series of clinical and implementation trials measuring outcomes in oncology, primary care, nephrology, chronic illness, surgical and emergency settings and adapting it to culturally diverse populations. The plan is to launch the System nationally in the fall of 2015 through a collaborative of approximately 20 health care networks to test it in different populations across the country.
Even before System launch, I’ve heard some potential concerns about the System from health care professionals who work with seriously ill patients day to day:
Pushback 1: “Discussions with patients with serious illness near the end of life are intensely personal and depend on an individual’s health care trajectory, views on life, death, and religion, financial situation as well as family dynamics. No standardized set of conversation guides, scripts, checklists and reminders can be practically useful.”
Counterpoint: “Standardized” doesn’t necessarily mean one size fits all. Though the System hasn’t yet been publicly released, based on Dr. Block’s body of work, my bet is that the System will direct physicians to take into account individualized variations in patient background, prognoses, situations and preferences. It should also help the physicians structure their communications according to those variations.
Pushback 2: “The reason why the medical profession does a “lousy job” in end of life communications is because many doctors have little motivation or interest to get good at it. Changes to the U.S. health care delivery system of a more fundamental nature have to be made before the medical profession current approach to communications with seriously ill patients will change.”
Counterpoint: So what are health care professionals supposed to do: sit on their hands until fundamental changes happen? Communicating with patients is an integral part of the provision of health care. Health care professionals have an ethical imperative not to do a “lousy job” in that regard, whether or not these improvements are financially rewarded.
Pushback 3: “The medical profession would be better off leaving the task of difficult discussions near the end of life to those who presently deal with it best, namely palliative care physicians, nurses and nurse practitioners, hospice care specialists, social workers and patient advocates.
Counterpoint: One of the driving forces behind the development of the System is to raise the recognized standard of care of all physicians who treat seriously ill patients. Leaving the task of having appropriate end of life planning and communications in the hands of a cadre of specialists does nothing to address the “lousy job” physicians do that Dr. Block bemoaned. Any improvement in serious illness communications and the heightened sensitivities that the System might help bring about would also enhance the prospects that physicians will work collaboratively with the rest of the health care team to improve patient care near the end of life.
From a broader view, these potential concerns about the System seem symptomatic of the threat that innovative ideas present to the status quo. Personally, I’m excited about the possibilities of the System, in part because of my great respect for Ariadne Labs and its leaders, including Executive Director Atul Gawande, M.D.