Hospitalist David Mitchell, MD, PhD, was moonlighting in an Ohio hospital when a nurse called him about a gravely ill older patient who was experiencing shortness of breath. Should she administer the diuretic Lasix to help clear his lung congestion?
Dr. Mitchell, now a hospitalist at Sibley Memorial Hospital in Washington, D.C., and a member of SHM’s Performance Standards Committee, decided to see the patient in person and review his charts. He found that the patient had severe dementia, hadn’t walked in months, and was declining despite more than two weeks in the hospital and daily visits by three specialists.
Dr. Mitchell called the patient’s son and explained the situation, then asked whether the son thought his father would want to continue receiving aggressive therapy. “The son said, ‘Oh, no. He would never want to continue like this.’ So we stopped all the treatments, and he died by the next day,” Dr. Mitchell says.
To him, the anecdote highlights how far medicine has to go in providing personalized palliative care that honors the wishes of patients and their families. It also demonstrates how ignoring those wishes and failing to communicate can contribute to the huge costs associated with end-of-life medical care. Every day, the three specialists seeing the patient were recommending the same course of therapy. “But nobody was being the quarterback and saying, ‘Hey, listen. This is not working,’ ” Dr. Mitchell says.
Hospitalists, he says, are in an ideal position to step up and play a pivotal role in providing the kind of patient-centered care that could improve both quality and cost. So far, however, Dr. Mitchell says he’s seen wide variation in how hospitalists communicate with a patient’s family about end-of-life decisions. “For the ones who do have these conversations, the family is almost always glad that somebody finally said, ‘Do we have to do these tests? Do we have to continue to try to save his life?’ ” Dr. Mitchell says.
Time constraints, he says, are the main reason why hospitalists don’t have such conversations more often. “The communication dies when you’re busy.” And the remedy? Dr. Mitchell says the only thing that will help shift the focus from seeing as many patients as possible to making sure every encounter is a high-quality, efficient one is payment reform in the form of bundled payments to hospitals and physicians. In theory, professional standards can encourage more uniformity, he says. “But when it hits the trenches, it’s the payment that speaks.”