Bradley Flansbaum, DO, MPH, SFHM, director of the hospitalist program at Lenox Hill Hospital in New York City, recently posted "A Hospitalist's Lament," on the SHM-sponsored The Hospitalist Leader blog about the nuances of palliative care and advanced-care-planning discussions for patients nearing the end of life.
Dr. Flansbaum writes that, when asked to name a medical specialty other than HM that he might have enjoyed pursuing, he replies: "pain and palliative care." As he explains, "I didn’t discover that this was an area of interest for me until my career was much advanced," too late to pursue new opportunities for advanced training in palliative-care fellowships.
Yet he views eliciting the needs and wishes of terminally ill hospitalized patients as an art worth mastering. Hospitalists inevitably deal with end-of-life issues as a routine part of their jobs. "It's in our bailiwick. It's what we do, and it behooves us to get better at it," he says.
In his post, Dr. Flansbaum examines the recent medical literature (Sudore RL, Fried TR. Ann Int Med 2010;153:256; Perkins HS. Ann Int Med 2007;147:51-57; Sulmasy DP, Snyder L. JAMA 2010;304:1946-1947) questioning the benefits of advanced-care planning and advance-directive documents, such as living wills, in shaping the care patients want and need at the end of their lives. While these documents are not wasted effort, he says, "too often they're not very useful. We're learning that it's an incredibly dynamic process, contingent on cultural factors, and changing over time. One piece of paper with a static declaration isn't going to cover the bases. I've come to realize that it is about a talking, ongoing process."
Part of his "lament" as a hospitalist is that caring for terminally ill patients can be rife with ambiguities. Meanwhile, "everybody talks about how there's so much money wasted at the end of life, and we should be corralling our healthcare resources in a more efficient way. And yet the solutions we will need to get us to that place are damned hard," he says. (Listen to excerpts from the interview with Dr. Flansbaum [MP3 12.8MB])
Dr. Flansbaum recommends hospitalists make detailed conversations with patients confronting life-limiting illnesses a priority, which requires setting aside enough time for patients and understanding that such conversations are not singular events. He also encourages physicians to consider what their own values and priorities might be in such a situation, an exercise he recently conducted with his residents.