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Hospitalists can do better at end-of-life care, expert says


 

As a 99-year-old friend neared the end of her life, she offered a lesson for the health care world, said Deborah Korenstein, MD, chief of general internal medicine and director of clinical effectiveness at Memorial Sloan Kettering Cancer Center, N.Y., in the Tuesday session “Finding High Value Inpatient Care at the End of Life.”

The woman, nicknamed “Mitch,” had bluntly made her preference clear, Dr. Korenstein said: “She wanted to live independently as long as she could, and then, she wanted to be dead.”

But when a pathology report showed urothelial cancer, that preference didn’t stop an oncology urologist from suggesting that Mitch enter a clinical trial on an unproven therapy. Worse, Mitch initially said “yes” to this idea, seemingly because she thought that’s what she was expected to say.

It was only when Dr. Korenstein spoke with her that she changed her mind, entered inpatient hospice care, and died peacefully.

“I think it’s a cautionary tale about when a patient is crystal clear about their wishes,” she said. “The wave of the medical system kind of pushes them along in a particular direction that may go against their wishes.”

Dr. Korenstein said U.S. health care system does fairly well in some areas – for instance, research shows that about 60% of people die in their preferred location, whether at home or somewhere else. But it does not do so well in others – a 2013 Journal of General Internal Medicine study found that, during 2002-2008, Medicare beneficiaries typically spent $39,000 out of pocket on their medical care, and in 25% of cases, what they spent exceeded the total value of their assets.

As far as individual preferences, these tend to correlate poorly with the care that people actually get, Dr. Korenstein said. Patients often don’t express their wishes, doctors are poor judges of what matters to individual people, and care is largely driven by physician preferences and by the care setting involved, she said.

Given those problems, she said, “we cannot possibly be providing high-value individualized care.”

Hospitalists are well positioned to help patients’ preferences align with care, she added. Sometimes, a sustained relationship with a patient, while generally a positive thing, might lead a provider to become invested in their care in “ways that are not always rational.” So a hospitalist can have a helpful vantage point.

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