Hawaii of­fers model for en­cour­ag­ing and pay­ing for end-of-life plan­ning

Modern Healthcare - - COMMENT - Dr. An­gelo Volan­des

White sand beaches and sweet-scented leis are the trop­i­cal images most peo­ple con­jure of Hawaii. Now it is con­ceiv­able that the Aloha State will help un­tan­gle the Gor­dian knot of end-of-life health­care is­sues.

We know the statis­tics: Most Amer­i­cans die in hos­pi­tals even though most pre­fer to die at home; nearly 1 out of 3 Medi­care dol­lars are spent in the last six months of life, much of it with­out sig­nif­i­cant sur­vival ben­e­fit; and hospice care re­mains un­der­uti­lized de­spite an in­creas­ing num­ber of stud­ies sug­gest­ing it pro­longs life and im­proves qual­ity of life.

As the In­sti­tute of Medicine re­cently con­cluded, end-of-life care in this coun­try is largely bro­ken and in des­per­ate need of an over­haul. A yawn­ing gap ex­ists. Doc­tors are ex­pected to be endof-life com­mu­ni­ca­tion ex­perts, but it is not in­te­gral to their med­i­cal train­ing.

Look­ing to­ward a so­lu­tion, an un­prece­dented coali­tion of com­peti­tors—ma­jor hos­pi­tals, nurs­ing homes, hospices and in­sur­ers in Hawaii— agreed to a three-year project to change the cul­ture of end-of-life care in the state. They made it a pri­or­ity for pa­tients, fam­i­lies and clin­i­cians to have con­ver­sa­tions about end-of-life care be­fore get­ting sick. There was a gen­eral recog­ni­tion in the Hawaii med­i­cal com­mu­nity that pa­tients’ wishes were not be­ing hon­ored and re­spected. Most pa­tients sur­veyed in the state pre­ferred to die out­side of hos­pi­tals and in com­fort, but most were dy­ing in health­care in­sti­tu­tions, of­ten teth­ered to ma­chines and in pain.

As a re­sult, the ma­jor health­care or­ga­ni­za­tions agreed to shift re­sources from ag­gres­sive end-of-life care to­ward in­ten­sive con­ver­sa­tions on ad­vance care plan­ning.

The not-for-profit Hawaii Med­i­cal Ser­vice As­so­ci­a­tion, a Blue Cross and Blue Shield health plan, now trains hun­dreds of clin­i­cians across the state to have th­ese con­ver­sa­tions with pa­tients and fam­i­lies and many have be­come mas­ter com­mu­ni­ca­tors. Doc­tors, nurses, so­cial work­ers and chap­lains are slow­ing down and ask­ing pa­tients: What kinds of things are im­por­tant to you in your life? If you were not able to do the ac­tiv­i­ties you en­joy, are there any med­i­cal treat­ments that would be too much? What fears do you have about get­ting sick or re­ceiv­ing med­i­cal care? Do you have any be­liefs that guide you when you make med­i­cal de­ci­sions?

Hawaii uses how-to ed­u­ca­tional videos to teach peo­ple about their med­i­cal op­tions at the end of life and what ques­tions to ask, help­ing to em­power them to make their own health­care de­ci­sions. The videos have been trans­lated into all the ma­jor lan­guages spo­ken in the state, in­clud­ing Chi­nese, Ja­panese, Il­lo­cano and Ta­ga­log.

Pi­o­neer­ing ef­forts are also un­der­way to pro­vide se­ri­ously ill pa­tients with what’s called sup­port­ive care, where pa­tients re­ceive life-pro­long­ing in­ter­ven­tions along with hospice care. In most of the coun­try, tap­ping into your hospice ben­e­fit of­ten means for­go­ing treat­ments with cu­ra­tive in­tent. Re­mark­ably, in­sur­ers are work­ing to­gether to en­sure providers are re­im­bursed for such care, putting the pa­tient truly at the cen­ter of care.

Dur­ing one visit to Hawaii, I in­ter- viewed a physi­cian from a nurs­ing home who had re­cently ad­mit­ted an 89-year-old grand­fa­ther who had been shuf­fled from the nurs­ing home to the hos­pi­tal and back six times that year. On his most re­cent re­turn to the nurs­ing home, the physi­cian started a con­ver­sa­tion with him and showed one of the ed­u­ca­tional videos in Ja­panese, the pa­tient’s na­tive lan­guage. Af­ter view­ing the video, the pa­tient said, “This is the first time that any­one has asked me what I want.” At the age of 89, with many med­i­cal de­ci­sions yet to be made, he was fi­nally tak­ing con­trol of his med­i­cal care.

Tens of thou­sands of pa­tients in Hawaii are tak­ing back their health­care. One of the first hos­pi­tals that ini­ti­ated ef­forts to re­design care at the end of life was Hilo (Hawaii) Med­i­cal Cen­ter, which is in an area where about a fifth of the pop­u­la­tion lives be­low the poverty line. In only 18 months, the hos­pi­tal has dou­bled doc­u­men­ta­tion of its sick­est pa­tients’ care wishes and has de­creased deaths in the hos­pi­tal by 30%.

If a re­source-poor area can find a way to align care with pa­tient choices, why can’t the rest of us? We re­cently marked the fifth an­niver­sary of the Af­ford­able Care Act. Be­cause many of its prom­ises for pa­tient-cen­tered care re­main elu­sive, we need in­no­va­tive so­lu­tions to shake off old ways of think­ing. How­ever, some­times old so­lu­tions are bet­ter. Let’s en­cour­age—and in­cen­tivize— clin­i­cians to slow down like they used to and re­ally lis­ten to their pa­tients.

Dr. An­gelo Volan­des is an in­ter­nal medicine physi­cian and ad­vance care plan­ning re­searcher at Har­vard Med­i­cal School and Mas­sachusetts Gen­eral Hos­pi­tal, Bos­ton. His book The Con­ver­sa­tion: A Rev­o­lu­tion­ary Plan for End-of-Life Care was pub­lished this year.

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