‘Rev­o­lu­tion­ary’ change for life’s fi­nal choices would cut un­wanted care

Modern Healthcare - - NEWS - By An­dis Robeznieks

When Bernard “Bud” Hammes be­gan his ca­reer in 1984 as the clin­i­cal ethi­cist at Gun­der­sen Lutheran Hos­pi­tal in La Crosse, Wis., he had near-daily talks with fam­i­lies whose loved ones could no longer speak for them­selves.

Par­tic­u­larly dif­fi­cult cases in­volved el­derly kid­ney-fail­ure pa­tients who had suf­fered de­bil­i­tat­ing strokes. De­ci­sions needed to be made whether to con­tinue with dial­y­sis or whether to sub­ject them to “heroic” mea­sures, like rib­break­ing CPR or in­tu­ba­tions that are of­ten more abu­sive than heal­ing.

“They were par­a­lyzed, un­con­scious and un­re­spon­sive,” Hammes re­called. “We’d ask ‘What would your mother or fa­ther want to do if they knew ev­ery­thing you know?’ They all gave the same an­swer, which was: ‘We don’t know.’ ”

In 2014, CMS data found that 55% of U.S. nurs­ing-home res­i­dents had an ad­vance di­rec­tive.

To com­bat what sys­tem lead­ers per­ceived as a stigma sur­round­ing death, the Gun­der­sen Health Sys­tem’s Re­spect­ing Choices ad­vance­care plan­ning pro­gram was born. It started with dial­y­sis pa­tients in 1986, and by March 1996, it was found that, of the 540 adult La Crosse res­i­dents who had died in the pre­vi­ous year, 96% had ad­vance di­rec­tives in their med­i­cal record.

At least partly due to Gun­der­sen’s Re­spect­ing Choices pro­gram, end-of-life med­i­cal costs in La Crosse are nearly half the na­tional av­er­age. Now the rest of the coun­try maybe be able to fol­low in La Crosse’s foot­steps. In its draft of the next Medi­care fee sched­ule, the CMS has pro­posed pay­ing healthcare providers for time spent with pa­tients dis­cussing end-of-life med­i­cal choices, start­ing Jan 1. The pro­posed rule is a re­mark­able come­back for a pro­vi­sion that was re­moved from healthcare re­form leg­is­la­tion in 2009 fol­low­ing crit­i­cism from Sarah Palin and oth­ers who said it would ra­tion care and cre­ate “death pan­els.”

But many be­lieve the tide has turned po­lit­i­cally. Ear­lier this year, Sens. Johnny Isak­son (R-Ga.) and Mark Warner (D-Va.) co-spon­sored a bill to pay for end-of-life talks be­tween doc­tors and pa­tients.

The pro­posal fol­lows the 2014 In­sti­tute of Medicine re­port “Dy­ing in Amer­ica,” which rec­om­mended pay­ing providers for ad­vance-care plan­ning that would re­duce un­nec­es­sary and un­wanted pro­ce­dures.

Hammes called the CMS pro­posal an “ex­traor­di­nar­ily im­por­tant step for­ward,” but won­ders about its im­pact, ques­tion­ing who will be re­im­bursed and for how much.

The CMS pro­poses pay­ment on two lev­els: one for the first 30 min­utes of con­sul­ta­tion and another for ev­ery 30-minute block af­ter that. Hammes orig­i­nally es­ti­mated this would re­sult in pay­ments of $54 and $50, re­spec­tively, but the CMS later an­nounced that the fig­ures would be ap­prox­i­mately $86 and $75. For physi­cians, he said, the is­sue is more a mat­ter of time than money. But healthcare ad­min­is­tra­tors may say the rates are not worth an hour of a doc­tor’s time.

Hammes hopes the CMS plan in­cludes pay­ment for oth­ers be­sides physi­cians. At Gun­der­sen, a doc­tor starts the pa­tient con­ver­sa­tion and then hands it off to a nurse, so­cial worker or chap­lain with the physi­cian avail­able to con­sult.

The goal is to get pa­tients talk­ing about what they would want in the event of “se­vere and per­ma­nent” changes to their health. Pa­tients are told that af­ter such changes they might be un­com­fort­able and con­fused. If a med­i­cal emer­gency oc­curred, would they want treat­ment that kept them alive in that con­di­tion? Ex­perts be­lieve these con­ver­sa­tions should hap­pen early on.

“Peo­ple can get their hands around that,” Hammes said. “Ask­ing peo­ple about spe­cific treat­ments is dif­fi­cult

be­cause there’s no con­text.”

Pa­tients’ wishes are on a one-page doc­u­ment stored in Gun­der­sen’s elec­tronic healthrecord sys­tem, and they can be shared elec­tron­i­cally or on pa­per with other providers.

Physi­cians say that while ef­forts such as the online form sys­tem called eMOLST fa­cil­i­tate this process, it’s of­ten not easy to get area hos­pi­tals on­board.

“It’s a great frus­tra­tion if you take the time to talk to a pa­tient ... (but then) no one looks at” the di­rec­tive, said Dr. Nancy Gi­rard, a solo fam­ily physi­cian in Alexandria Bay, N.Y.

Rep. Earl Blu­me­naur (DOre.), who orig­i­nally in­tro­duced the end-of-life re­im­burse­ment that was left out of the Af­ford­able Care Act, is mo­bi­liz­ing sup­port for the Per­son­al­ize Your Care Act. His pro­posal would al­low providers to be paid for up­dat­ing vol­un­tary ad­vance-care plan­ning with pa­tients ev­ery five years. It may also in­clude ad­vance-plan­ning qual­ity mea­sures and grant-fund­ing op­por­tu­ni­ties.

Illi­nois State Med­i­cal So­ci­ety Pres­i­dent Dr. Scott Cooper said “it will be rev­o­lu­tion­ary” to medicine if the CMS im­ple­ments the pay­ments.

Cooper, an emer­gency physi­cian with the Vista Health Sys­tem in Waukegan, Ill., said that with­out doc­u­mented and ac­ces­si­ble records declar­ing a pa­tient’s wishes, emer­gency room doc­tors will in­stinc­tively pull out all the stops if a pa­tient goes into car­diac ar­rest.

Washington-based lawyer Charles Sa­batino said ad­vance di­rec­tives can be part of an “es­tate-plan­ning pack­age” but the le­gal form isn’t very thought­ful.

“I al­ways tell at­tor­neys that these stan­dard­ized forms are only as good as the con­ver­sa­tion they’re based on,” said Sa­batino, a for­mer pres­i­dent of the Na­tional Academy of El­der Law At­tor­neys.

Sa­batino sup­ports the Physi­cian Or­ders for Life-Sus­tain­ing Treat­ment par­a­digm, or POLST (which is re­ferred to as Med­i­cal Or­ders for Life-Sus­tain­ing Treat­ment, or MOLST, in some states), and serves as le­gal ad­viser for the Na­tional POLST Par­a­digm Task Force. The pro­gram is de­signed for peo­ple who are ter­mi­nally ill. These pa­tients have their pref­er­ences doc­u­mented, and those pref­er­ences are given the au­thor­ity of a med­i­cal or­der that must be fol­lowed.

Sa­batino gave credit to or­ga­ni­za­tions like Gun­der­sen and in­di­vid­u­als like Dr. Pa­tri­cia Bomba in Rochester, N.Y., for ac­cel­er­at­ing change.

Bomba has been rec­og­nized as a leader of the move­ment. She worked on the com­mit­tee that wrote the IOM re­port and serves as pro­gram di­rec­tor of the eMOLST elec­tronic reg­istry. She is also vice pres­i­dent and di­rec­tor of geri­atrics for Rochester-based Ex­cel­lus Blue Cross and Blue Shield.

While Sa­batino called her a guru, Bomba de­scribes her late mother, Sophia, as the “pa­tron saint of the New York MOLST pro­gram.” Bomba said her mother first brought up the sub­ject of healthcare prox­ies af­ter the fam­ily’s 1992 Thanks­giv­ing din­ner, and then ev­ery year un­til her death in De­cem­ber 2007.

Bomba’s daugh­ter is a hos­pice and pal­lia­tive-care physi­cian, and So­phie Bomba at­tended her grand­daugh­ter’s grad­u­a­tion from med­i­cal school de­spite hav­ing Stage 4 can­cer.

Bomba has car­ried on her mother’s mes­sage. She said a tele­phone sur­vey this year found that 42% of adults in the 39-county Ex­cel­lus cov­er­age area had a proxy healthcare de­ci­sion­maker. Within the Rochester area, the av­er­age was 49% while 60% of Ex­cel­lus em­ploy­ees had a proxy.

Ex­cel­lus has been pay­ing for ad­vance-care plan­ning since 2009, Bomba said. She de­clined to say how much the pay­ment was, but noted that it was “time-based” rather than a flat fee.

“Ad­vance-care plan­ning is the process of talk­ing to your doc­tor and fam­ily about what mat­ters most, about who do you trust, and putting it in writ­ing,” she said.

Hammes agrees. But some­times a big­ger prob­lem is the out-of-town adult child who shows up and in­sists “We have to do some­thing” af­ter the other sib­lings have made the ag­o­niz­ing de­ci­sion to end their par­ent’s treat­ment.

Lin­ger­ing doubts over whether the right de­ci­sion was made can fes­ter for years, Hammes said. Physi­cians and other providers of­ten have sim­i­lar doubts.

Hammes once asked an ex-Gun­der­sen emer­gency physi­cian why he left. “He said ‘That’s easy, I got tired of beat­ing up old peo­ple,’ ” Hammes re­called.

“What kind of life are we fight­ing for peo­ple to have, and does that match the kind of life they want?” asked Dr. Atul Gawande, a sur­geon and au­thor who of­ten talks about im­prov­ing the fi­nal days of life. “We need time to have these con­ver­sa­tions. Cur­rently, we don’t re­ward doc­tors or oth­ers for tak­ing that time.”

Gun­der­sen Health Sys­tem’s Bernard “Bud” Hammes talks with Ida Korfage of Univer­sity Med­i­cal Cen­ter, Rot­ter­dam, Nether­lands, about the Re­spect­ing Choices pro­gram. A Euro­pean Union study will use the pro­gram as a model for how to talk to pa­tients and their fam­i­lies about end-of-life care.


Rep. Earl Blu­me­naur, (D-Ore.) who tried to in­clude end-of-life re­im­burse­ment in the Af­ford­able Care Act, is mo­bi­liz­ing sup­port for the Per­son­al­ize Your Care Act. It would pay physi­cians to help pa­tients up­date ad­vance-care plans ev­ery five years.

Sophia Bomba, far right, shown at her grand­daugh­ter’s grad­u­a­tion from med­i­cal school, first be­gan dis­cussing healthcare prox­ies with her fam­ily over Thanks­giv­ing din­ner in 1992. Dr. Pa­tri­cia Bomba, left, calls her mother the “pa­tron saint of the New York MOLST pro­gram.”

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