Growing Importance of Advance Directives: A Focus on End-of-Life

By Rhea Go-Coloma, LMSW

Elisabeth, 89, who has a history of heart failure and spinal stenosis, lives at home with her elderly husband. Over the past few months, she’s been admitted twice to the hospital with symptoms of heart failure. Her Medicare Advantage plan used a predictive algorithm to identify Elisabeth as a candidate for home-based palliative care. When seen at home on the first visit, the palliative nurse discussed with her specific goals of care.

Elisabeth’s preference was to avoid aggressive care and hospitalization, and to disable her implantable cardioverter defibrillator — decisions that were documented in an advance directive (AD), a legal document that spelled out Elisabeth’s end-of-life (EOL) care ahead of time. Typically, ADs specify wishes surrounding the use of dialysis and breathing machines, resuscitation if breathing or heartbeat stops, tube feeding and organ or tissue donation.

ADs were developed as a result of widespread concerns over patients undergoing unwanted medical treatments and procedures in an effort to preserve life at any cost. They are essential for patients who wish to remain at home during EOL care — the majority of Americans.

Specialized Palliative Care

One innovative model developed by Turn-Key Health uses an optimal predictive model that identifies such patients This model is designed to integrate with specialized interventions and a community-based palliative care model that supports members to remain at home and avoid non-beneficial treatment (NBT) — any treatment, procedure or test administered to patients who are naturally dying that will not make a difference to their survival, will probably impair their remaining quality of life, can potentially cause them pain or prolonged suffering, or leave them in a worse state of health than they were.

The candidates identified are high opportunity rather than simply high cost, and at risk of over-medicalized care and, ultimately, over-medicalized death in the next six months.  This results in a higher return on quality improvement and investment in resources.

A growing number of individuals with serious illnesses, payers and providers now recognize the value of such an approach for addressing goals of care and the importance of ADs. The importance of utilizing community-based, specially trained Palliative Extensivists (PEs), including palliative care nurses and clinical social workers, cannot be overstated.

Palliative Extensivists Bridge Communication Gaps

A PE-led team is not only experienced in relieving the multiple, socio-economic burdens associated with advanced illnesses, but also has the sensitivity and expertise to conduct meaningful, thoughtful discussions that help to establish goals of care and match treatments to personal wishes.  This is a critical part of completing and executing an AD.     

Communications are a key component of advance care planning and shared decision making, and can make a significant difference for those who are so fragile and vulnerable.

This approach effectively fills gaps in care, providing relief from symptoms and stress, medication management, care coordination and other emotional and psychological support that have gone missing from traditional care models. 

Helping Patients Live Longer

Research reported in the New England Journal of Medicine shows palliative care can also help patients live longer:  in a study of 151 patients with advanced lung cancer, those given early palliative care survived 11.6 months, nearly three months longer than those who received standard medical care. 

Elisabeth’s experience demonstrates the value of home-based palliative care provided by PEs, and the importance of addressing goals of care and completing ADs. The goal of palliative care is to improve quality of life for patients at any stage of illness regardless of current treatment plans, and is tailored to the needs of the patient and the family.

PEs represent a natural go-to source of professional talent that makes it possible for home-based palliative care programs to match the appropriate resources to individual needs and scale the programs for large populations. They are equipped with the technology, tools and training required to decrease variability in care, and help to drive positive outcomes.

PEs effectively interact and coordinate care with the designated physicians or other professionals who are responsible for the patient’s ongoing medical care.  This collaborative approach advances care coordination, reduces the cost of care, and results in greater patient/caregiver satisfaction.

This more personalized, high-touch approach to care facilitates communication and enhances psychological and physical comfort at a time when people, like Elisabeth, need it the most.

Rhea Go-Coloma, LMSW, is Chief Administrative Officer for Hospice of the West.

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