Health care providers issue new end-of-life guidelines

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A coalition of leading Southern California health care providers is trying to change how medical professionals handle end-of-life issues facing their patients. The coalition, which includes Kaiser Permanente, L.A. County-USC Medical Center and the UCLA Health System, among other SoCal institutions, is issuing a new set of guidelines for doctors and nurses calling for more compassionate care while respecting patients' wishes.

"One of the major issues that we face is really trying to enhance end-of-life care," Cedars-Sinai's Dr. Glenn Braunstein tells KPCC. 

RELATED: For SoCal hospice nurse, wife's death was 1 too many

Braunstein says that there needs to be better planning, so a number of doctors put together a series of recommendations and developed a group statement on end-of-life care.

"[Patients] should express their wishes, and their preferences, and their values, not only to their family, but also to their doctors. And they should fill out a document," Braunstein said.

The guidelines call for doctors and medical systems to do the following:

  • Encourage all patients to engage in advance care planning, and make this approach standard so providers can deliver appropriate care that reflects each patient’s values and preferences
  • Facilitate timely access to palliative care and other support services such as hospice care for patients with chronic and progressive illnesses
  • Advise patients about the potential benefits and drawbacks of medical treatments, and whether such care can deprive individuals of a peaceful death
  • Engage in “shared-decision making” with patients to reach conclusions about what constitutes optimal care in particular situations

"The time to have that conversation is when people are well, not when they're very sick," Braunstein said. "Because if an individual is very sick, and you start having that conversation, then one of the messages that the patient may get is that 'Boy, I'm really on my way out, and these are very tough things to consider when I'm not feeling very well.'"

The other health providers endorsing the recommendations are Cedars-Sinai, HealthCare Partners Medical Group and Affiliated Physicians, Keck Medical Center of USC, MemorialCare Health System, Olive View-UCLA Medical Center, Providence Little Company of Mary Medical Center Torrance, and Providence TrinityCare Hospice. It's rare for so many institutions to agree that they can do more to improve people's quality of life, and death, said Dr. Daniel Stone, medical director of the Cedars-Sinai Medical Group.

"It's a complete departure, because doctors don't tend to say, 'we've been doing this wrong,'" said Stone.

Braunstein said that his own mother and his in-laws show the contrast in ways to die. He said that his mother had an advance directive, but that it wasn't immediately available when she suffered a pulmonary embolism, leading to paramedics resuscitating her against her will. She died three days later in the intensive care unit.

"My in-laws went on to hospice when they were terminally ill," Braunstein said. "They were able to stay at home, they had a lot of care, they were pain free, and they were very comfortable, and they died surrounded by family."

He said that he felt his in-laws had relatively good deaths, while his own parents did not.

Braunstein says that having a conversation about the end of life shouldn't be difficult.

"Talking about end-of-life issues can be very emotionally wrenching. But it's an important issue. I mean, we talk about all other things in life, why can't we talk about what we want toward the end of life?"

Braunstein says that physicians haven't been well-trained for these conversations, and that they can take some time. He noted that an earlier version of the Affordable Care Act provided payment for this type of conversation, but that was later stripped out.

The health care providers involved are trying to involve faith-based leaders in the community to present these issues to their congregations, Braunstein said.

"We do a lot of unnecessary things that are basically harmful to people at the end of life. Just because nobody wants to give up. And we aren't talking about giving up; we're talking about not doing ineffective medical care," Braunstein said.

He also noted that it's partially to help cut expenses, as the last month of someone's life in particular can be tremendously expensive.

A statement from the health care providers involved cites research from the California HealthCare Foundation, which notes that nearly 80 percent of Californians say they'd want to talk to their doctors about end-of-life care but that fewer 1 in 10 say they have. They also note that 82 percent say it's important to put those wishes in writing, while less than one-quarter have actually done so.

 

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