IMPROVING PATIENT CARE
Scott D. Halpern, MD, PhD; Ezekiel J. Emanuel, MD, PhD
This article was published online first at www.annals.org on 9 December 2014.
Grant Support: Dr. Halpern was supported by a Greenwall Foundation Faculty Scholar Award in Bioethics.
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-2476.
Requests for Single Reprints: Scott D. Halpern, MD, PhD, University of Pennsylvania, 719 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021; e-mail, email@example.com.
Current Author Addresses: Dr. Halpern: University of Pennsylvania, 719 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021.
Dr. Emanuel: Department of Medical Ethics and Health Policy, University of Pennsylvania, 3401 Market Street, Suite 320, Philadelphia, PA 19104.
Author Contributions: Conception and design: S.D. Halpern, E.J. Emanuel.
Drafting of the article: S.D. Halpern, E.J. Emanuel.
Critical revision of the article for important intellectual content: S.D. Halpern, E.J. Emanuel.
Final approval of the article: S.D. Halpern, E.J. Emanuel.
Administrative, technical, or logistic support: S.D. Halpern.
Collection and assembly of data: E.J. Emanuel.
Halpern S., Emanuel E.; Can the United States Buy Better Advance Care Planning?. Ann Intern Med. 2015;162:224-225. doi: 10.7326/M14-2476
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Published: Ann Intern Med. 2015;162(3):224-225.
Since the early 1980s, the delivery of care near the end of life in the United States has changed dramatically—and improved—often without much notice. The rights of persons to refuse all types of medical interventions are well-established and no longer litigated. Pain is now the fifth vital sign. Specialized palliative care consultative services are available in most U.S. hospitals (1). Increasing numbers of persons in the United States die while receiving hospice care, including 60% of those who have died of cancer (2). And new initiatives are increasingly prompting clinicians and patients to engage in advance care planning, such as completing written advance directives.
Patricia A. Bomba, MD, FACP, Salimah H. Meghani, PhD, MBE, RN, FAAN
Excellus BlueCross BlueShield, University of Pennsylvania
December 23, 2014
Conflict of Interest:
The authors declare no financial or non-financial conflicts of interest. Dr. Bomba and Dr. Meghani served on the Institute of Medicine Committee Report, Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life
Thoughtful Discussions Take Time: Inadequate Clinician Reimbursement is a Barrier
We find the article by Halpern and Emanuel provocative but not representative of the recommendations of the recent Institute of Medicine (IOM) report, Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. In their article, they state that one of the IOM Committee's “central recommendations, to reimburse physicians for engaging patients in advance care planning, merits careful consideration”. To clarify, the specific recommendations around Clinician-Patient Communication and Advance Care Planning (ACP) focus on establishing quality standards for clinician-patient communication and ACP that are measurable, actionable and evidence-based and recommend tying “such standards to reimbursement” (p. 3-57). Improving ACP and end-of-life communication is complex and cannot be addressed with a single central recommendation. Several changes must occur synergistically to move the needle on this issue. The 507-page report recommends a multidimensional approach to enhancing advance care planning, including enhancements in professional training and education, system and policy change, and public engagement. The report defines ACP as a process of planning and discussion that occurs over time, recognizes the limitations of the living will, and distinguishes advance directives from actionable medical orders. We direct the readers to the Life-Cycle Model of ACP presented in the report, which emphasizes a wellness-illness approach towards planning and normalizing conversations around end-of-life care. Such a model has been developed and implemented in New York[3-5]. Rather than acute care based reactive models, ACP should occur long before the patient arrives in the intensive care unit, a time when many patients do not have the capacity to make medical decisions. Clinicians in Upstate New York (NY) identified inadequate reimbursement as a barrier to end-of-life discussions. In response, Excellus BlueCross BlueShield developed a comprehensive reimbursement model for thoughtful discussions with seriously ill persons who might die in the next year, coupled with shared decision making that is well-informed, which has led to completion of NY’s Medical Orders for Life-Sustaining Treatment (MOLST). The reimbursement model includes face-to-face time with the patient, as well as non-face-to-face time with family and care planning to support MOLST orders. Eligible clinicians (physicians, nurse practitioners, physician assistants) are trained to conduct these discussions and enrolled in eMOLST, NY’s electronic form and discussion completion system that serves as NY’s eMOLST registry. Utilization of eMOLST ensures all clinicians who access eMOLST in an emergency retrieve both MOLST and documentation of the discussion ensuring preference-consistent end-of-life care for patients and families. References1. Halpern, S.D. and E.J. Emanuel, Can the United States Buy Better Advance Care Planning? Ann Intern Med, 2014.2. Institute of Medicine (IOM), Dying in America: Improving quality and honoring individual preferences near the end of life. 2014, Washington, D.C: The National Academies Press.3. Belluck, P., Coverage for End-of-Life Talks Gaining Ground, in New York Times. August 30, 2014.4. Bomba, P.A., Landmark Legislation in New York Affirms Benefits of a Two-Step Approach to Advance Care Planning Including MOLST: A Model of Shared, Informed Medical Decision-Making and Honoring Patient Preferences for Care at the End of Life. Widener Law Review, 2011. XVII(2): p. 475-500.5. Compassion and Support at the End of Life, MOLST Provider Training: Beyond the Health Care Proxy: Advance Care Planning for Patients with Serious Illness. 2009. Available: http://www.compassionandsupport.org/index.php/for_professionals/molst_training_center/provider_training
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End-of-Life Care, Healthcare Delivery and Policy.
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