When I visit my older patients, conversation often turns to "the end": "When my time comes, I want hospice," they say. These individuals are not necessarily near death; in many cases they are patients with chronic illnesses whom I have long cared for as a geriatrician. Some have experienced hospice through the decline and death of a spouse. Others have suffered from debilitating health crises from which they have, thankfully, bounced back.
But they all have one thing in common: for every health condition, they know they need a "Plan B." They must consider what kind of care, curative or comfort, they want in any given situation, and they need to make informed decisions while their health is relatively stable.
They realize this because I've been discussing these issues with them throughout my time as their physician. Moving these kinds of conversations about care upstream can greatly benefit patients and their families.
Care That Yields Positive Results
In a 2007 study by the National Hospice and Palliative Care Organization, researchers found that among patients suffering from six terminal diagnoses, those who received hospice care lived nearly a month longer than those without that care. The study suggested this may be due to the enhanced psychosocial support and intensive monitoring that hospice provides, along with an absence of aggressive treatments (www.nhpco.org/files/public/ JPSM/march-2007-article.pdf).
A 2010 study of patients with metastatic non-small-cell lung cancer, published in the New England Journal of Medicine (www.nejm.org/doi/pdf/10.1056/NEJMoal000678), found that patients who received palliative care lived more than two months longer than those who received standard care, and had "clinically meaningful improvements in quality of life and mood." Patients who received palliative care were less depressed, their "resuscitation preferences" were more likely to be documented in their medical record and their end-of-life care was less invasive.
These outcomes are no accident. Palliative medicine is effective because it focuses on honest discussions, early decision making, and ensures physical, emotional and spiritual comfort along the way.
Our practice is part of a movement toward the medical home concept of care, a sort of Marcus Welby-practicing-as-ateam approach. Our physicians and nurse practitioners, who serve as medical directors and staff clinicians in the office, on hospital units, at independent living, assisted living and skilled care facilities and at hospice, are able to follow patients as they move through the healthcare continuum.
Depending upon when we begin caring for our patients, we can help them create or add to patient stories (wishes for care, including advance directives). We can assure …