The Institute of Medicine (IOM) recently called for broad improvements in the care provided to patients at the end of their lives. Honoring preferences and promoting quality of life for these patients should be a national priority, according to the “Dying in America” report, released on Sept. 17.
The report offers recommendations for change in care delivery, clinician-patient communication and advance care planning, professional education and development, payment systems and policies, and public engagement and education.
Since hospitalists are heavily involved in many of those areas of end-of-life care, ACP Hospitalist recently spoke to one of the report's expert authors, Diane E. Meier, MD, FACP, professor of geriatrics and palliative medicine at Mount Sinai Medical Center in New York and director of the Center to Advance Palliative Care. She offered her perspective on these proposed improvements in the health care system and hospitalists' role in the changes.
Q: What do you hope the report accomplishes?
A: The new Institute of Medicine report recognizes that the overwhelming majority of people with serious and complex illness and their families will never encounter a specialist in palliative care. Their needs for attention to symptom management, skilled communication, and coordination across settings are inevitably the responsibility of the frontline clinicians who take care of them. In hospitals, increasingly that professional is a hospitalist, and the IOM report calls for much more attention to and investment in education and training of frontline clinicians, like hospitalists, in the core principles and practices of palliative medicine. If the report does nothing more than that—make it both easier and a requirement for people who care for the seriously ill to have this training—that will lead to a sea change in the quality of care in the United States.
Q: Are the needed changes all systemic, or can individual physicians work toward these goals?
A: Hospitalists are key leaders in conveying the message that palliative care is not brink-of-death care and that palliative care should be delivered from the point of diagnosis of a serious illness throughout its course, maybe more than a decade. If hospitalists champion that message, it is much more likely to be heard and understood by others. Also hospitalists are, in many ways, in the best position to protect hospitalized patients from some of the worst depredations of the health care system, such as overtreatment, overdiagnosis, overintervention, hospital-acquired conditions, hospital-acquired infections.
Q: What would you like to see happen in response to the report?
A: I hope to see discipline-specific organizations, like hospitalists, like oncologists, like cardiologists, take up this report and figure out how to implement its recommendations within their own spheres. In the case of national organizations that serve hospitalists, it's about prioritizing education and training in palliative care for members.
Q: Is there anything else hospitalists in particular should take from the report?
A: The other major recommendation in the report that is groundbreaking is the recommendation that payers, insurers of all types, reimburse not only for medical needs, medically necessary services, but also for social support needs, like safe housing, food, transportation, substance use counseling, things that have traditionally been thought to be outside the world of medical obligation or medical responsibility.
Q: Should physicians be more active in treating social determinants of health?
A: Yes, if we're going to look at improving quality for our patients and measuring that by [whether] they are readmitted within 30 days [or] end up dying in the hospital, if we really want to impact those metrics, we have got to address the social situations we're discharging them into. Those are driving those patterns. It behooves us to recognize that the setting we are discharging people into is at least as important, if not more important, than the medication list, for example.