A systemwide approach to end-of-life care

One health system developed an advance directive toolkit for patients and communication training for clinicians.

Rod Hochman, MD, FACP, is using his experiences as a physician and family member to improve end-of-life care on a systems level as CEO of Providence St. Joseph Health, a seven-state health system based in Renton, Wash.

Dr. Hochman's father had a stroke and died in the hospital after receiving aggressive, possibly futile, treatment in the ICU. After that experience, his family opted out of aggressive care for his mother, who died peacefully at home. To help other patients and families approach the end of life on their own terms, he is now leading the hospital chain in a systematic effort to get every elderly and seriously ill patient to document their wishes for end-of-life care and designate a surrogate decision maker.

Photo courtesy of Dr Hochman
Photo courtesy of Dr. Hochman

The health system established the Institute for Human Caring, which developed an advance directive online toolkit in multiple languages for patients and conducts advanced communication training sessions for its doctors, nurses, social workers, and chaplains. Training includes education on how to present advanced directives and enter them into the electronic health record. So far, the institute has trained more than 2,200 clinicians to have goal-setting conversations with patients and their families. The health system has also made familiarity and completion of advance directives part of its employee health insurance incentive program.

Dr. Hochman recently spoke with ACP Hospitalist about the challenges surrounding end-of-life care and making the inevitable a less painful process for patients and families.

Q: What led you to focus on end-of-life care as an administrator?

A: I think a lot of families are frustrated with care . . . End-of-life care really has problems with it in so many different ways. We like to think in terms of not just end-of-life care, but whole-person care. As we reach that experience that we all come to in some way, shape, or form, you have to work with the whole family and the whole patient. I think all of those issues sometimes get forgotten in this era of fragmented care, and really no one's in charge. Unless we get our hands around how we deal with that, we're never going to get a handle on quality of care, satisfaction of our patients and families, and, importantly, the total cost of what we spend on health care.

Q: What is your health system doing to address the issue?

A: It's been a five- to six-year journey. One of the smartest things we did was hire Ira Byock, MD, who established an institute in Southern California, which is part of our system, called the Institute for Human Caring, and one of the goals of the institute was to look at advance directives. One of the efforts that we had was with our own employees. We have 118,000 caregivers, and we said, “What are we going to do to educate them on advance directives?” It was overwhelming, the number of our folks that filled out advance directives, and it taught us that if you start to have the conversation, you can really change people's attitudes toward this topic.

The second part of work that the institute is doing is working with all seven of our states and regions to establish protocols in palliative care and in caring for people facing the end of life in all of our 51 hospitals and clinics. It was particularly important to start, as we usually do, with those places that are most problematic. We chose our ICUs and the work that our hospitalists do inside the hospital. That said, it's awfully hard when you're a hospitalist and you are faced with someone who's critically ill to have that conversation for the first time.

The third part of it is also to extend this work to the clinic because oftentimes, the best time to have the conversation about end of life is not when you're facing an illness or you're in the ICU, but it's to have that discussion well in advance of that. So it's moving this whole effort into the clinic and not just inside the hospital. For the hospitalists, it's sometimes hard because they're just at the point when things are happening in the hospital. We really need to bring this care back into the clinic so that the internists and the family practitioners and the folks that are seeing patients in the outpatient setting are addressing these issues.

Q: What have been the main challenges of taking on this project?

A: I think you can correlate “doing everything” for a patient with good care, and sometimes it's harder to have the conversation than it is just to recommend one more course of treatment. I feel for my fellow physicians because sometimes it's easier just to prescribe one more thing than it is to have the conversation that this may be the time that there is no other treatment that's going to change the course of this disease or illness and that we need to think about comfort measures and maybe not the next round of chemotherapy and being realistic about what the prognosis is. Those are hard conversations to have, and unfortunately, I was fairly guilty [of that]. Being a physician for 40 years, I wasn't taught that when I was in medical school and training. We also have to do a better job with educating our medical students, our nursing students, and our nurses and physicians. We're starting to, but I don't think we're doing a good enough job training our clinicians, both our nurses and doctors, in this whole area.

Q: What are your next steps?

A: We want to provide a kind of template for other systems to see what we're doing with the institute's work, so I think the next thing for us is to continue the work in our own system but then also see if we can start other partners as we go forward. I think trying to make [advance directives] simpler and easier to adopt is also really important. But it's a journey, there's no question. This is not an easy one, but it has tremendous benefits for patients and their families.