April 18, 2016

If it's Good for Wisconsin...

The big news in palliative care circles this week was the results of the PerryUndem Research poll that surveyed physicians on their views about advance care planning discussions. It made the Boston Globe, it made Forbes, and it made US News and World Report, though I couldn’t find any mention of it in the NY Times, the Washington Post, or the Wall Street Journal—maybe they are holding off until Sunday. Or maybe they realized that the poll is new, but the findings aren’t. Physicians still don’t talk to their patients about advance care planning very much.

To be fair, what is new is that physicians who take care of the sixty-five plus population on a regular basis, or at least primary care physicians, oncologists, pulmonary doctors, and cardiologists, overwhelmingly think they should be talking to patients about their goals of care and their preferences in the face of advanced illness. They think it’s important and that it’s their job to do so. They support Medicare’s decision to reimburse directly for such conversations. But then comes the disconnect. While acknowledging the importance of having such conversations, they have all kinds of excuses for not having them: not enough time, uncertainty about what to say, no formal training. Even those who say that the new reimbursement policy provides a strong incentive to have “the conversation” haven’t actually billed Medicare as yet—only 14 percent of the 470 primary care doctors and 266 subspecialists who were surveyed say they have submitted a bill for advance care planning since the new rule went into effect in January.

The Patient Self-Determination Act of 1990, which mandated that all health care facilities that receive federal money ask patients if they have an advance directive and offer them the opportunity to create one if they don’t, didn’t push doctors to do their job. The availability of Medicare reimbursement hasn’t pushed doctors to act—though perhaps it’s too early to judge. All the publicity given to the last phase of life with projects such as the Conversation Project and books such as Atul Gawande’s bestselling Being Mortal has raised awareness and has perhaps moved physicians to accept that advance care planning is an important part of medical care for patients with advanced illness, but it hasn’t had the kind of impact we’d like to see. So what would work?

The survey identifies two promising areas, formal training and a systematic approach to implementing advance care planning. When either of these was in place, physicians were more likely to report that they had conversations with patients about their preferences. Physicians who had had some sort of training said they had such discussions at least once a week in 79 percent of those polled, but only 61 percent who those who hadn’t had the training reported discussing acp. Among physicians whose practices or health care systems had a system in place to promote advance care planning, 81 percent had the talk versus 68 percent who didn’t work in a such a system. Perhaps even more important was the use of an electronic health record that had a place to document preferences for care: 79 percent of physicians with such an EHR said they had conversations at least weekly, compared to 51 percent who did not.

Maybe the solution to increased advance care planning is to do more formal training and promote systems to support this activity, including electronic medical records with a special “field” to enter the results of such conversations. But I suspect that these approaches, though laudable, will not be enough. After all, we don’t know how often physicians actually have advance care planning discussions with their patient; we only know their estimate of how often they discuss such matters—and we also know that when physicians are asked to estimate how much time they spend with each patient, they are notoriously inaccurate. If we really want to ensure that advance care planning takes place, at least for patients with advanced illness, we need to promote advance care planning to the public as well as to doctors. 

Earlier public campaigns to promote advance care planning were not very successful: the Robert Wood Johnson Foundation spent millions and their efforts achieved little. But the one approach that by all  accounts has worked is the “Respecting Choices” program in La Crosse, Wisconsin, which introduced specialized training for clinicians, a systematic approach for implementation within the Gundersen Health System, and educated patients and families. If we truly want to make a difference, it's not going to be enough to focus on a single approach. We need to use the kind of comprehensive approach that worked in Wisconsin, and we need to use it throughout the country.

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