First Do No Harm - UCLA Researchers Find Patient-Centered Care At End Of Life Results In Happier Patients Who Live Longer In Less Pain

Main Category: Palliative Care / Hospice Care
Also Included In: Public Health
Article Date: 20 Mar 2013 - 13:00 PDT


New doctors take an oath to first do no harm, but physicians often go too far in their quest to keep that oath - exposing patients to aggressive treatments that don't improve outcomes and drive up healthcare costs.

Researchers from UCLA Urology have found that patient-centered care at end-of-life - ensuring a dying person's wishes are known and followed - results in happier, less depressed patients who are in less pain and survive longer.

This type of care also helps to keep healthcare costs down for patients with advanced cancers and other diseases that can't be effectively treated by eliminating aggressive measures that the patients might not want.

"You can improve care while reducing cost by making sure that everything you do is centered on what the patients want, what his or her specific goals are and tailor a treatment plan to ensure we provide the specific care he or she wants," said Dr. Jonathan Bergman, a Robert Wood Johnson Clinical Scholar at UCLA.

The perspective piece appears March 20, 2013 in the peer-reviewed journal JAMA Surgery.

Medical care during the final stages of life often is poorly coordinated and inattentive to a patient's preferences, the perspective states. End-of-life care also consumes the lion's share of healthcare dollars. A 2004 study found that 30 percent of Medicare resources are expended on the 5 percent of beneficiaries who die every year, and one-third of costs in life's last year are accounted for during the final month.

Studies also have found that patient-centered care can reduce costs in the last week of life by 36 percent and death, when it comes, is less likely to occur in an intensive care unit.

UCLA researchers are testing the patient-centered care model on cancer patients being treated at the West Los Angeles Veterans Affairs Medical Center. One of the first things done with these critically ill patients is to determine their goals in a multidisciplinary environment, integrating a palliative care specialist at the outset. The physician and specialist see the patient on the same day to coordinate their care.

"Unfortunately, the opposite is usually what happens. They come in with incurable diseases and there's no discussion of prognosis and goals of care," Bergman said. "Then a lot of very aggressive treatments can occur due to inertia. Patients are placed in an intensive care unit with oxygen and feeding tubes, and that's not always in line with their goals."

Patients who want aggressive care should, of course, receive it, Bergman said. But the UCLA research team is finding that there are many who don't that and they just haven't been queried about their needs.

To change this, the perspective suggests that one of the first things that needs to happen is educating residents about patient-centered care. Physicians will be better prepared to practice in the 21st century, and to maximize patient outcomes, if they are guided toward appropriate care for their patients in life's final stages, Bergman said.

Secondly, changes should be considered to Medicare, which pays for the majority of care at the end of life. However, meaningful policy discussions on this issue have proven elusive, and recent suggested changes have been characterized as creating "death panels," causing policy makers to shy away from such decision making, Bergman said.

"Given the disproportionate cost of care at the very end of life, the issue should be revisited," the perspective states. "Addressing goals of care, not to deny aggressive care to those who want it, but to ensure that we deliver aggressive care only to those who do, reduces costs and improves outcomes."

Lastly, UCLA researchers suggest that hospital scorecards be changed to reflect this new care model. The Joint Commission, which accredits hospitals, has an annual report on quality and safety that ranks hospitals using evidence-based processes known to be linked to patient outcomes. However, none of the 44 accountability measures or the six non-accountability measures in the report address end-of-life care or assessment of patient preferences.

"Adding such measures to the report would improve practice as well as inform patient-centered care by empowering individuals to make educated decisions," Bergman said. "Better care in life's final stages should and can be led by physicians, who have accepted the mission of skillfully - and thoughtfully - caring for patients at every step of life's journey."

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