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Opinion: Tough Decisions About End-of-life Care Require Careful Consideration

As a practicing physician, I deal with life-and-death issues every day. Of particular personal and professional importance to me is a palliative care initiative the Trenton Health Team has undertaken to educate clinicians in central New Jersey about improving end-of-life care for their patients while at the same time reducing futile care. Central to that effort is the understanding that we should provide the care patients want and need rather than what is medically expedient. Given the choice, people at the end of life or facing the downhill course of a long-term disease often do not want aggressive treatment that reduces the quality of their remaining life. Also, our healthcare system can’t afford it.

A disproportionate share of America’s healthcare dollar goes to end-of-life care. Medicare NewsGroup reported that of the $554 billion spent by Medicare in 2011, almost one-third – $170 billion – was spent on patients’ last six months of life. And in New Jersey, these costs are higher than in almost any other state. In the city of Trenton, the average annual Medicare expenditure is approximately $10,000, but in the frailest patients above the age of 85 with multiple medical conditions, the cost rises 10-fold to nearly $100,000.

Yet, for all this spending, studies have shown we do not live longer and actually have more complications than people in other countries. If patients receive extensive and expensive care at the end of their life, without attention to their goals for care, we have not done a good enough job as healthcare providers.

My thoughts on the matter were tested the night of a raging blizzard a few years back. My 86-year-old father had six weeks to live, having been diagnosed with metastatic lung cancer, when I received a call from an area hospital’s emergency room. Dad had suffered a heart attack and was rushed there despite his desire to remain home. When I arrived at the ER, I informed the resident physician that my father had an advanced directive and a “do not resuscitate” order. Despite that, the young doctor tried to convince me that he could provide cardiac intervention and other invasive therapy.

“And, what do you truly hope to accomplish by intervening?” I responded. When I said that, I thought to myself, am I being horrible, not caring about my father? A more experienced ER doctor overheard the exchange and came over and said to me, “You’re doing the right thing, because this is how people with this disease die. And that’s OK.” That solidified my convictions, and Dad was admitted into hospice. But it was still difficult for me, both as a son and a physician, to challenge the request of another doctor and advocate for my father. I can only imagine the anxiety a non-clinical family member would go through in the same situation.

We often see our patients face the slow, but steadily downhill course of their disease. I believe it is our obligation as physicians to begin the conversation early, and to state, “All right, we’ve made a diagnosis here. How do you want to approach this? What are your goals for care at this point? What if things change down the road?” That is not an easy conversation to have with a patient, and physicians are not well-trained to lead it, but our patients expect us to do just that.

The new statewide process for communicating patients’ wishes, POLST (Practitioner Orders for Life-Sustaining Treatment), was introduced earlier this year to help patients and physicians address this conundrum. Different than an advanced directive, this form is completed with the patient by a physician or nurse practitioner and enables the patient to make decisions about the types of medical treatment he or she wishes to receive toward the end of life. It is part of the patient’s medical record and must be followed by all clinical personnel.

All licensed physicians, nurses and other medical professionals in New Jersey must receive at least two hours of additional training in the proper use of this form and how to address the difficult issues surrounding chronic disease and end-of-life care.

In these days of spiraling healthcare costs and daily discussions about the new Affordable Care Act, it is so timely that we ask the simple question: “What is your goal for treatment?” The new healthcare law outlines three aims: improve the patient experience of care, improve the quality of that care and lower the overall cost of care. I believe that understanding how palliative care, and the proper use of the new POLST legislation, will help our most frail patients have a better healthcare experience and live their lives with even greater dignity – because we will be doing what the patient wants. This is truly the goal of healthcare reform, and it is our goal at the Trenton Health Team.

Robert Remstein, D.O., M.B.A., is president of the Trenton Health Team, a collaborative including Capital Health, St. Francis Medical Center, Henry J. Austin Health Center and Trenton’s Department of Health and Human Services. He is also vice president of Accountable Care at Capital Health.

About the Trenton Health Team
Trenton Health Team (THT) is an alliance of the city’s major providers of healthcare services including Capital Health, St. Francis Medical Center, Henry J. Austin Health Center and the city’s Health Department. In collaboration with residents and the city’s active social services network, THT is developing an integrated healthcare delivery system to transform the city’s fragmented primary care system and restore health to the city. THT aims to make Trenton the healthiest city in the state. Support for the Trenton Health Team was provided in part by a grant from The Nicholson Foundation. For more information, visit