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Advance Directives: Rarely Easy, Always Important

Inside Health Care
Tuesday, April 10th, 2012

Inside Health Care posts feature recent news and blog posts from the health care community and are part of the Center for Advancing Health’s portfolio of free, evidence-based coverage of what it takes to find good care and make the most of it.  By Monica Kriete, CFAH Communications Associate.

“Without advance directives, even a loving child may be ignorant of her parent’s wishes,” author Susan Jacoby writes in a recent New York Times editorial, Taking Responsibility for Death.  When Susan’s own mother died, many years after writing her directives, Susan said, “It was an immense comfort to me, at a terrible time, to have no doubts about what she wanted.”

Unfortunately, implementing an advance directive can sometimes be more complicated than writing one.  Amy Berman, Program Officer for the John A. Hartford Foundation, writes about her uncle being pressured to rescind his “do not resuscitate” order (DNR) in order to undergo surgery to repair a broken hip.  Her blog post, Can Someone Override Your Advance Directive?, raises a number of questions: Did the doctor pressure her uncle because “DNRs can hurt the physician’s quality metrics”?  Or was it because, as a commenter points out, “putting a patient under anesthesia for a procedure constitutes a positive intrusion into their own life support mechanisms”? And lastly, is it possible to write a directive that will account for every contingency?

Even in more clear-cut situations, implementing an advance directive is not always easy.  At the GeriPal blog, Dr. Dan Matlock writes about Being Accused of Murder in spite of a patient’s very clear-cut advance directive: “The patient had suffered a devastating stroke. Her advance directive (notarized no less) stated that she did not want any artificial means of life support, specifically mentioning artificial nutrition or hydration.” Yet in order to convince the primary care team that the artificial hydration the patient had been given should be discontinued, Dr. Matlock had to call the patient’s sister, who had been granted medical power of attorney. Remarkably, the patient’s primary care doctor accused Dr. Matlock of murder, an experience that is not uncommon among palliative care specialists, according to a study Dr. Matlock cites.

All three essays show that carrying out an advance directive can be tricky and appointing a health care proxy or medical power of attorney with whom you’ve had a frank discussion about your end-of-life wishes can help.  For more information, check out the Prepared Patient® feature article Advance Directives: Caring for You and Your Family.

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The Clinician’s Role in Patient Engagement

Inside Health Care
Monday, February 27th, 2012

Inside Health Care posts feature recent news and blog posts from the health care community and are part of the Center for Advancing Health’s portfolio of free, evidence-based coverage of what it takes to find good care and make the most of it.  By Monica Kriete, CFAH Communications Associate.

Patient engagement initiatives often focus on how patients can or should change their behavior. Certainly, more of the responsibility for finding good care and making the most of it falls on patients and their caregivers.  But recently, several health care insiders noted the importance of providers’ behavior in promoting and/or preventing patient engagement.

At Mind the Gap, Stephen Wilkins asks, “Patient engagement versus physician engagement – which comes first?“  He points out that “Research shows that on average, physicians interrupt [patients'] opening statements within 18 seconds.” He adds, “How do you feel when a friend, a colleague, or your spouse interrupts you when you are trying to make a point?”  Stephen suggests that a clinician who is unwilling to consider the patient’s values and desires, for example, about using medication as a first course of treatment, can effectively block patients’ attempts to become engaged.

Patient safety expert Dr. Peter Pronovost also emphasizes the importance of listening to patients at The Doctor Weighs In.  In What I learned from listening to a patient he writes, “Health care needs to recognize that patients or their parents or spouses have the tacit wisdom, from years of experience, to understand the ins and outs of a particular scenario, and that this type of wisdom can complement the physician’s wisdom.  Sometimes it is even more important.”  Listening to patients and their loved ones, as well as to less senior clinicians, is a key component of creating a culture that values patients’ care and safety over individual doctors’ authority, he explains.

Health Beat’s Anne Polta echoes Peter’s sentiments in her blog When the Patient Complains.  “When patients complain,” she writes, “it’s often a reliable sign that a health care organization is falling short in some area.”  Changing attitudes about patient satisfaction now lead some care providers and administrators to view these complaints not as mere criticism, but as an opportunity to receive feedback and improve patients’ care.

 

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The Price of Paperwork

Inside Health Care
Thursday, January 26th, 2012

Inside Health Care posts feature recent news and blog posts from the health care community and are part of the Center for Advancing Health’s portfolio of free, evidence-based coverage of what it takes to find good care and make the most of it.  By Monica Kriete, CFAH Communications Associate.

Administrative costs for U.S. health care, whether measured in dollars and cents or time, are an ongoing hot topic in health care spending discussions.  Recently, on the New York Times Economix blog, Uwe Reinhardt asks, “What price do we pay for pluralism in health insurance?”  He notes that choosing between health insurance plans in countries like Switzerland is relatively easy because each plan is required to offer a federally specified benefits package.  The diversity of American health insurance plans makes choosing between them more complicated.  Comparatively, the time that prospective enrollees spend comparing options is astronomical.  “Choice in the United States is expensive, because it requires prospective enrollees to do near-Talmudic studies of the fine print of each insurer’s offerings — many times multiple distinct offerings per insurer.”

Dr. Patricia Salber asks a similar question at The Doctor Weighs In: “How much are we paying for ‘choice’ of insurers?, ” citing a recent study that compared the administrative costs of practicing medicine in Canada, a single payer system, with the U.S.  The researchers found that if U.S. physicians had administrative costs similar to Ontario physicians the total savings would be $27.6 billion per year.  Why?  Due to the extra time spent interacting with insurance companies.  However, Dr. Salber writes, “The authors are careful to point out that we really don’t know the value of the benefits that may be reaped by these insurance company interactions.  For example, how much inappropriate care is avoided by prior authorizations and how much innovation is stimulated by competition between the various payers?”

At least some of these administrative burdens may decrease starting in 2014, thanks to a new rule proposed by the Obama administration, Julie Rovner reports for NPR’s Shots blog.  This rule could save doctors and hospitals between $3 and $4.5 billion dollars a year by standardizing how insurance companies pay electronic claims and encouraging the use of electronic claims rather than paper ones.  While the rules may be costly initially for insurance companies to implement, those costs will be more than made up in savings over the next ten years, according to administration officials.

 

 

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A New Year and a New Big Picture Look at Weight Loss?

Inside Health Care
Monday, January 9th, 2012

Inside Health Care posts feature recent news and blog posts from the health care community and are part of the Center for Advancing Health’s portfolio of free, evidence-based coverage of what it takes to find good care and make the most of it.  By Monica Kriete, CFAH Communications Associate.

“The first week of January is our Super Bowl for Weight Watchers,” said David Burwick, North America’s Weight Watchers president.  During most Januaries, many Americans’ minds are firmly resolved to lose weight, however, their bodies may seem to be equally determined that they fail.  Why?

Tara Parker-Pope explains in The Fat Trap that during and after weight loss, the brain and body change in ways that make it very difficult to avoid gaining weight back.   “The human body continues to fight against weight loss long after dieting has stopped.  This translates into a sobering reality: once we become fat, most of us, despite our best efforts, will probably stay fat.”  Tara goes into detail, describing both the scientific evidence for the “fat trap” and the ways in which some people succeed in keeping a substantial amount of lost weight off despite the odds.

In response, Dr. David Katz writes at the Huffington Post, “If we are fighting our own bodies, we have cause to ask who started it, and where it’s likely to end.”  He points out a non-biological barrier to weight loss.  “It stands to reason that even a moderate array of environmental modifications would go a long way toward fixing the problem at its origins.” Dr. Katz advocates for seeing obesity as a social problem, rather than a strictly biological one.  But how do we change society?

The LA Times’ Booster Shots blog suggests one place to start.  In Wealthy nations with lots of fast food: Destined to be obese? Jeannine Stein describes a recent study that found that nations like the U.S. and Canada, which have a relatively high per capita density of fast food restaurants, have high obesity rates.  Likewise, nations with fewer fast food restaurants per capita, such as Norway and Japan, have lower obesity rates.  Said lead study author Roberto De Vogli, “In my opinion, the public debate is too much focused on individual genetics and other individual factors and overlooks the global forces in society that are shaping behaviors worldwide.”

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