Advancing Advance Directives
To the Editor,
I just read with interest the article “Advancing Advance Directives” by Dr. Richard Stefanacci.1 I was somewhat surprised that the tone of the article seemed to be about reinventing the wheel. I have spent the better part of three decades in the healthcare arena as a licensed social worker, and we are a tool that is used in many areas to inform, educate, and, in many cases, help execute documents needed for advance planning on end-of-life issues.
While the physicians are already overtaxed with current tasks, I have a hard time reconciling why one more task that can be very time-consuming would be added to their list of reimbursable duties. While advance directives are a wonderful gift to the patient in knowing that his or her wishes are known, it is also a gift to many families in knowing what their loved one’s desires are regarding care. However, you cannot mandate someone’s personal beliefs. There are cultural beliefs that everything should be done to promote life regardless of the quality of life that is measured by others. I feel that those beliefs should be respected, as well as beliefs that differ. I felt that the citing of percentages in ethnic groups was not needed in order to educate the reader. Social workers, particularly in long-term care, have had decades of experience in assisting with this area of care. I personally have addressed groups publicly, as well as assisted physician offices, churches, or anyone requesting help with advance directives. The healthcare delivery system is broken, but I don’t think it is appropriate to infer that personal beliefs are to blame. It is the individual’s choice to have or not to have a feeding tube, ventilator, etc, and it should not be placed solely on the shoulders of the physicians to educate the patient about the risks and benefits from a clinical standpoint instead of the more holistic standpoint taken by most social workers.
With regard to hospice, I would like to state that long-term care has been and is providing end-of-life care with care and respect for the patient. This has been the practice long before the Pilot Projects of 1979. If you want to look at costs, I would suggest that the same dollars be spent increasing education and staff for the many facilities that have hospice come into their facilities to duplicate what is already being done by the staff of the facility. My guess is that the savings would be staggering. I do believe that hospice is very valuable in the community but is not effective in all settings.
Thank you for the opportunity to express my thoughts.
Name withheld
Columbia, SC
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Dr. Stefanacci responds:
I sincerely appreciate the three areas of concern that were raised in this letter, and I believe that further clarification would aid this discussion.
To start, it should be stressed in all complex geriatrics care issues that care is best delivered through an interdisciplinary team. Advance directives are a clear example of where the interdisciplinary team can deliver better outcomes. As pointed out in the letter, social workers play a critical role; in our PACE program, social workers lead the process while utilizing the primary care physician team to provide clinical enlightenment. This provides our participants and their caregivers with a comprehensive picture to help base their decisions while having a process that is carefully driven by social workers to assure completion.
Regarding the second issue raised about the use of disparity data, it is critical to note that while disparity data are important to evaluate, they must be evaluated completely. As noted by the letter writer, disparity data may not mean that a disparity of caring exists, but rather may be the result of real differences among differing groups on their views. End-of-life care may, in fact, be one of those cases where disparity data are actually the result of better care than if the number among different groups were exactly the same. It is vital that we constantly examine disparities to determine whether it is the result of caring differences or true cultural differences regarding desires for care.
Lastly, while there is never enough space to provide complete detail, the concerns of hospice in long-term care certainly would benefit from a few additional comments. The Medicare Payment Advisory Commission (MedPAC), Centers for Medicare & Medicaid Services (CMS), and legislators share the writer’s concern regarding hospice expenditures. As a result, payment changes to hospice are being deployed to assure the most appropriate use of services.2 These payment changes call for payments being adjusted by location of care and period of care, with such a change likely resulting in reductions of payment for patients in long-term care hospice, as well as those with longer periods enrolled in hospice. Again, the goal here is improvement in the appropriateness of hospice services.
I appreciate the letter writer calling our attention to these important areas, which we will be certain to discuss in much greater detail in the near future.
Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD
Director of the Institute for Geriatric Studies
Mayes College of Healthcare Business & Policy University of the Sciences
Philadelphia, PA
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To the Editor,
I read with great interest the article by Dr. Stefanacci on “Advancing Advance Directives” in the November issue of Clinical Geriatrics.1 It is very good, and I congratulate you.
I wanted to discuss a troubling trend I see with our hospice providers. I live in a relatively small city in the Midwest. We have eight hospice organizations that are very competitive. They search for prospective patients, and they market themselves to family members and note clinical features of the patients that supposedly qualify them for hospice benefits. Often, the patients have a low body mass index or moderate-to-severe dementia, but there is no clear indication that the patients are facing death within 6 months or are having intractable pain. The hospice organization convinces families that they can add to the patient’s “dignity” and overall quality [of life], and even prevent the need for transfer to a higher level of care. They then give the family paperwork and directions to “just get the doctor to sign off on this.” Some doctors do just sign off, and hospice therefore has a relatively low-intensity case and gets a per diem payment.
I had a case like this that came onto my service that had already been on the hospice roles. The hospice team did very little for this patient, they never were needed, and when the patient did die, the hospice team just couldn’t make it.
In summary, I think there is a lot of abuse going on. I confronted one of the local medical directors about this. This physician wrapped herself in the “hospice flag” and denied it all. In this time of crisis for the economics of healthcare, isn’t there anything we can do about these obvious abuses?
Name withheld
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Dr. Spivack responds:
Thank you for your feedback regarding the “Advancing Advance Directives” article. You do raise an important issue within hospice and palliative care that clearly has an impact on primary care and other physicians asked to certify that patients meet hospice criteria. As a former medical director for a hospice provider, one of the key responsibilities of the medical director is to review patient diagnoses and functional status, and to assure that patients are appropriate for hospice services. I cannot comment on the competitive environment for hospice services in your area, or on the practices of individual hospice providers, but there is clearly greater competition for hospice services, and growth in for-profit hospices have accounted for much of the growth in numbers of hospice providers over the past decade.3 There has been some national attention focused on Medicare’s hospice spending, which has increased nearly four times over the past 10 years, and is projected to continue to increase further.3 In addition, the proportion of patients entering hospice with non-cancer diagnoses—which are less predictable—has increased, and there has been an increasing proportion of lengths of stay exceeding 6 months.2 Questions have been raised about the continuing certification for hospice services, given the “longevity” of some individuals accepted for hospice care. There will likely be ongoing focus on this issue as the healthcare reform debate continues nationally. In any case, as the article states, physicians should continue to appropriately and timely utilize hospice services for their patients who can benefit from these services, given their demonstrated value for patients, families, and healthcare providers.
Barney S. Spivack, MD, FACP, AGSF, CMD
Series Editor, Medicare Update
Associate Physician Editor, Clinical Geriatrics
Associate Clinical Professor of Medicine, Columbia University
New York, NY Consultant in Geriatric Medicine, Greenwich Hospital
Greenwich, CT
Medical Director, LifeCare, Inc.
Westport, CT