By Denise Brown, MD

It is very challenging in healthcare to talk with patients about death and dying.  These are very difficult conversations to have and even more challenging is that we usually only see patients in times of crises.  But when we do learn about what patients want in advance, a lot can be done to give them the quality of life that they want.  When I have seen palliative care work to its full effect and potential, I have seen patients live better and live longer.  In these cases we actually use less resources and the patients have better outcomes.    

It is an unfortunate phenomenon that patients frequently spend the last days of their life coming and going from a hospital.  In our country, the default type of care given is having every possible machine used and the maximum radiation level given until the end.  When there is a lack of conversation, it is always easy to do the most.  But doing what’s right and doing the most are not always the right thing.

Patients who actually live longer at home with palliative care illustrate quite a contrast to what is actually happening a majority of time.  A recent article reports that the Federal Government estimates that 80% of the healthcare costs for the elderly are spent on the last month of life, and a recent study also reports that higher intensity treatment may not be associated with quality of care of patient satisfaction.

While I do not have the answers as to what each individual should choose, I do think that palliative care is something that each individual should be informed of and given the available options.  Ideally it is best to have these conversations over time with a provider, nurse or therapist and before the patient is in the hospital.  The goal is to anticipate the care needed for the next year as much as possible and blend this with what the patient wants.  A path can then be created to improve the quality of their life along with the quantity of their life.  

The proactive planning can make a big difference as compared to reactively trying to treat a patient during intermittent ED visits. These conversations take time, and providers in the ED typically don’t have a lot of time.  However, at times it might have to take place there considering how many people are using the ED as their primary care physician these days.  But we should all be prepared and be ready to talk to patients about this difficult issue in an informative way.  And the reality is, we are all still trying to figure out the best way to talk about palliative care.  For me, I have seen that it usually takes a few discussions to make any progress.     

Fortunately, there is a tangible first step towards a solution with the Physician Orders for Life-Sustaining Treatment (POLST) form.  The POLST form is a document signed by both the patient and the physician detailing what kinds of medical treatments a patient wants towards the end of their lives.  For example, with a POLST form, the next time a panicked daughter comes in to the ED there will be some continuity of care that the patient had already requested.

Having these difficult conversations are a challenge, but starting this process leads to increased empowerment for everyone. Palliative care is a way to use fewer resources and have better outcomes, especially if you define outcome as quality of life.  A question for us all to think about may be, what does quality mean to you?

Denise Brown, MD, is the Medical Director of a Galen site in Redwood City, California. She holds a BA from the University of California, Berkeley where she was elected to Phi Beta Kappa, and an MD from the University of Chicago with election to Alpha Omega Alpha. She completed her Internal Medicine residency at Stanford University. Dr. Brown has been with Galen Inpatient Physicians since 2002.