A recent study showed doctors do not always have frequent end-of-life discussions with patients who have potentially fatal diseases despite recommendations to do so, a practice UCLA has been recently trying to improve.
The study was conducted by Dr. Katherine Kahn, professor of general internal medicine and health services research at the David Geffen School of Medicine. The study surveyed patients on a regional basis, who described their experiences with their general physicians.
Kahn said she is not sure if this is the result of a lack of education or if doctors are not comfortable with having these conversations, but that it is an important area that needs to be further surveyed.
If end-of-life discussions are held early, it is easier for doctors to target exactly what kind of treatment their patients want, without overshooting the use of hospital resources, said Dr. Neil Wenger, UCLA Health System ethicist.
It is important to discuss this care early and to thoroughly educate patients on the limits of treatment, emphasizing palliative care, which focuses on pain and symptoms rather than treatment, when it becomes necessary.
In some cases, he added, doctors must step in and reevaluate the chosen treatment when it is detrimental to the patient’s well-being.
Though these discussions are very important, they are not easy to have, and they are something doctors need to practice, as some patients may not want to talk about their chances of survival. This is especially true when they may have come to UCLA looking for a miracle, Wenger added.
Wenger said he thinks the UCLA Medical Center could improve regularity of end-of-life discussions with patients by reinforcing the importance of having them regularly and early on.
“(The) very complex medical care that we can offer to people saves many, many lives that may not have been savable maybe 10 years ago, but the diseases in these instances are stronger, and people do die,” said Dr. Thomas Rosenthal, chief medical officer of the UCLA Medical Center. “We are not immortal.”
Rosenthal echoed Wenger’s sentiment that placing an emphasis on patients planning their care with a physician will lead to more efficient and effective care.
UCLA’s pledge to keep as many patients alive as possible is a double-edged sword, given the limited number of resources available for a hospital full of patients in need of care.
A 2009 survey of Medicare fund use by hospitals across the nation by the Dartmouth Atlas of Health Care showed facilities that spent more money per patient were no more successful at saving lives than hospitals with lower spending.
The study, which showed UCLA on the high end of Medicare spending, prompted a survey of UC hospitals to help researchers understand the variations in hospital spending.
Dr. Michael Ong, co-author of the UC study and assistant professor of medicine at UCLA, said one of the most important aspects of both the Dartmouth and UC studies is that they focus exclusively on the end-of-life care, which should not be lumped in with statistics for all care.
In contrast against the Dartmouth study, the survey of UC hospitals showed that hospitals using more resources on patients had better outcomes and lower mortality rates, he said. The survey focused on elderly patients suffering from heart failure and differed from the Dartmouth study by focusing only on the five UC hospitals, including the Cedars-Sinai Medical Center, and factored in patients who survived in addition to mortality rates.
However, Ong said that though the results show this relationship between funds and mortality rates, it is up to society to decide whether this use of resources is worth it.
“It’s a society concern, how much we want to spend to get those benefits. There are potential inefficiencies in those outcomes,” he said.
The study has prompted follow-up work to determine which hospitals have the most success in order to help eliminate any inefficiencies.
“The main thing that most people would agree on is that variations exist in the U.S. … People certainly (have) a lot of suggestions (about how to address these variations), but we need to figure out whether the solutions make sense,” he said.
“There’s not a simple answer in terms of how to solve those problems.”