Wednesday, June 10, 2015

The Complex Reality of “Shared Decision Making” and Patient Autonomy

--By Marie Miller, Health Care Administrator & Personal Finance Professional

This author’s blog in the Yale Daily News posits some interesting things about how a patient and health care provider interact to come to a real decision that provides clarity for the patient and family and the provider alike.  
The author describes a few high level points regarding the, “ethics of persuading patients to pursue certain treatments and how physicians should navigate that tricky territory.”  The author is a PhD candidate who shared his thoughts on standard practice of decision-making in critical care, the power of framing information and how doctors should responsibly use that power. 
The balance of power in Shared Decision Making often lays in how well one party understands the facts, possibilities and repercussions of each potential path forward.
I am almost fully in line with what this researcher has to say.
In a skilled nursing facility, with transitional care capabilities, such as mine, labeled ‘sub-acute rehab’ as well as ‘long term care’ there are patients of varying ages, from early forties to over 100.
In managing this patient mix, one must learn to navigate the generational gap to be successful. In so doing, I have noticed certain qualities that the upper and lower ends of this spectrum share in common when it comes to the end-of-life discussion, in particular.
Furthermore, we have a ventilator unit in my facility, so end-of-life issues are constantly on my mind and necessarily part of my day to day job duties. I find that at the point of the admission process, where advanced directives are discussed as a matter of routine, a 90-something may be as indifferent to the conversation as a “young” (this term is obviously relative in the nursing home world) person. By indifferent I mean detached or so reluctant to think about the issue that they just want to move on and may more or less mentally shut-down. Because this is so reliably the case, I agree that physicians need to have a more direct hand in the decision making process.
It is indeed false to assume that patients and their families come in to the mix with predetermined values; I am constantly amazed at how often the exact opposite is true. “Young” patients or children of the elderly seem ignorant of the nature of end-of-life issues as well as the technical decisions involved in ventilator or feeding tube care. The elderly patients themselves are frequently past the point of making the decision or still in their generational stereotype of wanting the doctor to make the decisions (or allowing their children to do so).
Additionally, I concur with Dubov in his last statement about the presence of systematic failures in behavioral economics especially when linked so closely with emotions as in life and death health decisions.
I’ll give a brief example: a patient’s family made a split second (relatively) decision to put her on a ventilator though she had a living will stating her wishes were for no mechanical ventilation or artificial feeding. After many months of hoping for a miracle and going through the grieving process, they confronted the fact that she would not recover and put her on hospice. Hospice then used the living will as a means to justify decreasing her respiratory rate on the vent (without putting her in distress) and completely discontinuing the feeding tube (for legal reasons we are not cleared to just do an extubation at the facility). Though there was a system in place with the living will and prior physician/family discussions, it failed once the patient was incapable of communication and her family was faced with the immediate reality of losing their wife/mother.
This brings me to a final point about why doctors are in the best position to advise: a hospice marketer considered this example a “great success” because they were able to bring a vent patient on service without having to extubate at the ER then transport back to the facility (a logistical nightmare and big reason it is difficult to have vent patients on hospice). This meant having her linger for 11 days without nourishment.
Success, really? I don’t want this woman anywhere near my family at the time of our decision making process! I don’t feel comfortable with physicians directly making life/death decisions for their patients, especially given the lack of intimacy between a typical person and their physician and the monetary constraints already weighing on our system.  But at the end of the day, I can at least count on them having taken some course in ethics as well as I can hope that the Hippocratic Oath isn’t just a hollow recitation. We don’t have any hope for a functional, free, and fair healthcare system when the populace remains willfully ignorant about their choices. Until that root cause is addressed, physicians may be the best answer for an ethical outcome.  
 
Marie is health care and finance professional, working on the health care provider side in an administrative capacity. 

Friday, March 6, 2015

Rational Use of Antipsychotics in Long Term/ Sub-Acute Care or Even Home Care Depends on Your Perspective

 -----By Anna Shepherd, Health & Personal Finance Professional, Facility Asst Administrator

In a Wall Street Journal Blog published this past week, the feds are admonished for not doing more to help the elderly who are receiving too many antipsychotic drugs, whether they are in the nursing home or not.  See WSJ Blog
This is such a complex topic, but I believe it is telling that observers (whether they are GAO or HHS or others) believe that they can summarize and opine on a subject that requires 100% individualization.  Each case is unique and must be considered in its complete context.  And certainly, these drugs must be used at the lowest possible doses, especially in the elderly.
That said, I have a few issues with this story. It is accusatory to imply that having 61% of those diagnosed with dementia—and dangerous behaviors--on an antipsychotic is a bad thing. Dementia is a neurologic disorder and can trigger irrational and violent behavior on the level of schizophrenia. It is also a broad umbrella term that encapsulates many separate disorders—Lewy body, Alzheimer’s, Parkinson’s etc. One need go no further than an internet search to find hundreds of stories of disturbing violence in nursing homes among residents. The company I work for even experienced one such gruesome event this last fall. This is not to say that the nursing homes didn’t do their best to treat—or even that they did anything wrong. And it isn’t to say that lurking in every person with dementia is a homicidal maniac. But it does need to be said that nursing homes need to be allowed to treat the person as well as to keep the peace (remember we live in a highly litigious society).  Until the medical community knows more about the disease process of dementia and related disorders and can create new drugs to treat them, we’re left with finding the best fit from what is available.
I work in a sub-acute nursing facility and we frequently receive patients from the hospital who are medically stable (sometimes barely so) but who are undergoing such mental stress due to illness and rapid, drastic, changes in their health and overall quality of life that by the time they get to the nursing home setting they, frankly, may be on the verge of a psychotic episode—dementia or no. Another subset of these people may even have prescribed pysch meds (particularly something like Ambien) at home but are not continued on them while in the hospital. They may show up at the hospital with little ability to give a medical history or primary physician—if they have one to begin with. Thus, while they are in a very weak condition during their hospital stay, there may not be a need for these meds, but by the time they are in the nursing home and on the mend with therapy, they begin to lapse into whatever underlying mental condition they were once being medicated for.  The nursing home clinician must rationally deal with this scenario, and doing so may show up as a negative statistic for the nursing home, weighing against it as a negative metric for elderly people taking these tranquilizers.
Furthermore, upon admission of a new patient, our nursing staff often have no health history other than what the hospital discharge notes list as diagnoses; if included in this list is something like a ‘mood disorder’ or history of bipolar, then the first reaction by staff is to document any and every behavior and request orders for mood stabilizing drugs to bridge the individual’s transition into their rehab stay or long term care. I’m not saying this is right, but having one nurse in charge of 20 people means that a facility can only handle so many behavioral disruptions!  In this sense, staff education is most certainly warranted.
However, it must be said that in my building, most of the people who are on antipsychotics shortly after admission are tapered off of them at some point during their stay. This is how our medical director prefers to treat—and at the risk of sounding like a broken record--I think this is ultimately just another example of how our new health care system removes provider discretion in favor of uniformity and agreeable performance metrics. 
The needs of the individual patient and the other residents who are forced to live around them are often lost in translation!