Leigh A. Fredholm, MD

Recently, I had an unexpected hospitalization for what ultimately proved to be ovarian torsion. I spent 4 nights in the hospital, 2 preoperatively and 2 postoperatively. While I was pleased with the care I received, I also learned a few things that will influence my future hospital-based practice. Herewith, in no particular order, are my observations:

©SoberP/thinkstockphotos.com

• Emergency department wait times matter. Much has been written about inappropriate utilization of the ED and throughput. I realize that not everyone in the waiting room has a truly emergent problem, but the 75 minutes between my arrival and the time I was triaged were the longest 75 minutes of my life. I was in so much pain that I couldn’t even advocate for myself.

• When faced with equivocal diagnostic testing, return to the history and physical as Sir William Osler instructed.("Listen to your patient, he is telling you the diagnosis.") I am so fortunate to live in the 21st century and to have immediate access to diagnostic imaging, labs, and a good surgeon. It is not lost on me, however, that had CT and ultrasound not been available (and nondiagnostic), my exam and white blood cell count would have taken me to the operating room without delay, shortening both my hospital stay and my recovery time. Still, I recognize that the retrospectoscope has 100% accuracy, far exceeding that of we human physicians.

• Opioids are not the enemy. After receiving multiple doses of intravenous opioids in the ED, I asked for ketorolac. During the 2 days between onset of pain and surgery, I relied upon the ketorolac for most of my pain relief. This is in part because I felt it worked better than the opioids (but did not eliminate the need for opioids) but also in an effort to be a "good patient." When I thought I might be going home, I stopped asking for the ketorolac. In short order, the pain worsened, my vital signs worsened, and I was off to the OR for removal of what proved to be a hemorrhagic, necrotic ovary.

• Small things matter, communication. Our system has spent considerable energy improving communication between staff and patients, utilizing communication boards. The professionals caring for me performed wonderfully in this respect – without fail, I knew their names and their extensions. I never knew, though, when my doctor would be rounding.

Because of on-call responsibilities and emergencies, the times ranged between 6 a.m. and 2 p.m. I completely understand why this happens, as it has occurred in my own practice. I will remember to keep my patients informed about my own schedule as much as I can going forward.

• Small things matter, miscellaneous. Medical tape leaves adhesive residue that takes days to remove – nail polish remover is more effective than alcohol for adhesive removal. ...An improperly secured Foley catheter can wreak havoc. ... There is literally nothing on TV worth watching for days at a time, despite having 46 channels. ... Clear liquids have more sugar than should be allowed, even for those of us who are not diabetic.

Being sick is very tedious.

As a medical student (more years ago than I care to count), I participated in various activities intended to raise awareness and sensitivity to the patient experience. After my recent refresher course, I hope to be a better doctor to my patients.

Dr. Fredholm and her colleague Dr. Stephen Bekanich are codirectors of Seton Palliative Care, part of the University of Texas Southwest Residency Programs in Austin. They alternate contributions to the monthly Palliatively Speaking blog (http://tinyurl.com/Palliatively).

Recently, I had an unexpected hospitalization for what ultimately proved to be ovarian torsion. I spent 4 nights in the hospital, 2 preoperatively and 2 postoperatively. While I was pleased with the care I received, I also learned a few things that will influence my future hospital-based practice. Herewith, in no particular order, are my observations:

©SoberP/thinkstockphotos.com

• Emergency department wait times matter. Much has been written about inappropriate utilization of the ED and throughput. I realize that not everyone in the waiting room has a truly emergent problem, but the 75 minutes between my arrival and the time I was triaged were the longest 75 minutes of my life. I was in so much pain that I couldn’t even advocate for myself.

• When faced with equivocal diagnostic testing, return to the history and physical as Sir William Osler instructed.("Listen to your patient, he is telling you the diagnosis.") I am so fortunate to live in the 21st century and to have immediate access to diagnostic imaging, labs, and a good surgeon. It is not lost on me, however, that had CT and ultrasound not been available (and nondiagnostic), my exam and white blood cell count would have taken me to the operating room without delay, shortening both my hospital stay and my recovery time. Still, I recognize that the retrospectoscope has 100% accuracy, far exceeding that of we human physicians.

• Opioids are not the enemy. After receiving multiple doses of intravenous opioids in the ED, I asked for ketorolac. During the 2 days between onset of pain and surgery, I relied upon the ketorolac for most of my pain relief. This is in part because I felt it worked better than the opioids (but did not eliminate the need for opioids) but also in an effort to be a "good patient." When I thought I might be going home, I stopped asking for the ketorolac. In short order, the pain worsened, my vital signs worsened, and I was off to the OR for removal of what proved to be a hemorrhagic, necrotic ovary.

• Small things matter, communication. Our system has spent considerable energy improving communication between staff and patients, utilizing communication boards. The professionals caring for me performed wonderfully in this respect – without fail, I knew their names and their extensions. I never knew, though, when my doctor would be rounding.

Because of on-call responsibilities and emergencies, the times ranged between 6 a.m. and 2 p.m. I completely understand why this happens, as it has occurred in my own practice. I will remember to keep my patients informed about my own schedule as much as I can going forward.

• Small things matter, miscellaneous. Medical tape leaves adhesive residue that takes days to remove – nail polish remover is more effective than alcohol for adhesive removal. ...An improperly secured Foley catheter can wreak havoc. ... There is literally nothing on TV worth watching for days at a time, despite having 46 channels. ... Clear liquids have more sugar than should be allowed, even for those of us who are not diabetic.

Being sick is very tedious.

As a medical student (more years ago than I care to count), I participated in various activities intended to raise awareness and sensitivity to the patient experience. After my recent refresher course, I hope to be a better doctor to my patients.

Dr. Fredholm and her colleague Dr. Stephen Bekanich are codirectors of Seton Palliative Care, part of the University of Texas Southwest Residency Programs in Austin. They alternate contributions to the monthly Palliatively Speaking blog (http://tinyurl.com/Palliatively).

Recently, I had an unexpected hospitalization for what ultimately proved to be ovarian torsion. I spent 4 nights in the hospital, 2 preoperatively and 2 postoperatively. While I was pleased with the care I received, I also learned a few things that will influence my future hospital-based practice. Herewith, in no particular order, are my observations:

©SoberP/thinkstockphotos.com

• Emergency department wait times matter. Much has been written about inappropriate utilization of the ED and throughput. I realize that not everyone in the waiting room has a truly emergent problem, but the 75 minutes between my arrival and the time I was triaged were the longest 75 minutes of my life. I was in so much pain that I couldn’t even advocate for myself.

• When faced with equivocal diagnostic testing, return to the history and physical as Sir William Osler instructed.("Listen to your patient, he is telling you the diagnosis.") I am so fortunate to live in the 21st century and to have immediate access to diagnostic imaging, labs, and a good surgeon. It is not lost on me, however, that had CT and ultrasound not been available (and nondiagnostic), my exam and white blood cell count would have taken me to the operating room without delay, shortening both my hospital stay and my recovery time. Still, I recognize that the retrospectoscope has 100% accuracy, far exceeding that of we human physicians.

• Opioids are not the enemy. After receiving multiple doses of intravenous opioids in the ED, I asked for ketorolac. During the 2 days between onset of pain and surgery, I relied upon the ketorolac for most of my pain relief. This is in part because I felt it worked better than the opioids (but did not eliminate the need for opioids) but also in an effort to be a "good patient." When I thought I might be going home, I stopped asking for the ketorolac. In short order, the pain worsened, my vital signs worsened, and I was off to the OR for removal of what proved to be a hemorrhagic, necrotic ovary.

• Small things matter, communication. Our system has spent considerable energy improving communication between staff and patients, utilizing communication boards. The professionals caring for me performed wonderfully in this respect – without fail, I knew their names and their extensions. I never knew, though, when my doctor would be rounding.

Because of on-call responsibilities and emergencies, the times ranged between 6 a.m. and 2 p.m. I completely understand why this happens, as it has occurred in my own practice. I will remember to keep my patients informed about my own schedule as much as I can going forward.

• Small things matter, miscellaneous. Medical tape leaves adhesive residue that takes days to remove – nail polish remover is more effective than alcohol for adhesive removal. ...An improperly secured Foley catheter can wreak havoc. ... There is literally nothing on TV worth watching for days at a time, despite having 46 channels. ... Clear liquids have more sugar than should be allowed, even for those of us who are not diabetic.

Being sick is very tedious.

As a medical student (more years ago than I care to count), I participated in various activities intended to raise awareness and sensitivity to the patient experience. After my recent refresher course, I hope to be a better doctor to my patients.

Dr. Fredholm and her colleague Dr. Stephen Bekanich are codirectors of Seton Palliative Care, part of the University of Texas Southwest Residency Programs in Austin. They alternate contributions to the monthly Palliatively Speaking blog (http://tinyurl.com/Palliatively).

Today our team saw an 89-year-old gentleman on the hospitalist service with dementia, heart failure, atrial fibrillation, chronic kidney disease, and problems falling. His last known fall was less than 3 months ago and resulted in a broken hip requiring surgical intervention. This was his fourth hospitalization in 6 months, yet it was the first time he was seen by our service.

The frequency at which palliative care (PC) consults are ordered in a particular hospital varies widely. Some reasons for this are not easy fixes – PC is not available in each hospital (as was the case in two of this gentleman’s four hospitalizations), many PC teams are available only Monday-Friday, and patient volumes within a hospital ebb and flow with much less predictability than the tides.

However, some of the reasons are amenable to change. These might include the particular group of hospitalists, or one attending physician, utilizing PC consults less frequently than another. Or it may simply be that the connection was not made between the patient’s experience and the usefulness of an early PC consults. Screening tools are one method of decreasing variability in PC involvement as well as increasing the appropriateness of our service for a particular patient.

There are quite a few palliative care screening tools available. Many of them focus on what most of us would expect, which are the most common diagnoses we see (late-stage cancer, HF, cirrhosis, end-stage renal disease, dementia, etc.). Multiple studies have estimated that mature PC programs in large hospitals are consulted on 1%-2% of live discharges. However, we estimate that more than 10% of these discharged patients have palliative needs that go unmet. While it is true that we wish PC could be involved in all of these lives, this large number of people who spend time in the hospital with these diagnoses, coupled with a national shortage of PC providers, translates into an unbalanced equation.

Rather than looking at a specific diagnosis, we suggest incorporating inquiries on the presence of "palliative care–related problems." While these might require more thought or investigation into a patient’s situation, we find them to be more fruitful than using diagnosis alone.

Some examples? Mismatch between the expectations of the medical team vs. patient/family when it comes to prognosis or the goals of care would be one of them. Another might be persistent uncontrolled symptoms despite usual medical management. Family members disagreeing or demonstrating concerns about the goals of care is still another.

Having used various screening tools in multiple hospitals and clinical settings, we suggest the following considerations in setting up your own:

• Stakeholder management: The right services and staff need to agree on this being a way to improve quality of care (we always provide an "opt-out" option for those who don’t want us involved for some reason).

• Start small: Implement these on one unit at a time or limit the diagnoses to one or two conditions only. You can make the criteria less stringent if the PC team’s bandwidth is not too narrow.

• Be flexible: Even by starting small, there will be times that the PC teams are overwhelmed on a particular day leaving the occasional patient who meets criteria unseen. If the consult is urgent, a phone call is appropriate so that an assumption isn’t made that the screening tool will catch 100% of the patients.

• Track data: When using these tools, palliative care teams have been able to show things such as improved Hospital Consumer Assessment of Healthcare Providers and Systems survey results and decreased readmissions. Demonstrate what you’re doing for your institution so that you can expand the units or patients served.

PC screening tools are an effective way to decrease variability and improve quality. For examples of tools that we use, please get in touch. Find our contact info and read earlier columns at ehospitalistnews/Palliatively.

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

Today our team saw an 89-year-old gentleman on the hospitalist service with dementia, heart failure, atrial fibrillation, chronic kidney disease, and problems falling. His last known fall was less than 3 months ago and resulted in a broken hip requiring surgical intervention. This was his fourth hospitalization in 6 months, yet it was the first time he was seen by our service.

The frequency at which palliative care (PC) consults are ordered in a particular hospital varies widely. Some reasons for this are not easy fixes – PC is not available in each hospital (as was the case in two of this gentleman’s four hospitalizations), many PC teams are available only Monday-Friday, and patient volumes within a hospital ebb and flow with much less predictability than the tides.

However, some of the reasons are amenable to change. These might include the particular group of hospitalists, or one attending physician, utilizing PC consults less frequently than another. Or it may simply be that the connection was not made between the patient’s experience and the usefulness of an early PC consults. Screening tools are one method of decreasing variability in PC involvement as well as increasing the appropriateness of our service for a particular patient.

There are quite a few palliative care screening tools available. Many of them focus on what most of us would expect, which are the most common diagnoses we see (late-stage cancer, HF, cirrhosis, end-stage renal disease, dementia, etc.). Multiple studies have estimated that mature PC programs in large hospitals are consulted on 1%-2% of live discharges. However, we estimate that more than 10% of these discharged patients have palliative needs that go unmet. While it is true that we wish PC could be involved in all of these lives, this large number of people who spend time in the hospital with these diagnoses, coupled with a national shortage of PC providers, translates into an unbalanced equation.

Rather than looking at a specific diagnosis, we suggest incorporating inquiries on the presence of "palliative care–related problems." While these might require more thought or investigation into a patient’s situation, we find them to be more fruitful than using diagnosis alone.

Some examples? Mismatch between the expectations of the medical team vs. patient/family when it comes to prognosis or the goals of care would be one of them. Another might be persistent uncontrolled symptoms despite usual medical management. Family members disagreeing or demonstrating concerns about the goals of care is still another.

Having used various screening tools in multiple hospitals and clinical settings, we suggest the following considerations in setting up your own:

• Stakeholder management: The right services and staff need to agree on this being a way to improve quality of care (we always provide an "opt-out" option for those who don’t want us involved for some reason).

• Start small: Implement these on one unit at a time or limit the diagnoses to one or two conditions only. You can make the criteria less stringent if the PC team’s bandwidth is not too narrow.

• Be flexible: Even by starting small, there will be times that the PC teams are overwhelmed on a particular day leaving the occasional patient who meets criteria unseen. If the consult is urgent, a phone call is appropriate so that an assumption isn’t made that the screening tool will catch 100% of the patients.

• Track data: When using these tools, palliative care teams have been able to show things such as improved Hospital Consumer Assessment of Healthcare Providers and Systems survey results and decreased readmissions. Demonstrate what you’re doing for your institution so that you can expand the units or patients served.

PC screening tools are an effective way to decrease variability and improve quality. For examples of tools that we use, please get in touch. Find our contact info and read earlier columns at ehospitalistnews/Palliatively.

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

Today our team saw an 89-year-old gentleman on the hospitalist service with dementia, heart failure, atrial fibrillation, chronic kidney disease, and problems falling. His last known fall was less than 3 months ago and resulted in a broken hip requiring surgical intervention. This was his fourth hospitalization in 6 months, yet it was the first time he was seen by our service.

The frequency at which palliative care (PC) consults are ordered in a particular hospital varies widely. Some reasons for this are not easy fixes – PC is not available in each hospital (as was the case in two of this gentleman’s four hospitalizations), many PC teams are available only Monday-Friday, and patient volumes within a hospital ebb and flow with much less predictability than the tides.

However, some of the reasons are amenable to change. These might include the particular group of hospitalists, or one attending physician, utilizing PC consults less frequently than another. Or it may simply be that the connection was not made between the patient’s experience and the usefulness of an early PC consults. Screening tools are one method of decreasing variability in PC involvement as well as increasing the appropriateness of our service for a particular patient.

There are quite a few palliative care screening tools available. Many of them focus on what most of us would expect, which are the most common diagnoses we see (late-stage cancer, HF, cirrhosis, end-stage renal disease, dementia, etc.). Multiple studies have estimated that mature PC programs in large hospitals are consulted on 1%-2% of live discharges. However, we estimate that more than 10% of these discharged patients have palliative needs that go unmet. While it is true that we wish PC could be involved in all of these lives, this large number of people who spend time in the hospital with these diagnoses, coupled with a national shortage of PC providers, translates into an unbalanced equation.

Rather than looking at a specific diagnosis, we suggest incorporating inquiries on the presence of "palliative care–related problems." While these might require more thought or investigation into a patient’s situation, we find them to be more fruitful than using diagnosis alone.

Some examples? Mismatch between the expectations of the medical team vs. patient/family when it comes to prognosis or the goals of care would be one of them. Another might be persistent uncontrolled symptoms despite usual medical management. Family members disagreeing or demonstrating concerns about the goals of care is still another.

Having used various screening tools in multiple hospitals and clinical settings, we suggest the following considerations in setting up your own:

• Stakeholder management: The right services and staff need to agree on this being a way to improve quality of care (we always provide an "opt-out" option for those who don’t want us involved for some reason).

• Start small: Implement these on one unit at a time or limit the diagnoses to one or two conditions only. You can make the criteria less stringent if the PC team’s bandwidth is not too narrow.

• Be flexible: Even by starting small, there will be times that the PC teams are overwhelmed on a particular day leaving the occasional patient who meets criteria unseen. If the consult is urgent, a phone call is appropriate so that an assumption isn’t made that the screening tool will catch 100% of the patients.

• Track data: When using these tools, palliative care teams have been able to show things such as improved Hospital Consumer Assessment of Healthcare Providers and Systems survey results and decreased readmissions. Demonstrate what you’re doing for your institution so that you can expand the units or patients served.

PC screening tools are an effective way to decrease variability and improve quality. For examples of tools that we use, please get in touch. Find our contact info and read earlier columns at ehospitalistnews/Palliatively.

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

The Society of Hospital Medicine held its annual meeting recently in Las Vegas, and Stephen had the opportunity to speak on the topic of "Family Meetings: The Art and the Evidence." As a special edition of Palliatively Speaking, we thought we would highlight one aspect of this subject, with other elements forthcoming in future pieces.

As a hospitalist, I stumbled and stuttered through many family meetings until I eventually found myself on more comfortable ground. Overall, I found them rewarding when they went well but stressful and deflating when they did not. The latter sensation was enough to create some avoidant behavior on my part.

After a few years of practice, my hospitalist group began shadowing one another periodically on rounds to provide feedback to our colleagues in the hope of improving the quality of our communication skills. It was then that I noticed that one of my partners was a master at these meetings. A real Rembrandt. He had the ability to deliver bad or difficult news without the dynamic in the room becoming inflammatory or out of control.

I will never forget watching him mediate a disagreement between a nurse and a patient suspected of using illicit substances while hospitalized. He flipped an antagonistic, heated situation into one where the patient, nurse, and physician all agreed on putting the past to rest and forging ahead with his proposed plan. We all left the room with a genuine sense that we had mutual purpose. In my admiration I realized that some of these skills must be teachable.

While I didn’t act on learning those communication techniques immediately after that encounter, I would eventually be formally exposed to them during my palliative medicine training. As it turns out, I still have some uncomfortable meetings with patients and families, but they come around much less frequently and when they do I now have a variety of tools to deal with challenges.

My appreciation of these tools doesn’t stop when I walk through the hospital doors each evening. I have found them to be invaluable in my personal life. In fact, learning to communicate better has been a source of renewal for me at work and staves off burnout. These techniques include active listening, motivational interviewing, demonstration of empathy, conflict resolution, and also negotiation. For the Society of Hospital Medicine meeting audience, I dissected negotiation, citing how it and the other skills can inject vitality into your interactions.

In any negotiation, it’s all about the other party. You are the smallest person in the room, the least important.

This is counterintuitive. Oftentimes at work we are trying to convince everyone how important we are. The readmissions committee should implement your plan to reduce recurrent hospitalizations. Your fellow hospitalists should recognize your value and make you the leader of the group. Patients show their appreciation for you making the right diagnosis and averting a medical calamity for them. But when you enter a family meeting, the patient and his or her loved ones are the center stage. To be successful you have to listen more and talk less. Get to understand the pictures in their heads and then summarize those thoughts and ideas back to them to show you’ve listened.

Make emotional payments. I don’t get into the meat of the meeting until I’ve done that with the patient and every family member in the room. No one holds family meetings for patients who are thriving and have outstanding outcomes. We have family meetings to figure out goals in the face of terrible diseases, when elder abuse is a possibility, when insurance-funded resources are depleted, and for a host of other difficult reasons.

This means that everyone in the room is suffering, sacrificing, scared, confused, or worried. Acknowledge them. Hold them up. Thank them. Reflect on similar moments in your life and demonstrate empathy. Apologize when things haven’t gone right for them at your hospital. These payments will pay handsome dividends as your relationship evolves.

Not manipulation. The term negotiation might bring up images of used car salespeople. I strongly disagree. In manipulation, one side wins and the other doesn’t. In negotiation, the goal is improved communication and understanding. Manipulation is about one side of the equation having knowledge that the other side is lacking and using that to achieve its means. Negotiators hope everyone at the table has the same knowledge.

This leads to two key principles of negotiations: transparency and genuineness. Patients and families are excellent at taking the temperature of the room when you sit down to meet with them. Share knowledge. Don’t have any hidden agendas. Following this principle builds trust.

Be incremental. Taking patients from comfortable, familiar territory into that which is uncomfortable or unfamiliar should not be done in one giant leap. Let’s use code status (CS) as an example because of the frequency with which it comes up (though I rarely talk about CS without first understanding the patient’s goals and hopes).

Some patients refuse to talk about CS, so I think incrementally. I ask that they consider talking about CS with me in the future. Very few people refuse to consider something. Two or three days later I ask, "Have you considered talking to me about CS?" That by itself opens up the topic for conversation. In the extremely unusual case where they still won’t engage, I then ask them, "What would it take for you to consider talking to me about this?" More incrementalism.

While this is not nearly an exhaustive list of negotiation techniques, we hope it is stimulating enough that you might be curious enough to learn more on your own and try incorporating this into your practice. If you’re motivated to do so, please feel free to contact us for reading suggestions: E-mail [email protected].

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

The Society of Hospital Medicine held its annual meeting recently in Las Vegas, and Stephen had the opportunity to speak on the topic of "Family Meetings: The Art and the Evidence." As a special edition of Palliatively Speaking, we thought we would highlight one aspect of this subject, with other elements forthcoming in future pieces.

As a hospitalist, I stumbled and stuttered through many family meetings until I eventually found myself on more comfortable ground. Overall, I found them rewarding when they went well but stressful and deflating when they did not. The latter sensation was enough to create some avoidant behavior on my part.

After a few years of practice, my hospitalist group began shadowing one another periodically on rounds to provide feedback to our colleagues in the hope of improving the quality of our communication skills. It was then that I noticed that one of my partners was a master at these meetings. A real Rembrandt. He had the ability to deliver bad or difficult news without the dynamic in the room becoming inflammatory or out of control.

I will never forget watching him mediate a disagreement between a nurse and a patient suspected of using illicit substances while hospitalized. He flipped an antagonistic, heated situation into one where the patient, nurse, and physician all agreed on putting the past to rest and forging ahead with his proposed plan. We all left the room with a genuine sense that we had mutual purpose. In my admiration I realized that some of these skills must be teachable.

While I didn’t act on learning those communication techniques immediately after that encounter, I would eventually be formally exposed to them during my palliative medicine training. As it turns out, I still have some uncomfortable meetings with patients and families, but they come around much less frequently and when they do I now have a variety of tools to deal with challenges.

My appreciation of these tools doesn’t stop when I walk through the hospital doors each evening. I have found them to be invaluable in my personal life. In fact, learning to communicate better has been a source of renewal for me at work and staves off burnout. These techniques include active listening, motivational interviewing, demonstration of empathy, conflict resolution, and also negotiation. For the Society of Hospital Medicine meeting audience, I dissected negotiation, citing how it and the other skills can inject vitality into your interactions.

In any negotiation, it’s all about the other party. You are the smallest person in the room, the least important.

This is counterintuitive. Oftentimes at work we are trying to convince everyone how important we are. The readmissions committee should implement your plan to reduce recurrent hospitalizations. Your fellow hospitalists should recognize your value and make you the leader of the group. Patients show their appreciation for you making the right diagnosis and averting a medical calamity for them. But when you enter a family meeting, the patient and his or her loved ones are the center stage. To be successful you have to listen more and talk less. Get to understand the pictures in their heads and then summarize those thoughts and ideas back to them to show you’ve listened.

Make emotional payments. I don’t get into the meat of the meeting until I’ve done that with the patient and every family member in the room. No one holds family meetings for patients who are thriving and have outstanding outcomes. We have family meetings to figure out goals in the face of terrible diseases, when elder abuse is a possibility, when insurance-funded resources are depleted, and for a host of other difficult reasons.

This means that everyone in the room is suffering, sacrificing, scared, confused, or worried. Acknowledge them. Hold them up. Thank them. Reflect on similar moments in your life and demonstrate empathy. Apologize when things haven’t gone right for them at your hospital. These payments will pay handsome dividends as your relationship evolves.

Not manipulation. The term negotiation might bring up images of used car salespeople. I strongly disagree. In manipulation, one side wins and the other doesn’t. In negotiation, the goal is improved communication and understanding. Manipulation is about one side of the equation having knowledge that the other side is lacking and using that to achieve its means. Negotiators hope everyone at the table has the same knowledge.

This leads to two key principles of negotiations: transparency and genuineness. Patients and families are excellent at taking the temperature of the room when you sit down to meet with them. Share knowledge. Don’t have any hidden agendas. Following this principle builds trust.

Be incremental. Taking patients from comfortable, familiar territory into that which is uncomfortable or unfamiliar should not be done in one giant leap. Let’s use code status (CS) as an example because of the frequency with which it comes up (though I rarely talk about CS without first understanding the patient’s goals and hopes).

Some patients refuse to talk about CS, so I think incrementally. I ask that they consider talking about CS with me in the future. Very few people refuse to consider something. Two or three days later I ask, "Have you considered talking to me about CS?" That by itself opens up the topic for conversation. In the extremely unusual case where they still won’t engage, I then ask them, "What would it take for you to consider talking to me about this?" More incrementalism.

While this is not nearly an exhaustive list of negotiation techniques, we hope it is stimulating enough that you might be curious enough to learn more on your own and try incorporating this into your practice. If you’re motivated to do so, please feel free to contact us for reading suggestions: E-mail [email protected].

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

The Society of Hospital Medicine held its annual meeting recently in Las Vegas, and Stephen had the opportunity to speak on the topic of "Family Meetings: The Art and the Evidence." As a special edition of Palliatively Speaking, we thought we would highlight one aspect of this subject, with other elements forthcoming in future pieces.

As a hospitalist, I stumbled and stuttered through many family meetings until I eventually found myself on more comfortable ground. Overall, I found them rewarding when they went well but stressful and deflating when they did not. The latter sensation was enough to create some avoidant behavior on my part.

After a few years of practice, my hospitalist group began shadowing one another periodically on rounds to provide feedback to our colleagues in the hope of improving the quality of our communication skills. It was then that I noticed that one of my partners was a master at these meetings. A real Rembrandt. He had the ability to deliver bad or difficult news without the dynamic in the room becoming inflammatory or out of control.

I will never forget watching him mediate a disagreement between a nurse and a patient suspected of using illicit substances while hospitalized. He flipped an antagonistic, heated situation into one where the patient, nurse, and physician all agreed on putting the past to rest and forging ahead with his proposed plan. We all left the room with a genuine sense that we had mutual purpose. In my admiration I realized that some of these skills must be teachable.

While I didn’t act on learning those communication techniques immediately after that encounter, I would eventually be formally exposed to them during my palliative medicine training. As it turns out, I still have some uncomfortable meetings with patients and families, but they come around much less frequently and when they do I now have a variety of tools to deal with challenges.

My appreciation of these tools doesn’t stop when I walk through the hospital doors each evening. I have found them to be invaluable in my personal life. In fact, learning to communicate better has been a source of renewal for me at work and staves off burnout. These techniques include active listening, motivational interviewing, demonstration of empathy, conflict resolution, and also negotiation. For the Society of Hospital Medicine meeting audience, I dissected negotiation, citing how it and the other skills can inject vitality into your interactions.

In any negotiation, it’s all about the other party. You are the smallest person in the room, the least important.

This is counterintuitive. Oftentimes at work we are trying to convince everyone how important we are. The readmissions committee should implement your plan to reduce recurrent hospitalizations. Your fellow hospitalists should recognize your value and make you the leader of the group. Patients show their appreciation for you making the right diagnosis and averting a medical calamity for them. But when you enter a family meeting, the patient and his or her loved ones are the center stage. To be successful you have to listen more and talk less. Get to understand the pictures in their heads and then summarize those thoughts and ideas back to them to show you’ve listened.

Make emotional payments. I don’t get into the meat of the meeting until I’ve done that with the patient and every family member in the room. No one holds family meetings for patients who are thriving and have outstanding outcomes. We have family meetings to figure out goals in the face of terrible diseases, when elder abuse is a possibility, when insurance-funded resources are depleted, and for a host of other difficult reasons.

This means that everyone in the room is suffering, sacrificing, scared, confused, or worried. Acknowledge them. Hold them up. Thank them. Reflect on similar moments in your life and demonstrate empathy. Apologize when things haven’t gone right for them at your hospital. These payments will pay handsome dividends as your relationship evolves.

Not manipulation. The term negotiation might bring up images of used car salespeople. I strongly disagree. In manipulation, one side wins and the other doesn’t. In negotiation, the goal is improved communication and understanding. Manipulation is about one side of the equation having knowledge that the other side is lacking and using that to achieve its means. Negotiators hope everyone at the table has the same knowledge.

This leads to two key principles of negotiations: transparency and genuineness. Patients and families are excellent at taking the temperature of the room when you sit down to meet with them. Share knowledge. Don’t have any hidden agendas. Following this principle builds trust.

Be incremental. Taking patients from comfortable, familiar territory into that which is uncomfortable or unfamiliar should not be done in one giant leap. Let’s use code status (CS) as an example because of the frequency with which it comes up (though I rarely talk about CS without first understanding the patient’s goals and hopes).

Some patients refuse to talk about CS, so I think incrementally. I ask that they consider talking about CS with me in the future. Very few people refuse to consider something. Two or three days later I ask, "Have you considered talking to me about CS?" That by itself opens up the topic for conversation. In the extremely unusual case where they still won’t engage, I then ask them, "What would it take for you to consider talking to me about this?" More incrementalism.

While this is not nearly an exhaustive list of negotiation techniques, we hope it is stimulating enough that you might be curious enough to learn more on your own and try incorporating this into your practice. If you’re motivated to do so, please feel free to contact us for reading suggestions: E-mail [email protected].

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

The Society of Hospital Medicine held its annual meeting recently in Las Vegas, and Stephen had the opportunity to speak on the topic of "Family Meetings: The Art and the Evidence." As a special edition of Palliatively Speaking, we thought we would highlight one aspect of this subject, with other elements forthcoming in future pieces.

As a hospitalist, I stumbled and stuttered through many family meetings until I eventually found myself on more comfortable ground. Overall, I found them rewarding when they went well but stressful and deflating when they did not. The latter sensation was enough to create some avoidant behavior on my part.

After a few years of practice, my hospitalist group began shadowing one another periodically on rounds to provide feedback to our colleagues in the hope of improving the quality of our communication skills. It was then that I noticed that one of my partners was a master at these meetings. A real Rembrandt. He had the ability to deliver bad or difficult news without the dynamic in the room becoming inflammatory or out of control.

I will never forget watching him mediate a disagreement between a nurse and a patient suspected of using illicit substances while hospitalized. He flipped an antagonistic, heated situation into one where the patient, nurse, and physician all agreed on putting the past to rest and forging ahead with his proposed plan. We all left the room with a genuine sense that we had mutual purpose. In my admiration I realized that some of these skills must be teachable.

While I didn’t act on learning those communication techniques immediately after that encounter, I would eventually be formally exposed to them during my palliative medicine training. As it turns out, I still have some uncomfortable meetings with patients and families, but they come around much less frequently and when they do I now have a variety of tools to deal with challenges.

My appreciation of these tools doesn’t stop when I walk through the hospital doors each evening. I have found them to be invaluable in my personal life. In fact, learning to communicate better has been a source of renewal for me at work and staves off burnout. These techniques include active listening, motivational interviewing, demonstration of empathy, conflict resolution, and also negotiation. For the Society of Hospital Medicine meeting audience, I dissected negotiation, citing how it and the other skills can inject vitality into your interactions.

In any negotiation, it’s all about the other party. You are the smallest person in the room, the least important.

This is counterintuitive. Oftentimes at work we are trying to convince everyone how important we are. The readmissions committee should implement your plan to reduce recurrent hospitalizations. Your fellow hospitalists should recognize your value and make you the leader of the group. Patients show their appreciation for you making the right diagnosis and averting a medical calamity for them. But when you enter a family meeting, the patient and his or her loved ones are the center stage. To be successful you have to listen more and talk less. Get to understand the pictures in their heads and then summarize those thoughts and ideas back to them to show you’ve listened.

Make emotional payments. I don’t get into the meat of the meeting until I’ve done that with the patient and every family member in the room. No one holds family meetings for patients who are thriving and have outstanding outcomes. We have family meetings to figure out goals in the face of terrible diseases, when elder abuse is a possibility, when insurance-funded resources are depleted, and for a host of other difficult reasons.

This means that everyone in the room is suffering, sacrificing, scared, confused, or worried. Acknowledge them. Hold them up. Thank them. Reflect on similar moments in your life and demonstrate empathy. Apologize when things haven’t gone right for them at your hospital. These payments will pay handsome dividends as your relationship evolves.

Not manipulation. The term negotiation might bring up images of used car salespeople. I strongly disagree. In manipulation, one side wins and the other doesn’t. In negotiation, the goal is improved communication and understanding. Manipulation is about one side of the equation having knowledge that the other side is lacking and using that to achieve its means. Negotiators hope everyone at the table has the same knowledge.

This leads to two key principles of negotiations: transparency and genuineness. Patients and families are excellent at taking the temperature of the room when you sit down to meet with them. Share knowledge. Don’t have any hidden agendas. Following this principle builds trust.

Be incremental. Taking patients from comfortable, familiar territory into that which is uncomfortable or unfamiliar should not be done in one giant leap. Let’s use code status (CS) as an example because of the frequency with which it comes up (though I rarely talk about CS without first understanding the patient’s goals and hopes).

Some patients refuse to talk about CS, so I think incrementally. I ask that they consider talking about CS with me in the future. Very few people refuse to consider something. Two or three days later I ask, "Have you considered talking to me about CS?" That by itself opens up the topic for conversation. In the extremely unusual case where they still won’t engage, I then ask them, "What would it take for you to consider talking to me about this?" More incrementalism.

While this is not nearly an exhaustive list of negotiation techniques, we hope it is stimulating enough that you might be curious enough to learn more on your own and try incorporating this into your practice. If you’re motivated to do so, please feel free to contact us for reading suggestions: E-mail [email protected].

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

The Society of Hospital Medicine held its annual meeting recently in Las Vegas, and Stephen had the opportunity to speak on the topic of "Family Meetings: The Art and the Evidence." As a special edition of Palliatively Speaking, we thought we would highlight one aspect of this subject, with other elements forthcoming in future pieces.

As a hospitalist, I stumbled and stuttered through many family meetings until I eventually found myself on more comfortable ground. Overall, I found them rewarding when they went well but stressful and deflating when they did not. The latter sensation was enough to create some avoidant behavior on my part.

After a few years of practice, my hospitalist group began shadowing one another periodically on rounds to provide feedback to our colleagues in the hope of improving the quality of our communication skills. It was then that I noticed that one of my partners was a master at these meetings. A real Rembrandt. He had the ability to deliver bad or difficult news without the dynamic in the room becoming inflammatory or out of control.

I will never forget watching him mediate a disagreement between a nurse and a patient suspected of using illicit substances while hospitalized. He flipped an antagonistic, heated situation into one where the patient, nurse, and physician all agreed on putting the past to rest and forging ahead with his proposed plan. We all left the room with a genuine sense that we had mutual purpose. In my admiration I realized that some of these skills must be teachable.

While I didn’t act on learning those communication techniques immediately after that encounter, I would eventually be formally exposed to them during my palliative medicine training. As it turns out, I still have some uncomfortable meetings with patients and families, but they come around much less frequently and when they do I now have a variety of tools to deal with challenges.

My appreciation of these tools doesn’t stop when I walk through the hospital doors each evening. I have found them to be invaluable in my personal life. In fact, learning to communicate better has been a source of renewal for me at work and staves off burnout. These techniques include active listening, motivational interviewing, demonstration of empathy, conflict resolution, and also negotiation. For the Society of Hospital Medicine meeting audience, I dissected negotiation, citing how it and the other skills can inject vitality into your interactions.

In any negotiation, it’s all about the other party. You are the smallest person in the room, the least important.

This is counterintuitive. Oftentimes at work we are trying to convince everyone how important we are. The readmissions committee should implement your plan to reduce recurrent hospitalizations. Your fellow hospitalists should recognize your value and make you the leader of the group. Patients show their appreciation for you making the right diagnosis and averting a medical calamity for them. But when you enter a family meeting, the patient and his or her loved ones are the center stage. To be successful you have to listen more and talk less. Get to understand the pictures in their heads and then summarize those thoughts and ideas back to them to show you’ve listened.

Make emotional payments. I don’t get into the meat of the meeting until I’ve done that with the patient and every family member in the room. No one holds family meetings for patients who are thriving and have outstanding outcomes. We have family meetings to figure out goals in the face of terrible diseases, when elder abuse is a possibility, when insurance-funded resources are depleted, and for a host of other difficult reasons.

This means that everyone in the room is suffering, sacrificing, scared, confused, or worried. Acknowledge them. Hold them up. Thank them. Reflect on similar moments in your life and demonstrate empathy. Apologize when things haven’t gone right for them at your hospital. These payments will pay handsome dividends as your relationship evolves.

Not manipulation. The term negotiation might bring up images of used car salespeople. I strongly disagree. In manipulation, one side wins and the other doesn’t. In negotiation, the goal is improved communication and understanding. Manipulation is about one side of the equation having knowledge that the other side is lacking and using that to achieve its means. Negotiators hope everyone at the table has the same knowledge.

This leads to two key principles of negotiations: transparency and genuineness. Patients and families are excellent at taking the temperature of the room when you sit down to meet with them. Share knowledge. Don’t have any hidden agendas. Following this principle builds trust.

Be incremental. Taking patients from comfortable, familiar territory into that which is uncomfortable or unfamiliar should not be done in one giant leap. Let’s use code status (CS) as an example because of the frequency with which it comes up (though I rarely talk about CS without first understanding the patient’s goals and hopes).

Some patients refuse to talk about CS, so I think incrementally. I ask that they consider talking about CS with me in the future. Very few people refuse to consider something. Two or three days later I ask, "Have you considered talking to me about CS?" That by itself opens up the topic for conversation. In the extremely unusual case where they still won’t engage, I then ask them, "What would it take for you to consider talking to me about this?" More incrementalism.

While this is not nearly an exhaustive list of negotiation techniques, we hope it is stimulating enough that you might be curious enough to learn more on your own and try incorporating this into your practice. If you’re motivated to do so, please feel free to contact us for reading suggestions: E-mail [email protected].

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

The Society of Hospital Medicine held its annual meeting recently in Las Vegas, and Stephen had the opportunity to speak on the topic of "Family Meetings: The Art and the Evidence." As a special edition of Palliatively Speaking, we thought we would highlight one aspect of this subject, with other elements forthcoming in future pieces.

As a hospitalist, I stumbled and stuttered through many family meetings until I eventually found myself on more comfortable ground. Overall, I found them rewarding when they went well but stressful and deflating when they did not. The latter sensation was enough to create some avoidant behavior on my part.

After a few years of practice, my hospitalist group began shadowing one another periodically on rounds to provide feedback to our colleagues in the hope of improving the quality of our communication skills. It was then that I noticed that one of my partners was a master at these meetings. A real Rembrandt. He had the ability to deliver bad or difficult news without the dynamic in the room becoming inflammatory or out of control.

I will never forget watching him mediate a disagreement between a nurse and a patient suspected of using illicit substances while hospitalized. He flipped an antagonistic, heated situation into one where the patient, nurse, and physician all agreed on putting the past to rest and forging ahead with his proposed plan. We all left the room with a genuine sense that we had mutual purpose. In my admiration I realized that some of these skills must be teachable.

While I didn’t act on learning those communication techniques immediately after that encounter, I would eventually be formally exposed to them during my palliative medicine training. As it turns out, I still have some uncomfortable meetings with patients and families, but they come around much less frequently and when they do I now have a variety of tools to deal with challenges.

My appreciation of these tools doesn’t stop when I walk through the hospital doors each evening. I have found them to be invaluable in my personal life. In fact, learning to communicate better has been a source of renewal for me at work and staves off burnout. These techniques include active listening, motivational interviewing, demonstration of empathy, conflict resolution, and also negotiation. For the Society of Hospital Medicine meeting audience, I dissected negotiation, citing how it and the other skills can inject vitality into your interactions.

In any negotiation, it’s all about the other party. You are the smallest person in the room, the least important.

This is counterintuitive. Oftentimes at work we are trying to convince everyone how important we are. The readmissions committee should implement your plan to reduce recurrent hospitalizations. Your fellow hospitalists should recognize your value and make you the leader of the group. Patients show their appreciation for you making the right diagnosis and averting a medical calamity for them. But when you enter a family meeting, the patient and his or her loved ones are the center stage. To be successful you have to listen more and talk less. Get to understand the pictures in their heads and then summarize those thoughts and ideas back to them to show you’ve listened.

Make emotional payments. I don’t get into the meat of the meeting until I’ve done that with the patient and every family member in the room. No one holds family meetings for patients who are thriving and have outstanding outcomes. We have family meetings to figure out goals in the face of terrible diseases, when elder abuse is a possibility, when insurance-funded resources are depleted, and for a host of other difficult reasons.

This means that everyone in the room is suffering, sacrificing, scared, confused, or worried. Acknowledge them. Hold them up. Thank them. Reflect on similar moments in your life and demonstrate empathy. Apologize when things haven’t gone right for them at your hospital. These payments will pay handsome dividends as your relationship evolves.

Not manipulation. The term negotiation might bring up images of used car salespeople. I strongly disagree. In manipulation, one side wins and the other doesn’t. In negotiation, the goal is improved communication and understanding. Manipulation is about one side of the equation having knowledge that the other side is lacking and using that to achieve its means. Negotiators hope everyone at the table has the same knowledge.

This leads to two key principles of negotiations: transparency and genuineness. Patients and families are excellent at taking the temperature of the room when you sit down to meet with them. Share knowledge. Don’t have any hidden agendas. Following this principle builds trust.

Be incremental. Taking patients from comfortable, familiar territory into that which is uncomfortable or unfamiliar should not be done in one giant leap. Let’s use code status (CS) as an example because of the frequency with which it comes up (though I rarely talk about CS without first understanding the patient’s goals and hopes).

Some patients refuse to talk about CS, so I think incrementally. I ask that they consider talking about CS with me in the future. Very few people refuse to consider something. Two or three days later I ask, "Have you considered talking to me about CS?" That by itself opens up the topic for conversation. In the extremely unusual case where they still won’t engage, I then ask them, "What would it take for you to consider talking to me about this?" More incrementalism.

While this is not nearly an exhaustive list of negotiation techniques, we hope it is stimulating enough that you might be curious enough to learn more on your own and try incorporating this into your practice. If you’re motivated to do so, please feel free to contact us for reading suggestions: E-mail [email protected].

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

Whether we agree or not with the validity of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) or the penalties of high 30-day readmissions, it would be challenging to find a hospitalist group where these measures are not popping up on the dashboard reports. We argue that advance care planning can aid in bending these metrics in a favorable direction.

Approximately 30% of Medicare dollars are spent on the 5% of beneficiaries who die each year (Health Serv. Res. 2004;39:363-75). The last month of life for those Medicare benefits account for one-third of the expenditures. A longitudinal, multi-institutional study looked at whether having a discussion about end-of-life preferences made a difference in quality or cost of care (Arch. Intern. Med. 2009;169:480-8).

Patients were asked "Have you and your doctor discussed any particular wishes you have about the care you would want to receive if you were dying?" For those who answered yes, costs were lower by over 35%, quality of care was rated higher, and people were more likely to spend their final days at home (53.8% vs. 37.8%).

Perhaps the most tested, sophisticated, and celebrated model for advance care planning is practiced throughout the Gunderson Health System in La Crosse, Wis.

In its model, certified advance care planning facilitators (most of whom are nurses) see patients in all venues, from the home to the hospital. They craft disease-specific advance directives with patients and families, the results of which are shared with the patient’s entire community including providers, family members, and others within the community.

Their results, which have been reproduced by other systems using the Gunderson methods, are quite staggering. If we consider the percentage of patients with advanced illnesses who have completed advance directives, the percentage of physicians who are aware of those advance directives, and then have consistency between the directives and which treatments are actually delivered, then we find that national data show us hitting below the 50% mark on all three of these issues (J. Am. Geriatr. Soc. 2010;58:1249-55).

Using Gunderson’s advance care planning program, these metrics all skyrocket to 95% or higher.

The Dartmouth Atlas Study data from 2007 comparing the number of days spent in the hospital and cost of care over the last 2 years of life show the Gunderson numbers are better. Patients spend less than 14 days in the hospital and their cost of care is less than $19,000 over those 2 years. For similar patient populations in other medical centers, the days spent in the hospital are 40-55 and costs exceed $60,000.

In our quest to build the better system, let’s highlight the role of advance care planning and resource it appropriately.

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Health Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

Whether we agree or not with the validity of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) or the penalties of high 30-day readmissions, it would be challenging to find a hospitalist group where these measures are not popping up on the dashboard reports. We argue that advance care planning can aid in bending these metrics in a favorable direction.

Approximately 30% of Medicare dollars are spent on the 5% of beneficiaries who die each year (Health Serv. Res. 2004;39:363-75). The last month of life for those Medicare benefits account for one-third of the expenditures. A longitudinal, multi-institutional study looked at whether having a discussion about end-of-life preferences made a difference in quality or cost of care (Arch. Intern. Med. 2009;169:480-8).

Patients were asked "Have you and your doctor discussed any particular wishes you have about the care you would want to receive if you were dying?" For those who answered yes, costs were lower by over 35%, quality of care was rated higher, and people were more likely to spend their final days at home (53.8% vs. 37.8%).

Perhaps the most tested, sophisticated, and celebrated model for advance care planning is practiced throughout the Gunderson Health System in La Crosse, Wis.

In its model, certified advance care planning facilitators (most of whom are nurses) see patients in all venues, from the home to the hospital. They craft disease-specific advance directives with patients and families, the results of which are shared with the patient’s entire community including providers, family members, and others within the community.

Their results, which have been reproduced by other systems using the Gunderson methods, are quite staggering. If we consider the percentage of patients with advanced illnesses who have completed advance directives, the percentage of physicians who are aware of those advance directives, and then have consistency between the directives and which treatments are actually delivered, then we find that national data show us hitting below the 50% mark on all three of these issues (J. Am. Geriatr. Soc. 2010;58:1249-55).

Using Gunderson’s advance care planning program, these metrics all skyrocket to 95% or higher.

The Dartmouth Atlas Study data from 2007 comparing the number of days spent in the hospital and cost of care over the last 2 years of life show the Gunderson numbers are better. Patients spend less than 14 days in the hospital and their cost of care is less than $19,000 over those 2 years. For similar patient populations in other medical centers, the days spent in the hospital are 40-55 and costs exceed $60,000.

In our quest to build the better system, let’s highlight the role of advance care planning and resource it appropriately.

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Health Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

Whether we agree or not with the validity of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) or the penalties of high 30-day readmissions, it would be challenging to find a hospitalist group where these measures are not popping up on the dashboard reports. We argue that advance care planning can aid in bending these metrics in a favorable direction.

Approximately 30% of Medicare dollars are spent on the 5% of beneficiaries who die each year (Health Serv. Res. 2004;39:363-75). The last month of life for those Medicare benefits account for one-third of the expenditures. A longitudinal, multi-institutional study looked at whether having a discussion about end-of-life preferences made a difference in quality or cost of care (Arch. Intern. Med. 2009;169:480-8).

Patients were asked "Have you and your doctor discussed any particular wishes you have about the care you would want to receive if you were dying?" For those who answered yes, costs were lower by over 35%, quality of care was rated higher, and people were more likely to spend their final days at home (53.8% vs. 37.8%).

Perhaps the most tested, sophisticated, and celebrated model for advance care planning is practiced throughout the Gunderson Health System in La Crosse, Wis.

In its model, certified advance care planning facilitators (most of whom are nurses) see patients in all venues, from the home to the hospital. They craft disease-specific advance directives with patients and families, the results of which are shared with the patient’s entire community including providers, family members, and others within the community.

Their results, which have been reproduced by other systems using the Gunderson methods, are quite staggering. If we consider the percentage of patients with advanced illnesses who have completed advance directives, the percentage of physicians who are aware of those advance directives, and then have consistency between the directives and which treatments are actually delivered, then we find that national data show us hitting below the 50% mark on all three of these issues (J. Am. Geriatr. Soc. 2010;58:1249-55).

Using Gunderson’s advance care planning program, these metrics all skyrocket to 95% or higher.

The Dartmouth Atlas Study data from 2007 comparing the number of days spent in the hospital and cost of care over the last 2 years of life show the Gunderson numbers are better. Patients spend less than 14 days in the hospital and their cost of care is less than $19,000 over those 2 years. For similar patient populations in other medical centers, the days spent in the hospital are 40-55 and costs exceed $60,000.

In our quest to build the better system, let’s highlight the role of advance care planning and resource it appropriately.

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Health Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

Whether we agree or not with the validity of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) or the penalties of high 30-day readmissions, it would be challenging to find a hospitalist group where these measures are not popping up on the dashboard reports. Can advance care planning aid in bending these metrics in a favorable direction? We would argue in the affirmative.

Approximately 30% of Medicare dollars are spent on the 5% of beneficiaries who die each year (Health Serv. Res. 2004;39:363-75). The last month of life for those Medicare benefits account for one-third of the expenditures. A longitudinal, multi-institutional study following more than 600 incurable cancer patients looked at whether having a discussion about end-of-life preferences made a difference in quality or cost of care (Arch. Intern. Med. 2009;169:480-8).

Baseline end-of-life discussions were documented with a single question: "Have you and your doctor discussed any particular wishes you have about the care you would want to receive if you were dying?" For those who answered yes, not only did costs turn out to be lower by over 35% but quality of care was rated by family members to be higher and people were more likely to spend their final days at home rather than in the hospital (53.8% vs. 37.8%).

This is particularly impressive against the backdrop, demonstrated in many studies, that, when these conversations do occur they last for only a few minutes, the patients don’t have an opportunity to adequately express themselves, caregivers are left wanting more information, and details on specific elements of choices for care are scant.

Perhaps the most tested, sophisticated, and celebrated model for advance care planning is practiced throughout the Gunderson Health System in La Crosse, Wis.

In its model, certified advance care planning facilitators (most of whom are nurses) see patients in all venues, from the home to the hospital. They craft disease-specific advance directives with patients and families, the results of which are shared with the patient’s entire community including providers, family members, and others within the community.

Their results, which have been reproduced by other systems using the Gunderson methods, are quite staggering. If we consider the percentage of patients with advanced illnesses who have completed advance directives, the percentage of physicians who are aware of those advance directives, and then have consistency between the directives and which treatments are actually delivered, then we find that national data show us hitting below the 50% mark on all three of these issues (J. Am. Geriatr. Soc. 2010;58:1249-55).

Using Gunderson’s advance care planning program, these metrics all skyrocket to 95% or higher.

Translation? When using the Dartmouth Atlas Study data from 2007 to compare the number of days spent in the hospital and cost of care over the last 2 years of life, the Gunderson numbers are far more attractive. Their patients spend less than 14 days in the hospital and their cost of care is less than $19,000 over those 2 years. For similar patient populations in other medical centers, the days spent in the hospital are 40-55 and costs exceed $60,000 during the same period of time.

In our quest to build the better system, let’s highlight the role of advance care planning and resource it appropriately.

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Health Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

Whether we agree or not with the validity of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) or the penalties of high 30-day readmissions, it would be challenging to find a hospitalist group where these measures are not popping up on the dashboard reports. Can advance care planning aid in bending these metrics in a favorable direction? We would argue in the affirmative.

Approximately 30% of Medicare dollars are spent on the 5% of beneficiaries who die each year (Health Serv. Res. 2004;39:363-75). The last month of life for those Medicare benefits account for one-third of the expenditures. A longitudinal, multi-institutional study following more than 600 incurable cancer patients looked at whether having a discussion about end-of-life preferences made a difference in quality or cost of care (Arch. Intern. Med. 2009;169:480-8).

Baseline end-of-life discussions were documented with a single question: "Have you and your doctor discussed any particular wishes you have about the care you would want to receive if you were dying?" For those who answered yes, not only did costs turn out to be lower by over 35% but quality of care was rated by family members to be higher and people were more likely to spend their final days at home rather than in the hospital (53.8% vs. 37.8%).

This is particularly impressive against the backdrop, demonstrated in many studies, that, when these conversations do occur they last for only a few minutes, the patients don’t have an opportunity to adequately express themselves, caregivers are left wanting more information, and details on specific elements of choices for care are scant.

Perhaps the most tested, sophisticated, and celebrated model for advance care planning is practiced throughout the Gunderson Health System in La Crosse, Wis.

In its model, certified advance care planning facilitators (most of whom are nurses) see patients in all venues, from the home to the hospital. They craft disease-specific advance directives with patients and families, the results of which are shared with the patient’s entire community including providers, family members, and others within the community.

Their results, which have been reproduced by other systems using the Gunderson methods, are quite staggering. If we consider the percentage of patients with advanced illnesses who have completed advance directives, the percentage of physicians who are aware of those advance directives, and then have consistency between the directives and which treatments are actually delivered, then we find that national data show us hitting below the 50% mark on all three of these issues (J. Am. Geriatr. Soc. 2010;58:1249-55).

Using Gunderson’s advance care planning program, these metrics all skyrocket to 95% or higher.

Translation? When using the Dartmouth Atlas Study data from 2007 to compare the number of days spent in the hospital and cost of care over the last 2 years of life, the Gunderson numbers are far more attractive. Their patients spend less than 14 days in the hospital and their cost of care is less than $19,000 over those 2 years. For similar patient populations in other medical centers, the days spent in the hospital are 40-55 and costs exceed $60,000 during the same period of time.

In our quest to build the better system, let’s highlight the role of advance care planning and resource it appropriately.

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Health Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

Whether we agree or not with the validity of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) or the penalties of high 30-day readmissions, it would be challenging to find a hospitalist group where these measures are not popping up on the dashboard reports. Can advance care planning aid in bending these metrics in a favorable direction? We would argue in the affirmative.

Approximately 30% of Medicare dollars are spent on the 5% of beneficiaries who die each year (Health Serv. Res. 2004;39:363-75). The last month of life for those Medicare benefits account for one-third of the expenditures. A longitudinal, multi-institutional study following more than 600 incurable cancer patients looked at whether having a discussion about end-of-life preferences made a difference in quality or cost of care (Arch. Intern. Med. 2009;169:480-8).

Baseline end-of-life discussions were documented with a single question: "Have you and your doctor discussed any particular wishes you have about the care you would want to receive if you were dying?" For those who answered yes, not only did costs turn out to be lower by over 35% but quality of care was rated by family members to be higher and people were more likely to spend their final days at home rather than in the hospital (53.8% vs. 37.8%).

This is particularly impressive against the backdrop, demonstrated in many studies, that, when these conversations do occur they last for only a few minutes, the patients don’t have an opportunity to adequately express themselves, caregivers are left wanting more information, and details on specific elements of choices for care are scant.

Perhaps the most tested, sophisticated, and celebrated model for advance care planning is practiced throughout the Gunderson Health System in La Crosse, Wis.

In its model, certified advance care planning facilitators (most of whom are nurses) see patients in all venues, from the home to the hospital. They craft disease-specific advance directives with patients and families, the results of which are shared with the patient’s entire community including providers, family members, and others within the community.

Their results, which have been reproduced by other systems using the Gunderson methods, are quite staggering. If we consider the percentage of patients with advanced illnesses who have completed advance directives, the percentage of physicians who are aware of those advance directives, and then have consistency between the directives and which treatments are actually delivered, then we find that national data show us hitting below the 50% mark on all three of these issues (J. Am. Geriatr. Soc. 2010;58:1249-55).

Using Gunderson’s advance care planning program, these metrics all skyrocket to 95% or higher.

Translation? When using the Dartmouth Atlas Study data from 2007 to compare the number of days spent in the hospital and cost of care over the last 2 years of life, the Gunderson numbers are far more attractive. Their patients spend less than 14 days in the hospital and their cost of care is less than $19,000 over those 2 years. For similar patient populations in other medical centers, the days spent in the hospital are 40-55 and costs exceed $60,000 during the same period of time.

In our quest to build the better system, let’s highlight the role of advance care planning and resource it appropriately.

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Health Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

Metastatic lung cancer: a dreaded diagnosis with high symptom burden and universally fatal outcome.

For the patient we recently cared for alongside the hospitalist and oncologist, it also comes with inevitable readmissions. On the third such hospitalization over a period of 6 months, with the advent of adult respiratory distress syndrome, acute kidney injury, and pancytopenia (thought by oncology to be a new hematologic malignancy), our patient was clearly nearing the end of life.

Yet there we stood hearing the family talk of intubation, dialysis, and even future chemotherapy while the patient required daily infusions of platelets and red cells, experienced delirium, and was unable to wean off bilevel positive airway pressure. This family did not request escalation of treatments. The seemingly endless array of options under discussion were offered to them by well-intentioned, caring physicians.

Evidence-based practice (EBP) has been a driver for much of what we do. Can we say the opposite is equally true? Does EBP govern what we do not offer patients and families, with a similar conviction and frequency? If we are to be successful in reconstructing health care delivery to provide safe, comprehensive care that leaves no one behind, then tending to what is unwanted, unnecessary, and nonbeneficial is a vital part of the strategy.

We propose using the term evidence-based restraint (EBR) as a counterpart to evidence-based practice. Evidence of the harms of overdiagnosis and overtreatment is mounting—leading to efforts such as the Choosing Wisely campaign and the Affordable Care Act’s emphasis on comparative effectiveness research. Yet when faced with a dying patient, many physicians seem compelled to offer treatments that are nonbeneficial at best, demonstrably harmful at worst. Overtreatment is remunerated in multiple ways: financial, personal satisfaction, patient and family appreciation. The harms of overtreatment are not yet widely recognized by health care professionals or laypersons, particularly when erroneously viewed as potentially curative treatment.

One piece of EBR that is likely to be challenging for all is telling patients and families "no." Health care professionals don’t want to destroy hope even when redirecting hope is a necessity. Conflict is frequently avoided, amicability in provider-patient relationships is strongly desired, and always looming is the possibility of lawsuits should disagreements lead to outcomes that do not meet family expectations. However, if we do not support one another in saying "no," then the engine of change will stall. One example of where to begin is cardiopulmonary resuscitation status. In JAMA, the authors of an opinion piece titled, "Time to Revise the Approach to Determining Cardiopulmonary Resuscitation Status," challenge us by saying that it is "not only ethical, but also imperative, that CPR not be offered" to those deemed to receive no benefit from it (2011;307:917-8). Paths to compassionately resolve patient and family wishes that are misaligned with the evidence include changes in hospital policy, ethics consultation, and a multidisciplinary approach. Additionally, physicians will need training and support for engaging in difficult conversations.

There are brave and bold voices championing EBR and garnering more attention as it surfs the rising tide of the Affordable Care Act. While only 1.5 years old, "Bending the Cost Curve in Cancer Care," a Sounding Board piece from the New England Journal of Medicine by Dr. Thomas J. Smith and Dr. Bruce E. Hillner, is already considered a seminal work (2011; 364:2060-5.)

In their discussion of bending the cost curve in cancer care, they call for restraint in oncologists’ behavior, attitude, and practice that artfully not only curtails spending, but delivers more patient-centered care. Health care systems should be looking to realign incentives to reward oncologists for seeing these adjustments put into action. Similar thought processes around cardiology, critical care, neurology, and other disciplines are currently in development.

Evidence-based restraint will not win the day easily or quickly. With limited resources and a growing population, it is imperative that we seek to provide care that is cost effective and beneficial, and available to all.

Metastatic lung cancer: a dreaded diagnosis with high symptom burden and universally fatal outcome.

For the patient we recently cared for alongside the hospitalist and oncologist, it also comes with inevitable readmissions. On the third such hospitalization over a period of 6 months, with the advent of adult respiratory distress syndrome, acute kidney injury, and pancytopenia (thought by oncology to be a new hematologic malignancy), our patient was clearly nearing the end of life.

Yet there we stood hearing the family talk of intubation, dialysis, and even future chemotherapy while the patient required daily infusions of platelets and red cells, experienced delirium, and was unable to wean off bilevel positive airway pressure. This family did not request escalation of treatments. The seemingly endless array of options under discussion were offered to them by well-intentioned, caring physicians.

Evidence-based practice (EBP) has been a driver for much of what we do. Can we say the opposite is equally true? Does EBP govern what we do not offer patients and families, with a similar conviction and frequency? If we are to be successful in reconstructing health care delivery to provide safe, comprehensive care that leaves no one behind, then tending to what is unwanted, unnecessary, and nonbeneficial is a vital part of the strategy.

We propose using the term evidence-based restraint (EBR) as a counterpart to evidence-based practice. Evidence of the harms of overdiagnosis and overtreatment is mounting—leading to efforts such as the Choosing Wisely campaign and the Affordable Care Act’s emphasis on comparative effectiveness research. Yet when faced with a dying patient, many physicians seem compelled to offer treatments that are nonbeneficial at best, demonstrably harmful at worst. Overtreatment is remunerated in multiple ways: financial, personal satisfaction, patient and family appreciation. The harms of overtreatment are not yet widely recognized by health care professionals or laypersons, particularly when erroneously viewed as potentially curative treatment.

One piece of EBR that is likely to be challenging for all is telling patients and families "no." Health care professionals don’t want to destroy hope even when redirecting hope is a necessity. Conflict is frequently avoided, amicability in provider-patient relationships is strongly desired, and always looming is the possibility of lawsuits should disagreements lead to outcomes that do not meet family expectations. However, if we do not support one another in saying "no," then the engine of change will stall. One example of where to begin is cardiopulmonary resuscitation status. In JAMA, the authors of an opinion piece titled, "Time to Revise the Approach to Determining Cardiopulmonary Resuscitation Status," challenge us by saying that it is "not only ethical, but also imperative, that CPR not be offered" to those deemed to receive no benefit from it (2011;307:917-8). Paths to compassionately resolve patient and family wishes that are misaligned with the evidence include changes in hospital policy, ethics consultation, and a multidisciplinary approach. Additionally, physicians will need training and support for engaging in difficult conversations.

There are brave and bold voices championing EBR and garnering more attention as it surfs the rising tide of the Affordable Care Act. While only 1.5 years old, "Bending the Cost Curve in Cancer Care," a Sounding Board piece from the New England Journal of Medicine by Dr. Thomas J. Smith and Dr. Bruce E. Hillner, is already considered a seminal work (2011; 364:2060-5.)

In their discussion of bending the cost curve in cancer care, they call for restraint in oncologists’ behavior, attitude, and practice that artfully not only curtails spending, but delivers more patient-centered care. Health care systems should be looking to realign incentives to reward oncologists for seeing these adjustments put into action. Similar thought processes around cardiology, critical care, neurology, and other disciplines are currently in development.

Evidence-based restraint will not win the day easily or quickly. With limited resources and a growing population, it is imperative that we seek to provide care that is cost effective and beneficial, and available to all.

Metastatic lung cancer: a dreaded diagnosis with high symptom burden and universally fatal outcome.

For the patient we recently cared for alongside the hospitalist and oncologist, it also comes with inevitable readmissions. On the third such hospitalization over a period of 6 months, with the advent of adult respiratory distress syndrome, acute kidney injury, and pancytopenia (thought by oncology to be a new hematologic malignancy), our patient was clearly nearing the end of life.

Yet there we stood hearing the family talk of intubation, dialysis, and even future chemotherapy while the patient required daily infusions of platelets and red cells, experienced delirium, and was unable to wean off bilevel positive airway pressure. This family did not request escalation of treatments. The seemingly endless array of options under discussion were offered to them by well-intentioned, caring physicians.

Evidence-based practice (EBP) has been a driver for much of what we do. Can we say the opposite is equally true? Does EBP govern what we do not offer patients and families, with a similar conviction and frequency? If we are to be successful in reconstructing health care delivery to provide safe, comprehensive care that leaves no one behind, then tending to what is unwanted, unnecessary, and nonbeneficial is a vital part of the strategy.

We propose using the term evidence-based restraint (EBR) as a counterpart to evidence-based practice. Evidence of the harms of overdiagnosis and overtreatment is mounting—leading to efforts such as the Choosing Wisely campaign and the Affordable Care Act’s emphasis on comparative effectiveness research. Yet when faced with a dying patient, many physicians seem compelled to offer treatments that are nonbeneficial at best, demonstrably harmful at worst. Overtreatment is remunerated in multiple ways: financial, personal satisfaction, patient and family appreciation. The harms of overtreatment are not yet widely recognized by health care professionals or laypersons, particularly when erroneously viewed as potentially curative treatment.

One piece of EBR that is likely to be challenging for all is telling patients and families "no." Health care professionals don’t want to destroy hope even when redirecting hope is a necessity. Conflict is frequently avoided, amicability in provider-patient relationships is strongly desired, and always looming is the possibility of lawsuits should disagreements lead to outcomes that do not meet family expectations. However, if we do not support one another in saying "no," then the engine of change will stall. One example of where to begin is cardiopulmonary resuscitation status. In JAMA, the authors of an opinion piece titled, "Time to Revise the Approach to Determining Cardiopulmonary Resuscitation Status," challenge us by saying that it is "not only ethical, but also imperative, that CPR not be offered" to those deemed to receive no benefit from it (2011;307:917-8). Paths to compassionately resolve patient and family wishes that are misaligned with the evidence include changes in hospital policy, ethics consultation, and a multidisciplinary approach. Additionally, physicians will need training and support for engaging in difficult conversations.

There are brave and bold voices championing EBR and garnering more attention as it surfs the rising tide of the Affordable Care Act. While only 1.5 years old, "Bending the Cost Curve in Cancer Care," a Sounding Board piece from the New England Journal of Medicine by Dr. Thomas J. Smith and Dr. Bruce E. Hillner, is already considered a seminal work (2011; 364:2060-5.)

In their discussion of bending the cost curve in cancer care, they call for restraint in oncologists’ behavior, attitude, and practice that artfully not only curtails spending, but delivers more patient-centered care. Health care systems should be looking to realign incentives to reward oncologists for seeing these adjustments put into action. Similar thought processes around cardiology, critical care, neurology, and other disciplines are currently in development.

Evidence-based restraint will not win the day easily or quickly. With limited resources and a growing population, it is imperative that we seek to provide care that is cost effective and beneficial, and available to all.