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Discussing resuscitation preferences with patients: Challenges and rewards

Author(s)

Susannah T. Clark, MD

Steven Z. Pantilat, MD

Mrs. G is a 58‐year‐old woman with metastatic pancreatic cancer, diagnosed 8 months prior to admission when she presented to her primary care doctor with abdominal pain and weight loss. The cancer was locally advanced and metastatic to the liver at the time of diagnosis, and she underwent first‐line palliative chemotherapy with gemcitabine without objective or symptomatic improvement. She is now admitted to the hospitalist service with intractable abdominal pain, uncontrolled on her outpatient doses of opioids. On the day after admission, her pain is well controlled on morphine via patient‐controlled anesthesia. The hospitalist decides to talk with her about her about resuscitation status. At this point, she is full code.

Dr. S sits down with her and says, There's something I need to talk with you about that I talk with all of my patients about. And that is, if your heart were to stop, and mind you, I'm not expecting this to happen anytime soon, do you want us to do everything possible to bring you back?

Dr. S pauses to catch his breath, and then Mrs. G says, Well, I guess so, if you thought you could bring me back.

He continues, We are not always successful at bringing people back, but let me explain what this would entail: we could do chest compressions, administer shocks to your heart, put a breathing tube down into the back of your throat, hook you up to a machine that helps you breathe

Mrs. G glances up with a confused look. Dr. S says, You know, Mrs. G, I've started this conversation all wrong. I'm going to step out for a few minutes, collect my thoughts, and come back to talk with you again. Is that OK? Mrs. G smiles and says, Of course.

The doctor reenters the room about 20 minutes later, pulls up a chair next to her bed, and in a relaxed tone of voice says, Tell me what you understand about your illness.

Mrs. G says, I understand that I have cancer in my pancreas and liver and that I may not last very long, perhaps months if that. My oncologist offered me more chemotherapy, but I decided against it because it didn't seem that it would offer me much. And the first chemotherapy was really hard.

Dr. S then asks, As you look ahead, what worries you most?

Mrs. G replies, I really worry that I will die in terrible pain. That scares me terribly. I also worry about my husband and how he's going to cope with my worsening condition and with my death, let alone my pain.

Dr. S then says, That sounds really frightening. Tell me more about that. She continues, Well, I really want to spend the time I have left with my husband and familymy children and grandchildrenand I want to have some good time with them. But I keep worrying that it won't be able to be that way. She starts crying. You know, I'm so scared about going home and being in terrible pain again and having my husband and family be terrified

She pauses for a moment. The doctor doesn't say anything.

She starts up again, But I don't want to end up in the hospital again.I don't want to end up on machines like my mother‐in‐law did. She looks up at Dr. S, expecting a response.

Dr. S takes her hand and says, You know, I realize this is not easy to talk about, but it's really important for me to hear about your worries so that I can know how to help. The good news is we have many good methods to control your pain and that we can help you to be comfortable and to remain at home.

Thank you. Thank you so much.

As these conversations illustrate, discussing preferences regarding resuscitation is a challenging and important task for physicians. Understanding patients' wishes at the end of life allows clinicians to provide the type of care patients want, to avoid unwanted interventions, and to promote patient autonomy and dignity. Despite the frequency with which physicians have these conversations, they typically fall short when discussing code status with patients. Clinicians fail to address patients' concerns, monopolize conversations, and commonly misunderstand patients' resuscitation preferences.13 Often these discussions do not occur at all; more than 70% of seriously ill patients have never discussed advance directives with their physician.2, 4 The multicenter SUPPORT study, which demonstrated serious problems in the care of seriously ill hospitalized patients, documented that only 47% of physicians knew when their patients preferred do‐not‐resuscitate status.5

Hospitalists frequently conduct resuscitation discussions. Patients who are admitted to the hospital are usually seriously ill, and hospitalists need to assess rapidly whether an individual patient would want a resuscitation attempt if he or she had a cardiopulmonary arrest in the hospital. They need to build trust and rapport quickly with patients they have never met. Despite this challenge, hospitalists are in a good position to discuss resuscitation preferences.6 Patients may be more willing to discuss these issues in inpatient rather than outpatient settings because their acute deterioration may encourage self‐reflection.6 Furthermore, the time and productivity pressures of office practice often make it difficult for primary care physicians, who often know the patient and family best, to address advance directives. Although studies have documented that patients are interested in talking to their primary physicians about these matters,7, 8 these conversations do not occur with regularity. Preliminary research has raised the possibility that cancer patients may actually prefer to discuss these issues in an inpatient setting with a hospital‐based provider rather than with their oncologists.9 Studies have not addressed the question of whether patients with diseases other than cancer would prefer to discuss these issues with a hospitalist or their outpatient subspecialist.

Given that more than half of all Americans die in hospitals, hospitalists care for many people who are terminally ill and will need to assess preferences for cardiopulmonary resuscitation (CPR) and other treatments. Hospitalists need to be competent and compassionate in their approach to patients and their families. In this articles we review clinician barriers to holding these conversations, offer a variety of approaches to enhance these discussions, and review communication techniques that can be used to improve understanding.

Clinician Barriers to Discussing Resuscitation

Clinicians' own barriers may lead to infrequent and inadequate conversations about resuscitation. Understanding these barriers may allow providers to overcome them and facilitate better and more frequent communication. A discussion of patient barriers is beyond the scope of this article.

Unresolved Feelings about Death and Dying

When discussing resuscitation, or code status, physicians are discussing the possibility of death with a patient. In the first scenario above, the clinician lists the many procedures that could be done if the patient's heart were to stop without using the words die or death. The clinician never explicitly acknowledges that the patient has a serious illness that could lead to her death. Medical culture is focused on cure and on warding off death until the last possible moment. Because clinicians work in this culture, many have unresolved feelings of personal failure that are triggered when treating a dying patient.10 Also, the death of a patient can lead to anxieties about the clinician's own mortality and raise uncomfortable feelings of loss, related to the patient or to memories of deaths of the clinician's loved ones. In an attempt to avoid these feelings, whether conscious or not, physicians may resist talking to patients about death.10

Fear of Taking Away Hope

Clinicians fear that patients will lose hope if they are too honest about prognosis and acknowledge the inevitability of death. This concern may be true for a small minority of patients with advanced terminal illness who are solely focused on continued treatment and in such denial that they never consider the possibility of death. Most patients, however, understand on some level that they are getting sicker and may die, but expect clinicians to initiate discussions about death and dying.8, 11 Clinicians should understand that patients can have hope about many things beyond cure of their illness. For example, they can hope for good control of their symptoms so they can spend meaningful time with family and friends, heal troubled relationships, create a legacy, and say good‐bye. As in other developmental stages throughout life, the process of dying can be a time of emotional and spiritual growth and provide an opportunity to deepen relationships and find greater meaning.12 Despite their fears, physicians are much less likely to take away hope than they think. In fact, they can carry out the important actions of helping patients to refocus on more attainable goals and helping to return hope to what may be perceived by all as a hopeless situation.13, 14

Inadequate Training

There have been many educational interventions in both outpatient and inpatient settings to encourage physicians to discuss advance directives with patients.1521 In most of these studies, clinicians were sent reminders, but did not receive training or feedback to improve their communication skills. Although these interventions have led to modest increases in the number of advance directives, little is known about the quality of the conversations between clinician and patient.

There are acknowledged deficits in undergraduate22 and graduate medical education in discussing preferences and goals of care with patients.23, 24 A national survey of medical education deans showed that two‐thirds believed insufficient time was given to palliative care education including communication skills.25 Reflecting this lack of training, medical students and residents feel unprepared to take care of dying patients.26 In one survey, hospitalists reported that although palliative care was very important to their practice, they had not received enough training in palliative care knowledge and skills.27

Traditional Ethical Frameworks

Another difficulty arises from myths about the ethical perspectives that inform medical decision making and obtaining informed consent. Although these perspectives highlight the importance of patient autonomy and the right of the individual to choose medical treatments, they do not require physicians to describe every possible treatment if, in the clinician's judgment, a particular treatment would not benefit a patient. Physicians do have an obligation to use their medical knowledge and judgment in offering treatments and discussing side effects.28 In an attempt to honor a patient's autonomy when discussing advance directivesand possibly out of fear of coercing patientsclinicians sometimes offer a menu of treatment options without exploring the patient's underlying goals for these treatments. This approach can become meaningless out of context if the patient does not understand the probability that these interventions will work or the interrelatedness of the interventions. For example, when given a list of choices regarding resuscitation, a patient may say, I would like chest compressions and a chest tube, but no shocks please. Such a statement makes little sense clinically. Instead, physicians should have meaningful conversations with their patients in which they describe treatment options in the context of patient goals and values and help patients come to decisions in a shared process.

Practical Concerns

Outpatient providers find that time constraints and the competing demands that occur in caring for patients with multiple chronic health problems make it difficult to discuss advance directives.29 Hospitalists are also subject to productivity pressures and may feel similarly stressed for time. Outpatient providers spend about 5 minutes on each of these conversations,1 and medicine residents in the inpatient setting spend about 10 minutes.30 However, many of the conversations studied were inadequate; thus, it is unknown how long it takes to have an effective conversation. Hospitalists should keep in mind that they need not have these discussions every day with each patient and that having these conversations may end up saving time in the long run if they have a clearer sense of a patient's wishes and goals.

Laying Groundwork for the Discussion

The decision regarding resuscitation should be seen in the context of the patient's goals and values and overall health status. To address code status effectively, it is imperative first to elicit the person's view of his/her illness and then gently correct any misunderstandings. A patient who thinks her/his life will go on indefinitely may feel no need to consider her/his own mortality or alternatives to full resuscitation status. Alternatively, a patient who senses his/her mortality may have already thought about resuscitation and have clear preferences. A key first step in the conversation is to understand a patient's values and goals and comprehension of his/her illness. As in the second discussion above, a clinician can begin a discussion by saying, Tell me what you understand about your illness.

Discussing prognosis with patients can be difficult as physicians struggle with uncertainty. In the most comprehensive study to date of prognostication, physicians overestimated patient survival on average by a factor of 5.31 Nonetheless, there are compelling reasons to discuss prognosis. Failure to do so often results in patients spending their last days in the hospital receiving more aggressive treatments than they might choose if they understood their prognoses.32 Further, patients are denied the opportunity to address issues of life closure, such as spending time with family, thinking about legacy, and settling financial affairs. Physicians also fear they will take away hope with prognostication and believe patients expect greater accuracy than they can provide.33

Physicians can improve their prognostication skills by considering patients' functional status and clinical signs and symptoms and by using validated scales. The Karnofsky Performance Score (KPS) and the Eastern Cooperative Oncology Group (ECOG) Performance Status have been shown to correlate with survival,3440 and the Palliative Prognostic Score (PaP) has been validated in both cancer and noncancer patients.41, 4446 The PaP uses a combination of the KPS, clinical signs and symptoms, and the clinician's clinical prediction of survival. In addition, clinicians can be honest with patients about prognostic uncertainties and give prognoses in ranges, such as days to weeks, or weeks to months.

How to Broach the Subject of Resuscitation

In the first scenario presented in this article, the hospitalist says, There's something I need to talk with you about that I talk with all of my patients about. Although many clinicians begin resuscitation discussions this way, the question is problematic because often it is untrue. Most clinicians do not discuss code status with all patients who are admitted to the hospital. A better option would be to say, When I take care of patients with advanced cancer, I like to talk with them about their wishes regarding resuscitation. Is that all right? Better yet would be to ask a general question such as As you look ahead, what worries you most? or As you look to the future, what do you hope for? These and other useful questions appear in Table 1. These questions allow patients to bring up their concerns, show that the clinician cares about them, and often segue into a discussion of patients' hopes and worries about their own death and dying process. These questions often allow patients to bring up important goals that bear directly on the issue of resuscitation. For example, in the second scenario at the beginning of the article, the patient says she wants to have quality time with her family at home and does not want life‐sustaining technologies. Such a patient may not want resuscitation. When discussing CPR, it can also be helpful to state explicitly that resuscitation is used when a patient has died, rather than to use euphemisms such as, If your heart were to stop. The clinician can ask explicitly, If you were to die, would you want? There are other strategies for introducing the subject of resuscitation if these questions do not work. If a patient seems uncomfortable with the conversation, the clinician can address this discomfort directly by saying, This conversation seems to make you uncomfortable. Other strategies for exploring these issues include inquiring if the person has ever discussed resuscitation with his/her family or another physician, or asking if anyone else in the family has been very sick. Additionally, clinicians can ask questions about surrogate decision making. If you were to get so sick that you were unable to make decisions for yourself, who would you want to make them for you? This can then lead into a discussion of whether the patient has spoken to that person about his/her preferences, and if so, what was the content of that conversation. Another useful question is, Is there any state that would be worse than death for you? This question focuses on outcomes and allows the physician to put the issue of resuscitation into perspective for a patient.

Table 1.Introducing the Subject of Resuscitation
When I take care of patients with advanced cancer [or heart disease or lung disease, etc.], I like to talk with them about their wishes for care if they were to get very sick and even die suddenly. Is that all right?
As you look ahead, what worries you most?
As you look to the future, what do you hope for?
Has a close friend or family member ever been really sick?
If you were to get so sick that you were unable to make decisions for yourself, who would you want to make them for you?
Is there any state that would be worse than death for you?

Knowing the Facts about Cardiopulmonary Resuscitation

In general, about 1 in 7 patients who have undergone CPR in the hospital survive to hospital discharge. Two literature reviews, from 1989 and 1998, of hospitalized patients who underwent CPR in the hospital reported surprisingly similar statistics. Immediate survival in both series was 41%, and survival to hospital discharge was 13%‐14%. Factors that increased survival included arrest due to coronary artery disease or drug overdose/adverse reaction, and location of arrest in the intensive care unit (ICU). Factors that decreased survival included sepsis at time of arrest, cancer, whether localized or metastatic, dementia, acute renal failure, bed‐bound status, and residence in a nursing home. Neither age nor sex was associated with survival.47, 48 In a meta‐analysis of outcome studies of CPR in metastatic cancer patients, none of 117 patients survived to hospital discharge.49

Most people get their information about CPR survival rates from the mass media, which portray CPR as a very successful procedure. For instance, on television, the sole source of information on CPR for most patients, the rate of survival to hospital discharge is 64%, much higher than the 1314% cited in the medical literature.50 Thus, it is no surprise that a patient with metastatic cancer or another life‐limiting illness would assume a positive outcome with CPR.

Knowledge of the facts about CPR survival rates is key when a physician discusses code status with a patient because these data influence patients' decisions. Patients who have a realistic understanding of their chances are less likely to prefer resuscitation.51, 52 Offering patients information about the success rate for CPR in their particular situation is critical in helping them reach a decision consistent with their values and goals. This information can be given quantitatively or qualitatively depending on the clinician assessment of what the patient would prefer.

Avoiding Stark Dichotomies in Resuscitation Discussions

In clinical practice there are 3 ways in which physicians can present resuscitation decisions as black and white and ignore the shades of gray. First, clinicians may present the choice between resuscitation and do not resuscitate (DNR) as a choice between life and death. In the first scenario above, the physician states If your heart were to stop, do you want us to do everything to bring you back? implying he would be able to save the patient's life with resuscitation attempts. When discussing resuscitation, clinicians should avoid language that suggests such a stark dichotomy. The reality is that most patients die despite resuscitation attempts. In fact, a patient is actually choosing between certain death (without resuscitation) and likely death (if resuscitation is attempted). For a patient with a serious, life‐limiting illness, it may be more effective to frame the conversation in terms of how that person envisions the end of life, and not whether death will eventually occur.

Second, clinicians and patients sometimes equate DNR with doing nothing or giving up. Clinicians fail to discuss other treatment options or alternatives, such as continuing ongoing aggressive medical treatments with DNR status or pursuing palliative care. Performing resuscitation is equated with activity and treatment, whereas withholding resuscitation is seen as passivity and giving up. To the patient, this can feel like abandonment, as if the doctor is withholding a treatment and not offering anything in its place. Examples of positive phrases that demonstrate the physician will continue to offer excellent care include: We will continue maximal medical therapy. However, if you die despite these treatments, we will let you die peacefully and won't attempt to revive you; We'll continue the intravenous antibiotics, but we won't plan to move you to the ICU if things worsen53; and We will work hard to treat your pain and other symptoms and to get you home. In addition, hospitalists must ensure, when signing out to physician colleagues, nurses, respiratory therapists, and others, that DNR orders are not overinterpreted to mean no treatment. Although a DNR order states that in the event of a cardiac arrest, no attempt at resuscitation will be made, it should have no bearing on other appropriate and desired interventions, including antibiotics, chemotherapy, and artificial nutrition; treatment for pain and other symptoms; and even monitoring in an ICU. This misunderstanding of DNR status is common among health care providers and has led many to argue that DNR orders should be part of a more comprehensive treatment plan that outlines where the patient's wishes for treatment fall on the spectrum from otherwise aggressive measures to comfort care.54, 55 Physicians who have a clear understanding of a DNR order will be able to reassure a patient that they will continue to receive desired care, but that if the patient dies, no attempt to resuscitate will be made.

Third, it is important to remind patients who choose full resuscitation status that additional decisions will need to be made if resuscitation is successful. Most patients who survive cardiopulmonary arrest end up worse off clinically and spend time in an ICU with life‐support measures in place, such as mechanical ventilation and vasopressors. Even if they survive, there will likely be a period during which they are unable to speak for themselves. This situation puts the burden of decision making on their surrogates or an appointed durable power of attorney for health care (DPOA‐HC). It is important to ask patients ahead of time whether there are conditions under which they would not want ongoing life‐sustaining measures. For example, a person might opt for discontinuation of life‐support measures if the physician and family agreed that there was only a minimal chance of cognitive recovery existed and that ongoing support was only prolonging inevitable death. To clarify the patient's wishes in this situation, you might ask, Are there conditions that would be worse than death? Encouraging the patient to share his/her wishes in this situation with a surrogate or DPOA‐HC will help to ensure those wishes are respected.

Communication Techniques

When discussing advance directives, it is important to give patients the chance to describe their life goals and their values to establish a context for understanding the role of life‐sustaining treatments. One useful method to elicit these goals and values is to ask open‐ended questions, followed by periods of silence so the patient has time to express himself/herself. In the second scenario, above, the physician used open‐ended questions in several instances: Tell me what you understand about your illness and As you look ahead, what worries you most? Tulsky and colleagues documented that medical residents spoke 76% of the time in discussions with patients about code status.30 In an ideal case, this ratio should be reversed or at least be even, allowing patients the time to explain their thoughts. Acknowledging patients' emotions by stating simply, You seem [angry/sad/perplexed], and waiting for an answer can help patients feel they are being understood. Making empathic statements is another powerful communication technique that conveys understanding.56 Examples include, That must be really sad for you, and It must be frightening to be in so much pain. As noted, silence can also be a powerful tool. Clinicians tend to be uncomfortable with silence and so fill the gaps with words. Allowing for silence enables patients to digest what they have heard, encourages them to continue speaking, and shows them the clinician wants to hear what they have to say. When giving information about any medical issues and especially about CPR, it is important to explain concepts in lay terms and to avoid medical jargon.57 Additionally, nonverbal communication techniques such as making eye contact, head nodding, and leaning in toward the patient all help in communicating engagement in the conversation. Having the conversation in a quiet and private place and sitting at the same level as the patient or family is also important. It is always a good idea to check in with patients to assess their understanding. Simply asking, Do you have any questions about what I said? or Does that all make sense? gives patients the opportunity to ask for clarification. Attempting to summarize what a patient has said can also help to clarify misunderstandings. Useful phrases include, Let me see if I've gotten this right or I want to make sure that I understood what you're telling me, followed by the clinician's synopsis of important points discussed.58 A summary of important communication techniques can be found in Table 2.

Table 2.Useful Communication Techniques
Ask open‐ended questions followed by periods of silence
Tell me what you understand about your illness.
As you look ahead, what worries you most?
Acknowledge emotion
You seem [angry/sad/perplexed].
Make empathetic statements
That must be really hard for you.
It must be terrible to be in so much pain.
Use nonverbal communication techniques such as eye contact, head nodding, leaning in toward the patient, sitting down, and sitting at patient's level
Allow for silence
Assess patient's understanding
Do you have any questions about what I said?
Does that all make sense?
Confirm your own understanding
Let me see if I've gotten this right.
I want to make sure I understand what you've been telling me.
Avoid medical jargon
Use the I wish statement
I wish there were more chemotherapy we could give you that would make a difference.
Use the Hope for the best, prepare for the worst statement
I think we should hope that the chemotherapy works but prepare for the possibility that it might not.

There are 2 additional statements that can be very useful when patients and families are struggling with the reality of severe illness and are still hoping for longer life and cure. The first is the I wish statement, in which the clinician allies himself or herself with the patient's or family's wishes by stating, I wish it were different. I wish there were more chemotherapy we could give you that would make a difference.59 Occasionally, when tension is developing because the clinician does not believe an intervention is warranted but the patient desires it nonetheless, the I wish statement can be a powerful way of realigning with the patient. For example, responding to a patient who says, I want chemo to cure my cancer, with the statement There is no chemotherapy to help you can seem antagonistic. In contrast, saying, I wish there were a treatment that would make your cancer go away aligns the clinician with the patient and supports the patient. Another advantage of I wish statements is that they are truethe clinician does wish that there was an effective treatment and would gladly provide it if available. In general, I wish statements are more effective than I'm sorry statements, because the latter can be interpreted as the clinician taking responsibility for the situation. When a provider says, I'm sorry to give you this bad news, the patient may feel the need to say, That's OK. On the other hand, saying, I'm so sorry that your mother is dying, is very human and unlikely to be interpreted as the clinician taking responsibility for the death.

A similar technique is to use the statement Hope for the best, prepare for the worst when speaking with patients and families.60 For example, a physician could say, I really wish your mother could get better, and we should still hope for that; at the same time, we need to prepare for what will happen if she doesn't get better. Once again, this phrase both allows the patient or family to continue hoping things will improve and the clinician to support this hope, while simultaneously beginning the process of planning for the more likely outcome. Over time, the patient and family often move toward accepting that the patient is dying. Finally, trying to help the patient or family maintain hope in the face of illness and death is challenging but important: If your mother can't get better, are there other things you can hope for? Helping to identify tangible and realistic goals, such as being free from pain, seeing an important family member one last time, or getting home can provide hope at a difficult time.

Giving a Recommendation

Most patients with serious illness and their families want help making complex and ethically charged decisions. When clinicians ask patients to make decisions unilaterally, patients often feel anxious, sometimes for weeks.61 Families are often paralyzed when faced with the very difficult decision of whether to withdraw life‐sustaining interventions from a family member with an advanced terminal illness. Even if they understand on an intellectual level that ceasing to provide potentially curative or life‐prolonging therapies is the best choice, they are not yet able to accept this decision on an emotional level and ultimately may feel responsible and then guilty for the patient's death. Physicians need to carry some of the burden of making these difficult decisions. One way to relieve family members of some of this guilt is to recommend a plan of care based on substituted judgment, that is, on what the patient said she or he wanted or what the family thinks the patient would have wanted.6264 In addition, clinicians should use their medical expertise, experience, and understanding of the situation to make recommendations. The patient or family can then accept or reject the physician's advice, which maintains patient autonomy, yet not have to explicitly instruct the clinician to withdraw or limit life‐sustaining interventions.

The preceding discussion and recommendations can guide scenarios like those presented at the beginning of this article. In the second conversation, the clinician had just told the patient that he could help her to achieve her goal of pain control and of returning and staying home.

Dr. S says, I want to make sure I've understood what you've said. To summarize, you've told me how important it is to you to have your pain controlled, to have some good time with your husband and family at home, and not to come back to the hospital. Is that right?

Mrs. G: Yes, that's right.

Dr. S: And how is your pain today?

Mrs. G: So much better. I'm hoping I can go home soon.

Dr. S: That should be possible. In the next day or so, we will be getting you back onto medications that you can take by mouth. But before you go home, we need to figure out how we can support you and your family at home: get you ongoing help with pain control and any other issues that come up and support for your husband and family as well.

Mrs. G: Yes, my family really needs support.

Dr. S: Have you had any experience with hospice before? I'm thinking that that would be the best way to get you the support you and your family need.

Mrs. G: Yes. When my sister died, she had home hospice. They were very good and helpful, especially to her husband, my brother‐in‐law. Yes, I would like that, as I just don't want to come back to the hospital. Hopefully, they can help my husband adjust to things.

Dr. S continues: I think they will help your husband a lot, both before and also after your death. He pauses.

Mrs. G: That's good. I worry about him so much.

Dr. S: As you know, one of the important goals of hospice care is to keep you at home so you don't have to return to the hospital. And when the time comes, to help you die peacefully at home. Mrs. G nods. What this also means is that they would not use CPR, that is, not do chest compressions, when you were actively dying.

Mrs. G: Yes, I want to be able to go home and be at peace. The last thing I would want is someone thumping on my chest as I was dying. She smiles.

Dr. S.: Do you have any other thoughts or questions?

Mrs. G: Well, yes. I'm wondering if we can set up a time to talk with my husband about all of this. I think it would be helpful for him to talk with you. Would that be possible?

Dr. S: I would be happy to talk with your husband. When is he coming in?

They negotiate a time.

Mrs. G: I want to thank you for taking the time to talk with me. I am really grateful.

CONCLUSIONS

The decision about cardiopulmonary resuscitation is part of a larger conversation with a patient about how she or he wants to spend the rest of his/her life. Importantly, the decision should be made in context, rather than in isolation. Given the understanding that develops between physician and patient in the conversation above, it is not necessary to describe all the specific treatments that occur during CPR because the physician has already established that the patient does not want to return to the hospital, and she understands that she has a terminal condition and is dying. Through exploring a patient's goals and values, a clinician can discover a patient's preferences for care generally and come up with a comprehensive plan that addresses the particular individual's medical, social, and emotional needs. For physicians, few interventions are as important or rewarding as relieving patients' suffering and helping them attain their goals during and at the end of life.

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Reilly BM,Wagner M,Magnussen CR,Ross J,Papa L,Ash J.Promoting inpatient directives about life‐sustaining treatments in a community hospital. Results of a 3‐year time‐series intervention trial.Arch Intern Med.1995;155:2317–2323.
Holloran SD,Starkey GW,Burke PA,Steele GJ,Forse RA.An educational intervention in the surgical ICU to improve ethical decisions.Surgery.1995;118(2):294–299.
Sullivan AM,Lakoma MD,Block SD.The status of medical education in end‐of‐life care. A national report.J Gen Intern Med.2003;18:685–695.
Weissman DE,Block SD.ACGME Requirements for end‐of‐life training in selected residency and fellowship programs: a status report.Acad Med.2002;77(4):299–304.
Mullan PB,Weissman DE,Ambuel B,von Gunten C.End‐of‐life care education in internal medicine residency programs: an interinstitutional study.J Palliat Med.2002;5:487–496.
Sullivan AM,Warren AG,Lakoma MD,Liaw KR,Hwang D,Block SD.End‐of‐life care in the curriculum: a national study of medical education deans.Acad Med.2004;79:760–768.
Ury WA,Berkman CS,Weber CM,Pignotti MG,Leipzig RM.Assessing medical students' training in end‐of‐life communication: a survey of interns at one urban teaching hospital.Acad Med.2003;78:530–537.
Plauth W,Pantilat S,Wachter R,Fenton C.Hospitalists' perceptions of their residency training needs: results of a national surveyAm J Med.2001;111(3):247–254.
Meisel A,Kuczewski M.Legal and ethical myths about informed consent.Arch Intern Med.1996;156:2521–2526.
Morrison RS,Morrison EW,Glickman DF.Physician reluctance to discuss advance directives: an empiric investigation of potential barriers.Arch Intern Med.1994;154:2311–2318.
Tulsky J,Chesney M,Lo B.How do medical residents discuss resuscitation with patients?J Gen Intern Med.1995;10:436–442.
Christakis NA,Lamont EB,Smith JL,Parkes CM.Extent and determinants of error in doctors' prognoses in terminally ill patients: prospective cohort study.Br Med J.2000;320:469–473.
Christakis N.Death Foretold; Prophecy and Prognosis in Medical Care.Chicago:University of Chicago Press,1999.
Christakis N,Iwashyna T.Attitude and self‐reported practice regarding prognostication in a national sample of internists.Arch Intern Med.1998;158:2389–2395.
Janisch L,Mick R,Schilsky RL, et al.Prognostic factors for survival in patients treated in phase I clinical trials.Cancer.1994;74:1965–1973.
Maltoni M,Pirovani M,Scarpi E, et al.Prediction of survival of patients terminally ill with cancer. Results of an Italian prospective multicentric studyCancer.1995;75:2613–2622.
Yates JW,Chalmer B,McKegney FP.Evaluation of patients with advanced cancer using Karnovsky performance status.Cancer.1980;45:2220–2224.
Mor V,Laliberte L,Morris JN,Wiemann M.The Karnofsky Performance Status Scale. An exam of its reliability and validity in a research setting.Cancer.1984;53:2002–2007.
Lamont EB.A demographic and prognostic approach to defining the end of life.J Palliat Med.2005;8(suppl 1):s12–s21.
den Daas N.Estimating length of survival in end‐stage cancer: a review of the literature.J Pain Symptom Manage.1995;10:548–555.
Lassauniere JM,Vinant P.Prognostic factors, survival, and advanced cancer.J Palliat Care.1992;1992(8):4.
Pirovano M,Maltoni M,Nanni O.A new palliative prognostic score: a first step for the staging of terminally ill cancer patients.J Pain Symp Management1999;17(4):231–239.
Vigano A,Dorgan M,Buckingham J.Survival prediction in terminal cancer patients: A systematic review of the medical literature.Palliat Med.2000;14:363–374.
Reuben DB,Mor V,Hiris J.Clinical symptoms and length of survival in patients with terminal cancer.Arch Intern Med.1988;148:1586–1591.
Maltoni M,Nanni O,Pirovano M.Successful validation of the palliative prognostic score in terminally ill cancer patients.J Pain Symptom Manage.1999;17:240–247.
Glare P,Eychmueller S,Virik K.The use of the palliative prognostic score in patients with diagnoses other than cancer.J Pain Symptom Manage.2003;26:883–885.
Glare PA,Eychmueller S,McMahon P.Diagnostic accuracy of the palliative prognostic score in hospitalized patients with advanced cancer.J Clin Oncol.2004;22:4823–4828.
Ebell MH,Becker LA,Barry HC,Hagen M.Survival after in‐hospital cardiopulmonary resuscitation: a meta‐analysis.J Gen Intern Med,1998;13(12):805–16.
Moss A.Informing the patient about cardiopulmonary resuscitation: when the risks outweigh the benefits.J Gen Intern Med.1989;4:349–355.
Faber‐Langendoen K.Resuscitation of patients with metastatic cancer: Is transient benefit still futile?Arch Intern Med.1991;151:235–239.
Diem SJ,Lantos JD,Tulsky JA.Cardiopulmonary resuscitation on television—miracles and misinformation.N Engl J Med.1996;334:1578–1582.
Murphy DJ,Burrows D,Santilli S, et al.The influence of the probability of survival on patients' preferences regarding cardiopulmonary resuscitation.N Engl J Med.1994;330:545–549.
Schonwetter R,Walker R,Kramer D,Robinson B.Resuscitation decision making in the elderly: the value of outcome data.J Gen Intern Med.1993;8:295–300.
von Gunten CF.Discussing do‐not‐resuscitate status.J Clin Oncol.2001;19:1576–1581.
Lipton HL.Do‐not‐resuscitate decisions in a community hospital. Incidence, implications, and outcomes.JAMA.1986;256:1164–1169.
Tolle SW,Tilden VP,Nelson CA,Dunn PM.A prospective study of the efficacy of the physician order form for life‐sustaining treatment.J Am Geriatr Soc.1998;46:1170–1171.
Lo B,Quill T,Tulsky J, for theACPAE‐o‐LCCP.Discussing palliative care with patients.Ann Intern Med.1999;130:744–749.
Back AL,Arnold RM,Baile WF,Tulsky JA,Fryer‐Edwards K.Approaching difficult communication tasks in oncology.CA Cancer J Clin.2005;55(3):164–177.
Coulehan JL,Platt FW,Egener B, et al.“Let me see if I have this right…”: words that help build empathy.Ann Intern Med.2001;135(3):221–227.
Quill TE,Arnold RM,Platt F.“I wish things were different”: expressing wishes in response to loss, futility, and unrealistic hopes.Ann Intern Med.2001;135:551–555.
Back AL,Arnold RM,Quill TE.Hope for the best, and prepare for the worst.Ann Intern Med.2003;138:439–443.
Gattellari M,Voigt KJ,Butow PN,Tattersall MHN.When the treatment goal is not cure: are cancer patients equipped to make informed decisions?J Clin Oncol.2002;20:503–513.
Winzelberg GS,Hanson LC,Tulsky JA.Beyond autonomy: Diversifying end‐of‐life decision‐making approaches to serve patients and families.J Am Geriatr Soc.2005;53:1046–1050.
Ende J,Kazis l,Ash A,Moskowitz M.Measuring patients' desire for autonomy: decision making and information‐seeking preferences among medical patients.J Gen Intern Med.1989;4(1):23–30.
Quill TE,Brody H.Physician recommendations and patient autonomy: finding a balance between physician power and patient choice.Ann Intern Med.1996;125:763–769.

Article PDF

Issue

Journal of Hospital Medicine - 1(4)

Page Number

231-240

Legacy Keywords

resuscitation discussions, hospitalists, patient autonomy, communication techniques, advanced serious illness

Read more about Discussing Resuscitation Preferences

Sections

Reviews

Author(s)

Susannah T. Clark, MD

Steven Z. Pantilat, MD

Author(s)

Susannah T. Clark, MD

Steven Z. Pantilat, MD

Article PDF

Article PDF

Dr. S pauses to catch his breath, and then Mrs. G says, Well, I guess so, if you thought you could bring me back.

The doctor reenters the room about 20 minutes later, pulls up a chair next to her bed, and in a relaxed tone of voice says, Tell me what you understand about your illness.

Dr. S then asks, As you look ahead, what worries you most?

She pauses for a moment. The doctor doesn't say anything.

She starts up again, But I don't want to end up in the hospital again.I don't want to end up on machines like my mother‐in‐law did. She looks up at Dr. S, expecting a response.

Thank you. Thank you so much.

Clinician Barriers to Discussing Resuscitation

Unresolved Feelings about Death and Dying

Fear of Taking Away Hope

Inadequate Training

Traditional Ethical Frameworks

Practical Concerns

Laying Groundwork for the Discussion

How to Broach the Subject of Resuscitation

Table 1.Introducing the Subject of Resuscitation
When I take care of patients with advanced cancer [or heart disease or lung disease, etc.], I like to talk with them about their wishes for care if they were to get very sick and even die suddenly. Is that all right?
As you look ahead, what worries you most?
As you look to the future, what do you hope for?
Has a close friend or family member ever been really sick?
If you were to get so sick that you were unable to make decisions for yourself, who would you want to make them for you?
Is there any state that would be worse than death for you?

Knowing the Facts about Cardiopulmonary Resuscitation

Avoiding Stark Dichotomies in Resuscitation Discussions

Communication Techniques

Table 2.Useful Communication Techniques
Ask open‐ended questions followed by periods of silence
Tell me what you understand about your illness.
As you look ahead, what worries you most?
Acknowledge emotion
You seem [angry/sad/perplexed].
Make empathetic statements
That must be really hard for you.
It must be terrible to be in so much pain.
Use nonverbal communication techniques such as eye contact, head nodding, leaning in toward the patient, sitting down, and sitting at patient's level
Allow for silence
Assess patient's understanding
Do you have any questions about what I said?
Does that all make sense?
Confirm your own understanding
Let me see if I've gotten this right.
I want to make sure I understand what you've been telling me.
Avoid medical jargon
Use the I wish statement
I wish there were more chemotherapy we could give you that would make a difference.
Use the Hope for the best, prepare for the worst statement
I think we should hope that the chemotherapy works but prepare for the possibility that it might not.

Giving a Recommendation

Mrs. G: Yes, that's right.

Dr. S: And how is your pain today?

Mrs. G: So much better. I'm hoping I can go home soon.

Mrs. G: Yes, my family really needs support.

Dr. S: Have you had any experience with hospice before? I'm thinking that that would be the best way to get you the support you and your family need.

Dr. S continues: I think they will help your husband a lot, both before and also after your death. He pauses.

Mrs. G: That's good. I worry about him so much.

Mrs. G: Yes, I want to be able to go home and be at peace. The last thing I would want is someone thumping on my chest as I was dying. She smiles.

Dr. S.: Do you have any other thoughts or questions?

Mrs. G: Well, yes. I'm wondering if we can set up a time to talk with my husband about all of this. I think it would be helpful for him to talk with you. Would that be possible?

Dr. S: I would be happy to talk with your husband. When is he coming in?

They negotiate a time.

Mrs. G: I want to thank you for taking the time to talk with me. I am really grateful.

CONCLUSIONS

Dr. S pauses to catch his breath, and then Mrs. G says, Well, I guess so, if you thought you could bring me back.

The doctor reenters the room about 20 minutes later, pulls up a chair next to her bed, and in a relaxed tone of voice says, Tell me what you understand about your illness.

Dr. S then asks, As you look ahead, what worries you most?

She pauses for a moment. The doctor doesn't say anything.

She starts up again, But I don't want to end up in the hospital again.I don't want to end up on machines like my mother‐in‐law did. She looks up at Dr. S, expecting a response.

Thank you. Thank you so much.

Clinician Barriers to Discussing Resuscitation

Unresolved Feelings about Death and Dying

Fear of Taking Away Hope

Inadequate Training

Traditional Ethical Frameworks

Practical Concerns

Laying Groundwork for the Discussion

How to Broach the Subject of Resuscitation

Table 1.Introducing the Subject of Resuscitation
When I take care of patients with advanced cancer [or heart disease or lung disease, etc.], I like to talk with them about their wishes for care if they were to get very sick and even die suddenly. Is that all right?
As you look ahead, what worries you most?
As you look to the future, what do you hope for?
Has a close friend or family member ever been really sick?
If you were to get so sick that you were unable to make decisions for yourself, who would you want to make them for you?
Is there any state that would be worse than death for you?

Knowing the Facts about Cardiopulmonary Resuscitation

Avoiding Stark Dichotomies in Resuscitation Discussions

Communication Techniques

Table 2.Useful Communication Techniques
Ask open‐ended questions followed by periods of silence
Tell me what you understand about your illness.
As you look ahead, what worries you most?
Acknowledge emotion
You seem [angry/sad/perplexed].
Make empathetic statements
That must be really hard for you.
It must be terrible to be in so much pain.
Use nonverbal communication techniques such as eye contact, head nodding, leaning in toward the patient, sitting down, and sitting at patient's level
Allow for silence
Assess patient's understanding
Do you have any questions about what I said?
Does that all make sense?
Confirm your own understanding
Let me see if I've gotten this right.
I want to make sure I understand what you've been telling me.
Avoid medical jargon
Use the I wish statement
I wish there were more chemotherapy we could give you that would make a difference.
Use the Hope for the best, prepare for the worst statement
I think we should hope that the chemotherapy works but prepare for the possibility that it might not.

Giving a Recommendation

Mrs. G: Yes, that's right.

Dr. S: And how is your pain today?

Mrs. G: So much better. I'm hoping I can go home soon.

Mrs. G: Yes, my family really needs support.

Dr. S: Have you had any experience with hospice before? I'm thinking that that would be the best way to get you the support you and your family need.

Dr. S continues: I think they will help your husband a lot, both before and also after your death. He pauses.

Mrs. G: That's good. I worry about him so much.

Mrs. G: Yes, I want to be able to go home and be at peace. The last thing I would want is someone thumping on my chest as I was dying. She smiles.

Dr. S.: Do you have any other thoughts or questions?

Mrs. G: Well, yes. I'm wondering if we can set up a time to talk with my husband about all of this. I think it would be helpful for him to talk with you. Would that be possible?

Dr. S: I would be happy to talk with your husband. When is he coming in?

They negotiate a time.

Mrs. G: I want to thank you for taking the time to talk with me. I am really grateful.

CONCLUSIONS

References

Tulsky JA,Fischer GS,Rose MR,Arnold RM.Opening the black box: how do physicians communicate about advance directives?Ann Intern Med.1998;129:441–449.
Wenger N,Phillips R,Teno J, et al.Physician understanding of patient resuscitation preferences: insights and clinical implications.J Am Geriatr Soc.2000;48:S44–S51.
Fischer GS,Tulsky JA,Rose MR,Siminoff LA,Arnold RM.Patient knowledge and physician predictions of treatment preferences after discussion of advance directives.J Gen Intern Med.1998;13:447–454.
Pfeifer MP,Mitchell CK,Chamberlain L.The value of disease severity in predicting patient readiness to address end‐of‐life issues.Arch Intern Med.2003;163:609–612.
A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT).The SUPPORT Principal Investigators.JAMA.1995;274:1591–1598.
Reilly BM,Magnussen CR,Ross J,Ash J,Papa L,Wagner M.Can we talk? Inpatient discussions about advance directives in a community hospital. Attending physicians' attitudes, their inpatients' wishes and reported evidence.Arch Intern Med.1994;154:2299–2308.
Emanuel LL,Barry ML,Stoeckle JD,Ettelson LM,Emanuel EJ.Advance directives for medical care—a case for greater use.N Engl J Med.1991;324:889–895.
Lo B,McLeod G,Saika G.Patient attitudes to discussing life‐sustaining treatment.Arch Intern Med.1986;146:1613–1615.
Lamont EB,Siegler M.Paradoxes in cancer patients' advance care planning.J Palliat Med.2000;3(1):27–35.
Meier DE,Back AL,Morrison RS.The inner life of physicians and care of the seriously ill.JAMA.2001;286:3007–3014.
Johnston C,Pfeifer MP,McNutt R.The discussion about advance directives; patient and physician opinions regarding when and how it should be conducted.Arch Intern Med.1995;155:1025–1030.
Block SD.Psychological considerations, growth, and transcendence at the end of life: the art of the possible.JAMA.2001;285:2898–2905.
Pantilat S.Care of dying patients: beyond symptom management.West J Med.1999;171(4):253–256.
Clayton J,Butow P,Arnold R,Tattersall M.Fostering coping and nurturing hope when discussing the future with terminally ill cancer patients and their caregivers.Cancer.2005;103:1965–1975.
Wissow LS,Belote A,Kramer W,Compton‐Phillips A,Kritzler R,Weiner JP.Promoting advance directives among elderly primary care patients.J Gen Intern Med.2004;19:944–951.
Markson L,Fanale J,Steel K,Kern D,Annas G.Implementing advance directives in the primary care setting.Arch Intern Med.1994;154:2321–2327.
Hare J,Nelson C.Will outpatients complete living wills? A comparison of two interventions.J Gen Intern Med.1991;6:41–46.
Meier DE,Gold G,Mertz K, et al.Enhancement of proxy appointments for older persons: physician counselling in ambulatory settings.J Am Geriatr Soc.1996;44(1):37–43.
Sulmasy DP,Song KY,Marx ES,Mitchell JM.Strategies to promote the use of advance directives in a residency outpatient practice.J Gen Intern Med.1996;11:657–663.
Reilly BM,Wagner M,Magnussen CR,Ross J,Papa L,Ash J.Promoting inpatient directives about life‐sustaining treatments in a community hospital. Results of a 3‐year time‐series intervention trial.Arch Intern Med.1995;155:2317–2323.
Holloran SD,Starkey GW,Burke PA,Steele GJ,Forse RA.An educational intervention in the surgical ICU to improve ethical decisions.Surgery.1995;118(2):294–299.
Sullivan AM,Lakoma MD,Block SD.The status of medical education in end‐of‐life care. A national report.J Gen Intern Med.2003;18:685–695.
Weissman DE,Block SD.ACGME Requirements for end‐of‐life training in selected residency and fellowship programs: a status report.Acad Med.2002;77(4):299–304.
Mullan PB,Weissman DE,Ambuel B,von Gunten C.End‐of‐life care education in internal medicine residency programs: an interinstitutional study.J Palliat Med.2002;5:487–496.
Sullivan AM,Warren AG,Lakoma MD,Liaw KR,Hwang D,Block SD.End‐of‐life care in the curriculum: a national study of medical education deans.Acad Med.2004;79:760–768.
Ury WA,Berkman CS,Weber CM,Pignotti MG,Leipzig RM.Assessing medical students' training in end‐of‐life communication: a survey of interns at one urban teaching hospital.Acad Med.2003;78:530–537.
Plauth W,Pantilat S,Wachter R,Fenton C.Hospitalists' perceptions of their residency training needs: results of a national surveyAm J Med.2001;111(3):247–254.
Meisel A,Kuczewski M.Legal and ethical myths about informed consent.Arch Intern Med.1996;156:2521–2526.
Morrison RS,Morrison EW,Glickman DF.Physician reluctance to discuss advance directives: an empiric investigation of potential barriers.Arch Intern Med.1994;154:2311–2318.
Tulsky J,Chesney M,Lo B.How do medical residents discuss resuscitation with patients?J Gen Intern Med.1995;10:436–442.
Christakis NA,Lamont EB,Smith JL,Parkes CM.Extent and determinants of error in doctors' prognoses in terminally ill patients: prospective cohort study.Br Med J.2000;320:469–473.
Christakis N.Death Foretold; Prophecy and Prognosis in Medical Care.Chicago:University of Chicago Press,1999.
Christakis N,Iwashyna T.Attitude and self‐reported practice regarding prognostication in a national sample of internists.Arch Intern Med.1998;158:2389–2395.
Janisch L,Mick R,Schilsky RL, et al.Prognostic factors for survival in patients treated in phase I clinical trials.Cancer.1994;74:1965–1973.
Maltoni M,Pirovani M,Scarpi E, et al.Prediction of survival of patients terminally ill with cancer. Results of an Italian prospective multicentric studyCancer.1995;75:2613–2622.
Yates JW,Chalmer B,McKegney FP.Evaluation of patients with advanced cancer using Karnovsky performance status.Cancer.1980;45:2220–2224.
Mor V,Laliberte L,Morris JN,Wiemann M.The Karnofsky Performance Status Scale. An exam of its reliability and validity in a research setting.Cancer.1984;53:2002–2007.
Lamont EB.A demographic and prognostic approach to defining the end of life.J Palliat Med.2005;8(suppl 1):s12–s21.
den Daas N.Estimating length of survival in end‐stage cancer: a review of the literature.J Pain Symptom Manage.1995;10:548–555.
Lassauniere JM,Vinant P.Prognostic factors, survival, and advanced cancer.J Palliat Care.1992;1992(8):4.
Pirovano M,Maltoni M,Nanni O.A new palliative prognostic score: a first step for the staging of terminally ill cancer patients.J Pain Symp Management1999;17(4):231–239.
Vigano A,Dorgan M,Buckingham J.Survival prediction in terminal cancer patients: A systematic review of the medical literature.Palliat Med.2000;14:363–374.
Reuben DB,Mor V,Hiris J.Clinical symptoms and length of survival in patients with terminal cancer.Arch Intern Med.1988;148:1586–1591.
Maltoni M,Nanni O,Pirovano M.Successful validation of the palliative prognostic score in terminally ill cancer patients.J Pain Symptom Manage.1999;17:240–247.
Glare P,Eychmueller S,Virik K.The use of the palliative prognostic score in patients with diagnoses other than cancer.J Pain Symptom Manage.2003;26:883–885.
Glare PA,Eychmueller S,McMahon P.Diagnostic accuracy of the palliative prognostic score in hospitalized patients with advanced cancer.J Clin Oncol.2004;22:4823–4828.
Ebell MH,Becker LA,Barry HC,Hagen M.Survival after in‐hospital cardiopulmonary resuscitation: a meta‐analysis.J Gen Intern Med,1998;13(12):805–16.
Moss A.Informing the patient about cardiopulmonary resuscitation: when the risks outweigh the benefits.J Gen Intern Med.1989;4:349–355.
Faber‐Langendoen K.Resuscitation of patients with metastatic cancer: Is transient benefit still futile?Arch Intern Med.1991;151:235–239.
Diem SJ,Lantos JD,Tulsky JA.Cardiopulmonary resuscitation on television—miracles and misinformation.N Engl J Med.1996;334:1578–1582.
Murphy DJ,Burrows D,Santilli S, et al.The influence of the probability of survival on patients' preferences regarding cardiopulmonary resuscitation.N Engl J Med.1994;330:545–549.
Schonwetter R,Walker R,Kramer D,Robinson B.Resuscitation decision making in the elderly: the value of outcome data.J Gen Intern Med.1993;8:295–300.
von Gunten CF.Discussing do‐not‐resuscitate status.J Clin Oncol.2001;19:1576–1581.
Lipton HL.Do‐not‐resuscitate decisions in a community hospital. Incidence, implications, and outcomes.JAMA.1986;256:1164–1169.
Tolle SW,Tilden VP,Nelson CA,Dunn PM.A prospective study of the efficacy of the physician order form for life‐sustaining treatment.J Am Geriatr Soc.1998;46:1170–1171.
Lo B,Quill T,Tulsky J, for theACPAE‐o‐LCCP.Discussing palliative care with patients.Ann Intern Med.1999;130:744–749.
Back AL,Arnold RM,Baile WF,Tulsky JA,Fryer‐Edwards K.Approaching difficult communication tasks in oncology.CA Cancer J Clin.2005;55(3):164–177.
Coulehan JL,Platt FW,Egener B, et al.“Let me see if I have this right…”: words that help build empathy.Ann Intern Med.2001;135(3):221–227.
Quill TE,Arnold RM,Platt F.“I wish things were different”: expressing wishes in response to loss, futility, and unrealistic hopes.Ann Intern Med.2001;135:551–555.
Back AL,Arnold RM,Quill TE.Hope for the best, and prepare for the worst.Ann Intern Med.2003;138:439–443.
Gattellari M,Voigt KJ,Butow PN,Tattersall MHN.When the treatment goal is not cure: are cancer patients equipped to make informed decisions?J Clin Oncol.2002;20:503–513.
Winzelberg GS,Hanson LC,Tulsky JA.Beyond autonomy: Diversifying end‐of‐life decision‐making approaches to serve patients and families.J Am Geriatr Soc.2005;53:1046–1050.
Ende J,Kazis l,Ash A,Moskowitz M.Measuring patients' desire for autonomy: decision making and information‐seeking preferences among medical patients.J Gen Intern Med.1989;4(1):23–30.
Quill TE,Brody H.Physician recommendations and patient autonomy: finding a balance between physician power and patient choice.Ann Intern Med.1996;125:763–769.

References

Tulsky JA,Fischer GS,Rose MR,Arnold RM.Opening the black box: how do physicians communicate about advance directives?Ann Intern Med.1998;129:441–449.
Wenger N,Phillips R,Teno J, et al.Physician understanding of patient resuscitation preferences: insights and clinical implications.J Am Geriatr Soc.2000;48:S44–S51.
Fischer GS,Tulsky JA,Rose MR,Siminoff LA,Arnold RM.Patient knowledge and physician predictions of treatment preferences after discussion of advance directives.J Gen Intern Med.1998;13:447–454.
Pfeifer MP,Mitchell CK,Chamberlain L.The value of disease severity in predicting patient readiness to address end‐of‐life issues.Arch Intern Med.2003;163:609–612.
A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT).The SUPPORT Principal Investigators.JAMA.1995;274:1591–1598.
Reilly BM,Magnussen CR,Ross J,Ash J,Papa L,Wagner M.Can we talk? Inpatient discussions about advance directives in a community hospital. Attending physicians' attitudes, their inpatients' wishes and reported evidence.Arch Intern Med.1994;154:2299–2308.
Emanuel LL,Barry ML,Stoeckle JD,Ettelson LM,Emanuel EJ.Advance directives for medical care—a case for greater use.N Engl J Med.1991;324:889–895.
Lo B,McLeod G,Saika G.Patient attitudes to discussing life‐sustaining treatment.Arch Intern Med.1986;146:1613–1615.
Lamont EB,Siegler M.Paradoxes in cancer patients' advance care planning.J Palliat Med.2000;3(1):27–35.
Meier DE,Back AL,Morrison RS.The inner life of physicians and care of the seriously ill.JAMA.2001;286:3007–3014.
Johnston C,Pfeifer MP,McNutt R.The discussion about advance directives; patient and physician opinions regarding when and how it should be conducted.Arch Intern Med.1995;155:1025–1030.
Block SD.Psychological considerations, growth, and transcendence at the end of life: the art of the possible.JAMA.2001;285:2898–2905.
Pantilat S.Care of dying patients: beyond symptom management.West J Med.1999;171(4):253–256.
Clayton J,Butow P,Arnold R,Tattersall M.Fostering coping and nurturing hope when discussing the future with terminally ill cancer patients and their caregivers.Cancer.2005;103:1965–1975.
Wissow LS,Belote A,Kramer W,Compton‐Phillips A,Kritzler R,Weiner JP.Promoting advance directives among elderly primary care patients.J Gen Intern Med.2004;19:944–951.
Markson L,Fanale J,Steel K,Kern D,Annas G.Implementing advance directives in the primary care setting.Arch Intern Med.1994;154:2321–2327.
Hare J,Nelson C.Will outpatients complete living wills? A comparison of two interventions.J Gen Intern Med.1991;6:41–46.
Meier DE,Gold G,Mertz K, et al.Enhancement of proxy appointments for older persons: physician counselling in ambulatory settings.J Am Geriatr Soc.1996;44(1):37–43.
Sulmasy DP,Song KY,Marx ES,Mitchell JM.Strategies to promote the use of advance directives in a residency outpatient practice.J Gen Intern Med.1996;11:657–663.
Reilly BM,Wagner M,Magnussen CR,Ross J,Papa L,Ash J.Promoting inpatient directives about life‐sustaining treatments in a community hospital. Results of a 3‐year time‐series intervention trial.Arch Intern Med.1995;155:2317–2323.
Holloran SD,Starkey GW,Burke PA,Steele GJ,Forse RA.An educational intervention in the surgical ICU to improve ethical decisions.Surgery.1995;118(2):294–299.
Sullivan AM,Lakoma MD,Block SD.The status of medical education in end‐of‐life care. A national report.J Gen Intern Med.2003;18:685–695.
Weissman DE,Block SD.ACGME Requirements for end‐of‐life training in selected residency and fellowship programs: a status report.Acad Med.2002;77(4):299–304.
Mullan PB,Weissman DE,Ambuel B,von Gunten C.End‐of‐life care education in internal medicine residency programs: an interinstitutional study.J Palliat Med.2002;5:487–496.
Sullivan AM,Warren AG,Lakoma MD,Liaw KR,Hwang D,Block SD.End‐of‐life care in the curriculum: a national study of medical education deans.Acad Med.2004;79:760–768.
Ury WA,Berkman CS,Weber CM,Pignotti MG,Leipzig RM.Assessing medical students' training in end‐of‐life communication: a survey of interns at one urban teaching hospital.Acad Med.2003;78:530–537.
Plauth W,Pantilat S,Wachter R,Fenton C.Hospitalists' perceptions of their residency training needs: results of a national surveyAm J Med.2001;111(3):247–254.
Meisel A,Kuczewski M.Legal and ethical myths about informed consent.Arch Intern Med.1996;156:2521–2526.
Morrison RS,Morrison EW,Glickman DF.Physician reluctance to discuss advance directives: an empiric investigation of potential barriers.Arch Intern Med.1994;154:2311–2318.
Tulsky J,Chesney M,Lo B.How do medical residents discuss resuscitation with patients?J Gen Intern Med.1995;10:436–442.
Christakis NA,Lamont EB,Smith JL,Parkes CM.Extent and determinants of error in doctors' prognoses in terminally ill patients: prospective cohort study.Br Med J.2000;320:469–473.
Christakis N.Death Foretold; Prophecy and Prognosis in Medical Care.Chicago:University of Chicago Press,1999.
Christakis N,Iwashyna T.Attitude and self‐reported practice regarding prognostication in a national sample of internists.Arch Intern Med.1998;158:2389–2395.
Janisch L,Mick R,Schilsky RL, et al.Prognostic factors for survival in patients treated in phase I clinical trials.Cancer.1994;74:1965–1973.
Maltoni M,Pirovani M,Scarpi E, et al.Prediction of survival of patients terminally ill with cancer. Results of an Italian prospective multicentric studyCancer.1995;75:2613–2622.
Yates JW,Chalmer B,McKegney FP.Evaluation of patients with advanced cancer using Karnovsky performance status.Cancer.1980;45:2220–2224.
Mor V,Laliberte L,Morris JN,Wiemann M.The Karnofsky Performance Status Scale. An exam of its reliability and validity in a research setting.Cancer.1984;53:2002–2007.
Lamont EB.A demographic and prognostic approach to defining the end of life.J Palliat Med.2005;8(suppl 1):s12–s21.
den Daas N.Estimating length of survival in end‐stage cancer: a review of the literature.J Pain Symptom Manage.1995;10:548–555.
Lassauniere JM,Vinant P.Prognostic factors, survival, and advanced cancer.J Palliat Care.1992;1992(8):4.
Pirovano M,Maltoni M,Nanni O.A new palliative prognostic score: a first step for the staging of terminally ill cancer patients.J Pain Symp Management1999;17(4):231–239.
Vigano A,Dorgan M,Buckingham J.Survival prediction in terminal cancer patients: A systematic review of the medical literature.Palliat Med.2000;14:363–374.
Reuben DB,Mor V,Hiris J.Clinical symptoms and length of survival in patients with terminal cancer.Arch Intern Med.1988;148:1586–1591.
Maltoni M,Nanni O,Pirovano M.Successful validation of the palliative prognostic score in terminally ill cancer patients.J Pain Symptom Manage.1999;17:240–247.
Glare P,Eychmueller S,Virik K.The use of the palliative prognostic score in patients with diagnoses other than cancer.J Pain Symptom Manage.2003;26:883–885.
Glare PA,Eychmueller S,McMahon P.Diagnostic accuracy of the palliative prognostic score in hospitalized patients with advanced cancer.J Clin Oncol.2004;22:4823–4828.
Ebell MH,Becker LA,Barry HC,Hagen M.Survival after in‐hospital cardiopulmonary resuscitation: a meta‐analysis.J Gen Intern Med,1998;13(12):805–16.
Moss A.Informing the patient about cardiopulmonary resuscitation: when the risks outweigh the benefits.J Gen Intern Med.1989;4:349–355.
Faber‐Langendoen K.Resuscitation of patients with metastatic cancer: Is transient benefit still futile?Arch Intern Med.1991;151:235–239.
Diem SJ,Lantos JD,Tulsky JA.Cardiopulmonary resuscitation on television—miracles and misinformation.N Engl J Med.1996;334:1578–1582.
Murphy DJ,Burrows D,Santilli S, et al.The influence of the probability of survival on patients' preferences regarding cardiopulmonary resuscitation.N Engl J Med.1994;330:545–549.
Schonwetter R,Walker R,Kramer D,Robinson B.Resuscitation decision making in the elderly: the value of outcome data.J Gen Intern Med.1993;8:295–300.
von Gunten CF.Discussing do‐not‐resuscitate status.J Clin Oncol.2001;19:1576–1581.
Lipton HL.Do‐not‐resuscitate decisions in a community hospital. Incidence, implications, and outcomes.JAMA.1986;256:1164–1169.
Tolle SW,Tilden VP,Nelson CA,Dunn PM.A prospective study of the efficacy of the physician order form for life‐sustaining treatment.J Am Geriatr Soc.1998;46:1170–1171.
Lo B,Quill T,Tulsky J, for theACPAE‐o‐LCCP.Discussing palliative care with patients.Ann Intern Med.1999;130:744–749.
Back AL,Arnold RM,Baile WF,Tulsky JA,Fryer‐Edwards K.Approaching difficult communication tasks in oncology.CA Cancer J Clin.2005;55(3):164–177.
Coulehan JL,Platt FW,Egener B, et al.“Let me see if I have this right…”: words that help build empathy.Ann Intern Med.2001;135(3):221–227.
Quill TE,Arnold RM,Platt F.“I wish things were different”: expressing wishes in response to loss, futility, and unrealistic hopes.Ann Intern Med.2001;135:551–555.
Back AL,Arnold RM,Quill TE.Hope for the best, and prepare for the worst.Ann Intern Med.2003;138:439–443.
Gattellari M,Voigt KJ,Butow PN,Tattersall MHN.When the treatment goal is not cure: are cancer patients equipped to make informed decisions?J Clin Oncol.2002;20:503–513.
Winzelberg GS,Hanson LC,Tulsky JA.Beyond autonomy: Diversifying end‐of‐life decision‐making approaches to serve patients and families.J Am Geriatr Soc.2005;53:1046–1050.
Ende J,Kazis l,Ash A,Moskowitz M.Measuring patients' desire for autonomy: decision making and information‐seeking preferences among medical patients.J Gen Intern Med.1989;4(1):23–30.
Quill TE,Brody H.Physician recommendations and patient autonomy: finding a balance between physician power and patient choice.Ann Intern Med.1996;125:763–769.

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Most people believe the term hospitalist first appeared in the literature in the August 15, 1996, issue of the New England Journal of Medicine (NEJM). That issue carried an article that Lee Goldman and I wrote titled The Emerging Role of Hospitalists in the American Health Care System.1 But the term was actually coined about a year earlier, in an article I wrote for our University of California, San Francisco (UCSF), residents' newsletter, the Medical Residents' Progress Note (MRPN), circulation about 180. In that article, I mused about a new model of care in which separate physicians assumed the role of caring for inpatients in place of patients' primary care doctors. Several peopleboth residents and facultyapproached me soon after the MRPN article was published and said, I read your articleyou should really buff it up and send it to a real journal. (By the way, when you publish a scholarly article, people generally say, I saw your article, rather than I read your article). This prompting led me to polish up the piece, with Lee Goldman's able assistance, and send it to the NEJM.

Although people often introduce me today as the guy who invented hospitalists (to which I typically respond, yeah, just like Al Gore invented the Internet), I did no such thingI merely kept my eyes and ears open, spotted the trend early, and gave it a name that stuck. In the mid‐1990s, the California market was being besieged by managed care, which was seeking new ways to cut hospital utilization and costs. In 1994, the huge Kaiser Permanente system decided to reorganize its hospital care around a cadre of hospital‐based specialists (HBSs), essentially dichotomizing the roles of inpatient and outpatient physicians. (Interestingly, Kaiser's main motivations were to improve outpatient satisfaction by assuring constant availability of primary care physicians and to create a vehicle to promote inpatient quality improvement activities, not necessarily to improve inpatient efficiency.) Around the same time, I read reports in throwaway magazines about Park Nicollet in Minneapolis and the Scripps Clinic in La Jolla, California, doing the same thing. Then one day I heard that a talented young UCSF faculty member was leaving our VA system to take a job as the inpatient manager at a local community teaching hospital. A few weeks later, I took him out to lunchI was intrigued by this new role and wanted to better understand it. As he described it to me over sandwiches, it made all the sense in the world, and the seeds of the MRPNand later NEJMarticle was planted.

I have always had an abiding interest in the notion of valuea fundamental belief that our system is inexorably becoming one in which health care choices and competition will be based on demonstrable quality, safety, the patient's experience, and cost rather than on tradition, impression, and proximity. As I began thinking about hospital care, it seemed likely this new modeldichotomizing the roles of inpatient and outpatient doctors such that the former could be constantly available and become an expert in inpatient clinical care and hospital microsystemswould provide more value than the traditional structure, both in community settings (replacing the single primary care doctor managing both inpatients and outpatients) and the academic setting (replacing the traditional one‐month‐a‐year ward attending).

At the time I was thinking all this through, a new chairman of our department of medicine arrived from Harvard. Lee Goldman, who virtually invented the field of clinical epidemiology, came to UCSF with a powerful vision that matched mineto transform training and clinical care to improve both value and education. Lee had been a resident at UCSF 20 years earlier and returned in 1995 to an inpatient service whose structure and culture had barely changed over a generation. Lee (who, to my great chagrin, recently left UCSF to become Columbia's medical school dean, and who does not have the term good enough in his vocabulary) sat down with me and articulated his vision for a new type of academic inpatient model, led by faculty who cared for inpatients and taught trainees hospital medicine for a living. This was entirely in sync with my thoughts, and so we set out to build it.

Reaction to both the New England Journal of Medicine article and our vision for an academic hospitalist service was swift and negative. One letter to the NEJM said it all:

Patients ill enough to be in the hospital are those who need their regular physicians the most. This is especially true if the patients have incurable diseases, in the context of which the usual buzzwords of efficiency and outcomes have little meaning. It is sad, but the most important part of medicine, the relationship between the doctor and the patient, is being forgotten. It is especially sad that physicians are beginning to think like MBAs.2

Our response to this and the other letters emphasized the need for evidence:

Our description of the emerging role of hospitalists is based not on an assertion that the hospitalist model is the only way to provide in‐hospital care, but rather on irrefutable evidence that both teaching and non‐teaching hospitals are adopting the model. We do not believe the debate about hospitalists is served by anecdotal claims about greater satisfaction among patients and providers. We recommend that the shape of our health care system be guided by measuring clinical outcomes, costs, and satisfaction rather than by following passion or tradition.3

My father, a retired businessman living in Florida, brought the controversy to an even finer point a year later. I met this guy playing tennis today, he told me on the phone one day. And he's heard of you! I listened for the heartwarming sounds of fatherly pride, but none were forthcoming. He hates you, he added.

Our attempts to build an academic hospitalist program generated other concerns. Many faculty enjoyed serving as ward attendings and worried about being kicked off the wards (although many privately told me that they knew their time was up and were grateful for a way to exit with dignity.) One world‐famous faculty member bolted out of his seat during the Q&A period after my medical grand rounds at his institution in 1997. How will the house staff learn anything if we don't allow them to learn from their mistakes? he huffed. (I told him that I was flying cross‐country the next day, and I'll be really pissed off if my pilot is there to learn from his mistakes.) Our residents also worried terribly about losing their autonomy, having these bright young attendings breathing down our backs. Everyone worried about where the resources to pay for the program would come from.

At UCSF, our strategy was to reassure everyone that we would be measuring the impact of the new model in terms of cost, quality, patient satisfaction, and education. By making clear that the results of this research would guide further change (and that we were willing to end the experiment if it turned out negatively), the faculty and house staff largely suspended their disbelief for the first year. That study4 would demonstrate impressive cost savings with no adverse impact on quality and patient satisfaction and a hint of improved resident satisfaction (later proven more conclusively5), allowing us to expand the program over time and to make the argument for ongoing medical center support of the new model.

Just as Lee Goldman's arrival at UCSF in 1995 was a remarkable and crucial bit of serendipity, my partnership with Dr. Win Whitcomb and Dr. John Nelson was every bit as important for the growth of the movement nationally. John, at that time a young internist in Gainesville, Florida, had been practicing as a hospitalist (though it wasn't called that) since completing his internal medicine residency in the later 1980s. He had hooked up with Win, another young internist who had left a private practice job to begin a hospital‐based practice at Mercy Medical Center in Springfield, Massachusetts. Together the two of them had begun to network with the handful of physicians around the country who were practicing in this new model. But they needed a larger megaphone, both to let other hospitalists know about each other, and to make hospitals and systems more aware of this new model of care.

John tells the story of pulling the August 15, 1996, issue of the NEJM out of his mailbox, seeing my article, and literally running into to his house to tell his wife that his practice had finally been discovered. John's thoughtful exuberance is one of the reasons for the growth of our field, and he did something that is uniquely Johncalling the author of an article that piqued his interest to discuss its contents, something he'd been doing for years. At that point, Lee Goldman was an internationally known leader in internal medicine; as chair of a major academic department, he had several layers of administrative assistants running interference when he received cold calls. I, on the other hand, ran a sleepy medical service and had little to do other than to answer calls and to respond to this new thing called e‐mail. John didn't know that; in his experience, first authors of articles in major journals were nearly always too busy to answer calls from country docs like him. So he tried Lee Goldman first but failed to get through. Win, on the other hand, decided to call me and had no problem getting through immediately. We hit it off like we'd been buddies for decades, sharing our instinctive recognition that that we were at the cutting edge of a new specialty. In what, in retrospect, seems like an extraordinary amount of hubris, we essentially divided up the world, asking the question: what does an emerging specialty need in order to be successful? I'm reminded of one of my favorite parts of the brilliant dialogue by Mel Brooks and Carl Reiner, The 2000 Year Old Man. Brooks, playing the title part, describes his relationship with Joan of Arc (What a cutie, he gushes) to Reiner (playing the interviewer), and how Joan's mission got in the way of their ardor. She used to say to me, Ive got to save France,' says the 2000 Year Old Man. I said, Look, Ive got to wash up, you save France, I'll see you later' That was usWin and John agreed to focus on building a new professional society and on networking with community‐based hospitalists, while I emphasized the academic side of things: organizing meetings, developing training programs, publishing a textbook, and launching a research agenda.

The first national gathering of hospitalists was astonishing. In the spring of 1997, I hosted what I thought would be a small hospital medicine CME meeting at a Holiday Inn in San Francisco in a seedy part of town. I expected about 50 people to attend and was shocked to see 3 times that (plus several homeless people who wandered into the sessions). Most remarkably, at the end of day 1, following 8 hours of clinical lectures, Win, John, and I asked the attendees if anybody wanted to stay a while and discuss the possibility of forming a new society. To our amazement, virtually everybody stayedmore than 100 people! Would anybody be willing to contribute some money to get this started? asked John, expecting nothing. And people began passing $20 bills up to the front of the room. That was the moment we knew we were onto something very bigthe atmosphere was electric, the enthusiasm easily palpable.

We initially called the new society the National Association of Inpatient Physicians (NAIP), as the name hospitalist was still very controversial, and many thought it would not have legsthe term inpatient physician was believed to be more inclusive. NAIP rapidly reached a crucial turning point. Our few hundred dollars in dues collections and ad revenues lived in Win's shoebox in Massachusetts (and later in a checking account opened by Ron Angus in Texas), and Win, John, and I were keeping databases of hospitalists on our computers and the backs of napkins. It was clear we needed to either create a full‐fledged infrastructure or partner with an organization that could help us. I approached Hal Sox, now the editor of the Annals of Internal Medicine but at that time president of the American College of Physicians (and an old fellowship mentor of mine), about the possibility of NAIP establishing a formal relationship with the ACP. Hal was reluctant at first, noting many ACP members were pretty strongly against the idea of hospitalists. In one of many acts of brinksmanship, I told him we would need to look for other partners if ACP did not get over its ambivalence and embrace our new field. To his credit and to the credit particularly of Dr. Walt McDonald, ACP's executive director at the time, both recognized the potential growth of this new field and worked through the internal politics to offer us an affiliation. However, we found their initial offerto become the Section on Hospital Medicine within the ACPunattractive. Wanting to be a full‐fledged independent organization that enjoyed a relationship with the College, we proposed a relationship that would link us and allow ACP to support our infrastructure, but that allowed us to retain independent decision making, governance, and budget. John, in his charming Southern drawl, described our position to an early gathering of about 100 hospitalists at a NAIP meeting in San Diego. Their offer would have them up here, and we'd be down there, he said, his hands depicting an obvious hierarchy, with us on the bottom. But we insisted on being equal partners, he said, with his hands on the same plane. I turned to Win, sitting next to me in the audience, and whispered something like, Yeah, equalexcept for the small fact that they have 120,000 members and we have 87. Nevertheless, they agreed, and our relationship has been incredibly positive for hospitalists, and I believe for the ACP as well.

The rest, as they say, is history. The society, renamed the Society of Hospital Medicine in April 2003, has thrived under the leadership of a strong series of boards, a wonderful staff, and a charismatic and highly effective CEO, Dr. Larry Wellikson. We successfully navigated the many early challenges and took advantage of key opportunities. In this regard, I consider our 3 most important decisions and actions to be: 1) creating a body of research that demonstrated, in an evidence‐based way, that the theoretical promise of the field was real6 (it was this research that led hospitals to embrace the field more vigorously and that justified the crucial support that most hospitals provide their hospitalist programs); 2) vigorously pushing back against managed care‐based hospitalist models that had begun to force primary care physicians to hand their patients off to hospitalists against their will (NAIP's first policy pronouncement was to come out strongly against such mandatory models, which seemed counterintuitive to some but which markedly decreased our vulnerability to being tagged as a cost‐cutting vehicle of managed care); and 3) linking ourselves as strongly as possible with the growing quality and safety movements. When the IOM reports on medical errors7 and later quality8 were published, we immediately saw in the new agendas a tremendous opportunity to brand hospitalists as indispensable leaders of quality and safety in hospitalsanother key rationale for hospitalists' value proposition and another reason for hospitals and policymakers to support the young field.

Looking back at the 1996 New England Journal of Medicine article, I am struck by both the number of things I got right (even a blind squirrel) and the number that I did not anticipate or got wrong. Lee and I thought that many hospitalists would be subspecialists who would focus on hospital medicine for only part of their work. This was true early on, but the field has evolved to be more of a generalist endeavor (although recently there have emerged laborists, neurology hospitalists, and even surgical hospitalists). I probably could have anticipated the growth of the field in pediatrics, but it certainly was not on my radar screen until years later.9 I did not count on the work hours of house staff being regulated; even if I had, I'm not sure I would have fully recognized how the need to create nonteaching services would turbo‐charge the growth of the hospitalist field in teaching hospitals. The one mild disappointment: I anticipated stronger evidence by now of the field's salutary impact on safety and quality. The effort to study and hopefully demonstrate such improvements should be a major focus for the next 510 years. Finally, although I thought the field would grow rapidly, I did not anticipate that a decade later there would be 15,000 hospitalists nationally or 24 in my group at UCSF. I also did not guess that an April 2006 Medline search of hospitalist would find 561 articles or that a Google search of hospitalist would yield 689,000 entries (hell, there was no Google to search in 1996!).

As I reflect back on the last decade, I am humbled by the remarkable work I have seen from hospitalists around the country and grateful for the wonderful friendships I have enjoyed with my colleagues in our new field. I am even more convinced of the fundamental accuracy of my underlying premise: the U.S. health care system will increasingly embrace models, strategies, and providers who can demonstrably improve the value of care. I have no doubt thatcollectivelyAmerican hospitalists have saved tens of thousands of lives, prevented tens of thousands of errors, orchestrated tens of thousands of good deaths, comforted tens of thousands of families, and saved billions of dollars. It is an ongoing legacy that gives me considerable pride and joy.

References

Wachter RM,Goldman L.The emerging role of “hospitalists” in the American health care system.N Engl J Med.1996;335:514–517. http://content.nejm.org/cgi/content/full/335/7/514
Nakashima WF.The role of “hospitalists” in the health care system.N Engl J Med.1996;336:444–446.
Wachter RM,Goldman L.The role of “hospitalists” in the health care system.N Engl J Med.1996;336:444–446.
Wachter RM,Katz P,Showstack J,Bindman AB,Goldman L.Reorganizing an academic medical service: Impact on cost, quality, patient satisfaction, and education.JAMA.1998;279:1560–1565.
Hauer KE,Auerbach AD,McCulloch CM,Woo G,Wachter RM.Effects of hospitalist attendings on trainee satisfaction with teaching and with internal medicine rotations.Arch Intern Med.2004;164:1866–1871.
Wachter RM.The hospitalist movement 5 years later.J Am Med Assoc2002;282:487–494.
Kohn L,Corrigan J,Donaldson M.To Err Is Human: Building a Safer Health System.Washington, DC:Committee on Quality of Health Care in America, Institute of Medicine.National Academy Press;2000.
Committee on Quality of Health Care in America, IOM.Crossing the Quality Chasm: A New Health System for the 21st Century.Washington, DC:National Academy Press;2001.
Bellet PS,Wachter RM.The hospitalist movement and its implications for the care of hospitalized children.Pediatrics.1999;103:473–77.

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Reaction to both the New England Journal of Medicine article and our vision for an academic hospitalist service was swift and negative. One letter to the NEJM said it all:

Our response to this and the other letters emphasized the need for evidence:

Reaction to both the New England Journal of Medicine article and our vision for an academic hospitalist service was swift and negative. One letter to the NEJM said it all:

Our response to this and the other letters emphasized the need for evidence:

References

Wachter RM,Goldman L.The emerging role of “hospitalists” in the American health care system.N Engl J Med.1996;335:514–517. http://content.nejm.org/cgi/content/full/335/7/514
Nakashima WF.The role of “hospitalists” in the health care system.N Engl J Med.1996;336:444–446.
Wachter RM,Goldman L.The role of “hospitalists” in the health care system.N Engl J Med.1996;336:444–446.
Wachter RM,Katz P,Showstack J,Bindman AB,Goldman L.Reorganizing an academic medical service: Impact on cost, quality, patient satisfaction, and education.JAMA.1998;279:1560–1565.
Hauer KE,Auerbach AD,McCulloch CM,Woo G,Wachter RM.Effects of hospitalist attendings on trainee satisfaction with teaching and with internal medicine rotations.Arch Intern Med.2004;164:1866–1871.
Wachter RM.The hospitalist movement 5 years later.J Am Med Assoc2002;282:487–494.
Kohn L,Corrigan J,Donaldson M.To Err Is Human: Building a Safer Health System.Washington, DC:Committee on Quality of Health Care in America, Institute of Medicine.National Academy Press;2000.
Committee on Quality of Health Care in America, IOM.Crossing the Quality Chasm: A New Health System for the 21st Century.Washington, DC:National Academy Press;2001.
Bellet PS,Wachter RM.The hospitalist movement and its implications for the care of hospitalized children.Pediatrics.1999;103:473–77.

References

Wachter RM,Goldman L.The emerging role of “hospitalists” in the American health care system.N Engl J Med.1996;335:514–517. http://content.nejm.org/cgi/content/full/335/7/514
Nakashima WF.The role of “hospitalists” in the health care system.N Engl J Med.1996;336:444–446.
Wachter RM,Goldman L.The role of “hospitalists” in the health care system.N Engl J Med.1996;336:444–446.
Wachter RM,Katz P,Showstack J,Bindman AB,Goldman L.Reorganizing an academic medical service: Impact on cost, quality, patient satisfaction, and education.JAMA.1998;279:1560–1565.
Hauer KE,Auerbach AD,McCulloch CM,Woo G,Wachter RM.Effects of hospitalist attendings on trainee satisfaction with teaching and with internal medicine rotations.Arch Intern Med.2004;164:1866–1871.
Wachter RM.The hospitalist movement 5 years later.J Am Med Assoc2002;282:487–494.
Kohn L,Corrigan J,Donaldson M.To Err Is Human: Building a Safer Health System.Washington, DC:Committee on Quality of Health Care in America, Institute of Medicine.National Academy Press;2000.
Committee on Quality of Health Care in America, IOM.Crossing the Quality Chasm: A New Health System for the 21st Century.Washington, DC:National Academy Press;2001.
Bellet PS,Wachter RM.The hospitalist movement and its implications for the care of hospitalized children.Pediatrics.1999;103:473–77.

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Self‐check‐in kiosks started to appear in airports in the late 1990s, and within a few years, they seem to have become ubiquitous in the airline industry. Today, almost 70% of business travelers use them, and other sectors of the travel industry are beginning to experiment with the technology.1 Compared to this innovation in the airline industry, adoption of computerized physician order entry (CPOE) in U.S. hospitals, first pioneered in the early 1970s,2, 3 has taken a much more leisurely pace. Despite numerous studies documenting its benefits,47 promotion by prominent national patient safety advocacy groups such as LeapFrog,8 and numerous guides on best adoption practices.912 fewer than 10% of U.S. hospitals have fully adopted this technology.13 Moreover, as Lindenauer et al.14 pointed out, most hospitals that have successfully implemented CPOE are academic medical centers that rely on house staff to enter orders. With notable exceptions,3 adoption of CPOE in community hospitals where attending physicians write most orders remains anemic.

Although an increasing number of scholarly articles has documented the reasons for this slow rate of adoption even in hospitals that have the resources to invest in this technology, much of that research is based on expert opinion and case studies.11, 1519 In this context, Lindenauer et al.14 should be commended for using empirical evidence to delineate the predictors of adoption. Lindenauer et al. found that physicians who trained in hospitals with CPOE were more likely to be frequent users of CPOE in their new environment. Although the analysis did not account for possible confounding such as employment status of the physician, this result does confirm the conventional wisdom that physicians‐in‐training are more malleable and that residency is an important opportunity to expose physicians to safety technologies. If this finding is borne out by further research, it would bode well for the adoption of CPOE, as many physicians are trained in academic institutions, which are more likely to have CPOE,20 and almost all physicians spend part of their training in a VA hospital, which has uniformly adopted CPOE. Similarly, Lindenauer et al. found that physicians who use computers for personal purposes are more likely to be frequent users of CPOE. Given the increasingly ubiquitous use of computers in all spheres of life, time is on the side of increasing acceptance of CPOE.

However, a closer examination of the data presented by Lindenauer et al. raises several concerns. First, the substantial number of infrequent users across all demographic subgroups and clinical disciplines, even among users who were exposed to CPOE during training or those who used computers regularly for personal purposes, highlights the absence of shortcuts to the universal acceptance of CPOE. Second, whereas 63% of surveyed physicians believed that CPOE would reduce the incidence of medication errors and 71% believed that CPOE would prevent aspects of care from slipping through the cracks, only 42% of the surveyed physicians were frequent users of CPOE. This implies that even when physicians believe in the safety and quality benefits of CPOE, that belief alone may not be sufficient to convince all of them to adopt this technology wholeheartedly; other factors such as speed, ease of use, and training are likely important prerequisites. Third, although 66% of orders placed in person at the 2 study hospitals were entered through CPOE, acceptance of this technology, as measured by Lindenauer et al, was moderate at both institutions. This suggests that even when organizations have reached the 70% threshold set by Leapfrog as the proportion of orders placed in CPOE that qualifies as full implementation, they may continue to face resistance to full acceptance of the technology.

Compared to their academic counterparts, community hospitals face additional hurdles as they implement CPOE. Not only does their smaller size make it difficult to achieve economies of scale, they are also at a disadvantage because of the relationship the community hospital has with its physicians. Unlike physicians‐in‐training in academic medical centers, physicians in community hospitals function as largely autonomous agents over whom the hospital administration has little control. Although these physicians and their hospitals share the common goals of patient safety and quality, the financial incentives for the adoption of CPOE are often misaligned. For example, a recent cost benefit analysis21 showed the enormous potential for hospitals to cut costs if physicians fully adopt a CPOE system with rich decision support features. However, those savings typically accrue to the hospital, not to the physicians who use the system. Assuming the typical learning curve that accompanies the use of any new technology, physicians in community hospitals may have little incentive to invest the time to learn to use the system efficiently.

So what can be done to overcome these seemingly formidable barriers to full adoption of CPOE? Emerging research, which has so far largely focused on CPOE implementation at academic hospitals, suggests there is no silver bullet. Instead, it has taught us how the complex interplay among vendor capability, organizational behavior, clinician work flow, and implementation strategy determines the success or failure of adoption.11, 17, 18, 22 Although physician characteristics will play a role in determining whether an individual adopts this technology, local factors such as the presence of champions, governance model for the project, support for staff throughout the process, and relationship between administration and physicians are likely important determinants of success at both academic and community hospitals. In addition, organizations that embark on CPOE implementation need to understand the enormity of the task at hand and must devote not only sufficient financial but also human capital over time.11, 18 In the words of a chief medical information officer, Implementing CPOE should not be thought of as an event, but a long‐term commitment.

Beyond following proposed best practices for the implementation of CPOE, community hospitals may need to adopt additional strategies to address their unique challenges. Given the misalignment of incentives for physicians' use of CPOE, leadership in community hospitals must be particularly skilled at articulating the benefits of CPOE to physicians. These benefits include not only decreased professional liability from improved patient safety and better quality of care, but also fewer pharmacy callbacks, remote access, and rapid ordering through order sets. Hospitals may also want to elicit support from physicians early by empowering them to create order sets for their disciplines. Mechanisms for hospitals and physicians to engage in mutual cost‐sharing arrangements may provide addition opportunities for hospitals to entice physicians to adopt the technology. Finally, and of particular interest to the readership of this journal, as hospitalists become more prevalent and take care of an increasing proportion of hospitalized patients,23 they are often ideal candidates to lead the implementation of CPOE in community hospitals. Because hospitalists spend most of their time in the hospital, they are often in the best position to get fully trained on CPOE, to define their own order sets, and to redesign care processes in order to take full advantage of CPOE capabilities. In addition, as many hospitalists are directly employed or supported by the hospital, their goals for quality, safety, and efficiency are usually better aligned with those of the hospital.

The stakes involved in implementing CPOE are high. Hospitals invest enormous sums of money in these systems, and many will not have the financial or political capital to attempt a second implementation after an initial failure. In addition, as recent research has pointed out,24 inappropriate implementation strategies may lead to delays in essential care and direct patient harm. In many ways, the complex task of implementing CPOE is not unlike other endeavors in patient care, where optimal outcomes require sound knowledge and reliable processes and where disaster can strike for lack of attention to detail or common sense. If Hippocrates were alive today, he might have this to say about CPOE implementation: Life is short, the art long, opportunity fleeting, experience treacherous, judgment difficult.

References

Travel self‐serve kiosks here to stay.Adelman Group. Available at: http://www.adelmantravel.com/index_news_past.asp?Date=031406. Accessed March 14,2006.
Sittig DF,Stead WW.Computer‐based physician order entry: the state of the art.J Am Med Inform Assoc.1994;1:108–123.
Barrett JP,Barnum RA,Gordon BB,Pesut RN.Final report on evaluation of the implementation of a medical information system in a general community hospital.Battelle Laboratories NTIS PB.1975;248:340.
Bates DW,Leape LL,Cullen DJ, et al.Effect of computerized physician order entry and a team intervention on prevention of serious medication errors.JAMA.1998;280:1311–1316.
Teich JM,Merchia PR,Schmiz JL,Kuperman GJ,Spurr C,Bates DW.Effects of computerized physician order entry in prescribing practices.Arch Intern Med.2000;160:2741–2747.
Dexter PR,Perkins S,Overhage JM,Maharry K,Kohler RB,McDonald CJ.A computerized reminder system to increase the use of preventive care for hospitalized patients [see comments].N Eng J M.2001;345:965–970.
Overhage JM,Tierney WM,Zhou X,McDonald CJ.A randomized trial of “corollary orders” to prevent errors of omission.J Am Med Inform Assoc.1997;4:364–75.
The Leapfrog Group for Patient Safety: Rewarding Higher Standards.2001. Available at: www.leapfroggroup.org.
Stablein D,Welebob E,Johnson E,Metzger J,Burgess R,Classen DC.Understanding hospital readiness for computerized physician order entry.Jt Comm J Qual Saf.2003;29:336–344.
Lorenzi NM,Riley RT,Blyth AJ,Southon G,Dixon BJ.Antecedents of the people and organizational aspects of medical informatics: review of the literature.J Am Med Informatics Assoc.1997;4:79–93.
Ash JS,Stavri PZ,Kuperman GJ.A consensus statement on considerations for a successful CPOE implementation.J Am Med Informatics Assoc.2003;10:229–234.
AHA Guide to Computerized Physician Order‐Entry Systems.American Hospital Association:Chicago;2000.
Ash JS,Gorman PN,Seshadri V,Hersh WR.Computerized physician order entry in US hospitals: results of a 2002 survey.J Am Med Inform Assoc.2004;11:95–99.
Lindenauer PK,Ling D,Pekow PS, et al.Physician characteristics, attitudes, and use of computerized order entry.J Hosp Med.2006;1:.
Doolan DF,Bates DW.Computerized physician order entry systems in hospitals: mandates and incentives.Health Aff,2002;21(4):180–188.
Doolan DF,Bates DW,James BC.The use of computers for clinical care: a case series of advanced U.S. sites.J Am Med Inform Assoc.2003;10:94–107.
Ash JS,Berg M,Coiera E.Some unintended consequences of information technology in health care: the nature of patient care information system‐related errors.J Am Med Inform Assoc.2003;21:104–112.
Poon EG,Blumenthal D,Jaggi T,Honour MM,Bates DW,Kaushal R.Overcoming the barriers to implementing computerized physician order entry systems in US hospitals: perspectives from senior management.Health Aff.2004;23(4):184–190.
Aarts J,Doorewaard H,Berg M.Understanding Implementation: The case of a computerized physician order entry system in a large Dutch university medical cneter.J Am Med Inform Assoc.2004;11:207–216.
Cutler DM,Feldman NE,Horwitz JR.U.S. adoption of computerized physician order entry systems.Health Aff.2005;24:1654–1663.
Kaushal R,Jha AK,Franz C, et al.Return on investment for a computerized physician order entry system.J Am Med Inform Assoc.2006;13:261–266.
Ash JS,Lyman J,Carpenter J,Fournier L.A diffusion of innovations model of physician order entry.AMIA Annu Symp Proc.2001;2001:22–26.
Kravolec PD,Miller JA,Wellikson L,Huddleston JM.The status of hospital medicine groups in the United States.J Hosp Med.2006;1:75–80.
Han YY,Carcillo JA,Venkataraman ST, et al.Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system.Pediatrics.2005;116:1506–1512.

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Travel self‐serve kiosks here to stay.Adelman Group. Available at: http://www.adelmantravel.com/index_news_past.asp?Date=031406. Accessed March 14,2006.
Sittig DF,Stead WW.Computer‐based physician order entry: the state of the art.J Am Med Inform Assoc.1994;1:108–123.
Barrett JP,Barnum RA,Gordon BB,Pesut RN.Final report on evaluation of the implementation of a medical information system in a general community hospital.Battelle Laboratories NTIS PB.1975;248:340.
Bates DW,Leape LL,Cullen DJ, et al.Effect of computerized physician order entry and a team intervention on prevention of serious medication errors.JAMA.1998;280:1311–1316.
Teich JM,Merchia PR,Schmiz JL,Kuperman GJ,Spurr C,Bates DW.Effects of computerized physician order entry in prescribing practices.Arch Intern Med.2000;160:2741–2747.
Dexter PR,Perkins S,Overhage JM,Maharry K,Kohler RB,McDonald CJ.A computerized reminder system to increase the use of preventive care for hospitalized patients [see comments].N Eng J M.2001;345:965–970.
Overhage JM,Tierney WM,Zhou X,McDonald CJ.A randomized trial of “corollary orders” to prevent errors of omission.J Am Med Inform Assoc.1997;4:364–75.
The Leapfrog Group for Patient Safety: Rewarding Higher Standards.2001. Available at: www.leapfroggroup.org.
Stablein D,Welebob E,Johnson E,Metzger J,Burgess R,Classen DC.Understanding hospital readiness for computerized physician order entry.Jt Comm J Qual Saf.2003;29:336–344.
Lorenzi NM,Riley RT,Blyth AJ,Southon G,Dixon BJ.Antecedents of the people and organizational aspects of medical informatics: review of the literature.J Am Med Informatics Assoc.1997;4:79–93.
Ash JS,Stavri PZ,Kuperman GJ.A consensus statement on considerations for a successful CPOE implementation.J Am Med Informatics Assoc.2003;10:229–234.
AHA Guide to Computerized Physician Order‐Entry Systems.American Hospital Association:Chicago;2000.
Ash JS,Gorman PN,Seshadri V,Hersh WR.Computerized physician order entry in US hospitals: results of a 2002 survey.J Am Med Inform Assoc.2004;11:95–99.
Lindenauer PK,Ling D,Pekow PS, et al.Physician characteristics, attitudes, and use of computerized order entry.J Hosp Med.2006;1:.
Doolan DF,Bates DW.Computerized physician order entry systems in hospitals: mandates and incentives.Health Aff,2002;21(4):180–188.
Doolan DF,Bates DW,James BC.The use of computers for clinical care: a case series of advanced U.S. sites.J Am Med Inform Assoc.2003;10:94–107.
Ash JS,Berg M,Coiera E.Some unintended consequences of information technology in health care: the nature of patient care information system‐related errors.J Am Med Inform Assoc.2003;21:104–112.
Poon EG,Blumenthal D,Jaggi T,Honour MM,Bates DW,Kaushal R.Overcoming the barriers to implementing computerized physician order entry systems in US hospitals: perspectives from senior management.Health Aff.2004;23(4):184–190.
Aarts J,Doorewaard H,Berg M.Understanding Implementation: The case of a computerized physician order entry system in a large Dutch university medical cneter.J Am Med Inform Assoc.2004;11:207–216.
Cutler DM,Feldman NE,Horwitz JR.U.S. adoption of computerized physician order entry systems.Health Aff.2005;24:1654–1663.
Kaushal R,Jha AK,Franz C, et al.Return on investment for a computerized physician order entry system.J Am Med Inform Assoc.2006;13:261–266.
Ash JS,Lyman J,Carpenter J,Fournier L.A diffusion of innovations model of physician order entry.AMIA Annu Symp Proc.2001;2001:22–26.
Kravolec PD,Miller JA,Wellikson L,Huddleston JM.The status of hospital medicine groups in the United States.J Hosp Med.2006;1:75–80.
Han YY,Carcillo JA,Venkataraman ST, et al.Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system.Pediatrics.2005;116:1506–1512.

References

Travel self‐serve kiosks here to stay.Adelman Group. Available at: http://www.adelmantravel.com/index_news_past.asp?Date=031406. Accessed March 14,2006.
Sittig DF,Stead WW.Computer‐based physician order entry: the state of the art.J Am Med Inform Assoc.1994;1:108–123.
Barrett JP,Barnum RA,Gordon BB,Pesut RN.Final report on evaluation of the implementation of a medical information system in a general community hospital.Battelle Laboratories NTIS PB.1975;248:340.
Bates DW,Leape LL,Cullen DJ, et al.Effect of computerized physician order entry and a team intervention on prevention of serious medication errors.JAMA.1998;280:1311–1316.
Teich JM,Merchia PR,Schmiz JL,Kuperman GJ,Spurr C,Bates DW.Effects of computerized physician order entry in prescribing practices.Arch Intern Med.2000;160:2741–2747.
Dexter PR,Perkins S,Overhage JM,Maharry K,Kohler RB,McDonald CJ.A computerized reminder system to increase the use of preventive care for hospitalized patients [see comments].N Eng J M.2001;345:965–970.
Overhage JM,Tierney WM,Zhou X,McDonald CJ.A randomized trial of “corollary orders” to prevent errors of omission.J Am Med Inform Assoc.1997;4:364–75.
The Leapfrog Group for Patient Safety: Rewarding Higher Standards.2001. Available at: www.leapfroggroup.org.
Stablein D,Welebob E,Johnson E,Metzger J,Burgess R,Classen DC.Understanding hospital readiness for computerized physician order entry.Jt Comm J Qual Saf.2003;29:336–344.
Lorenzi NM,Riley RT,Blyth AJ,Southon G,Dixon BJ.Antecedents of the people and organizational aspects of medical informatics: review of the literature.J Am Med Informatics Assoc.1997;4:79–93.
Ash JS,Stavri PZ,Kuperman GJ.A consensus statement on considerations for a successful CPOE implementation.J Am Med Informatics Assoc.2003;10:229–234.
AHA Guide to Computerized Physician Order‐Entry Systems.American Hospital Association:Chicago;2000.
Ash JS,Gorman PN,Seshadri V,Hersh WR.Computerized physician order entry in US hospitals: results of a 2002 survey.J Am Med Inform Assoc.2004;11:95–99.
Lindenauer PK,Ling D,Pekow PS, et al.Physician characteristics, attitudes, and use of computerized order entry.J Hosp Med.2006;1:.
Doolan DF,Bates DW.Computerized physician order entry systems in hospitals: mandates and incentives.Health Aff,2002;21(4):180–188.
Doolan DF,Bates DW,James BC.The use of computers for clinical care: a case series of advanced U.S. sites.J Am Med Inform Assoc.2003;10:94–107.
Ash JS,Berg M,Coiera E.Some unintended consequences of information technology in health care: the nature of patient care information system‐related errors.J Am Med Inform Assoc.2003;21:104–112.
Poon EG,Blumenthal D,Jaggi T,Honour MM,Bates DW,Kaushal R.Overcoming the barriers to implementing computerized physician order entry systems in US hospitals: perspectives from senior management.Health Aff.2004;23(4):184–190.
Aarts J,Doorewaard H,Berg M.Understanding Implementation: The case of a computerized physician order entry system in a large Dutch university medical cneter.J Am Med Inform Assoc.2004;11:207–216.
Cutler DM,Feldman NE,Horwitz JR.U.S. adoption of computerized physician order entry systems.Health Aff.2005;24:1654–1663.
Kaushal R,Jha AK,Franz C, et al.Return on investment for a computerized physician order entry system.J Am Med Inform Assoc.2006;13:261–266.
Ash JS,Lyman J,Carpenter J,Fournier L.A diffusion of innovations model of physician order entry.AMIA Annu Symp Proc.2001;2001:22–26.
Kravolec PD,Miller JA,Wellikson L,Huddleston JM.The status of hospital medicine groups in the United States.J Hosp Med.2006;1:75–80.
Han YY,Carcillo JA,Venkataraman ST, et al.Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system.Pediatrics.2005;116:1506–1512.

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This issue of the Journal of Hospital Medicine contains the inaugural article in a planned series addressing key palliative care topics relevant for the practice, teaching, and study of hospital medicine. As was noted by Diane Meier in her article Palliative Care in Hospitals1 and in Steve Pantilat's accompanying editorial, Palliative Care and Hospitalists: A Partnership for Hope,2 hospitalists are well positioned to increase access to palliative care for all hospitalized patients. Achieving this goal will require that hospitalists attain at least basic competence in the components of high‐quality, comprehensive palliative care (assessment and treatment of pain and other symptom distress, communication about goals of care, and provision of practical and psychosocial support, care coordination, continuity, and bereavement services). Palliative care is becoming more prominent in medical school and residency curricula, palliative care fellowship opportunities are proliferating, a number of palliative care resources are available on the Internet, and motivated hospital‐based providers may attain palliative care education via a variety of educational programs and faculty development courses (see Table 1 in the Meier article).1 Some hospital medicine programs have specifically targeted faculty development in palliative care competencies.4

Recognizing the salience of palliative care for the practice of hospital medicine, the Society of Hospital Medicine (SHM) created the Palliative Care Task Force specifically to raise awareness of the importance of palliative care to hospital medicine and charged it with developing relevant palliative care educational materials. The Palliative Care Task Force has selected the Journal of Hospital Medicine as a means of disseminating palliative care content through a series of peer‐reviewed articles on palliative care topics relevant to hospital medicine. The articles will address practical matters relevant to care at the bedside in addition to policy issues. The article in this issue, Discussing Resuscitation Preferences: Challenges and Rewards,3 addresses the common barriers to and provides practical advice for conducting these frequent, but often difficult, conversations. Planned topics, addressing some of the key domains of palliative care clinical practice, include: pain management, symptom control, communicating bad news, caring for the clinical care provider, and importance of a multidisciplinary team approach to end‐of‐life care. Each of these articles will specifically address the relevance and implications of these topics for the practice of hospital medicine.

The Journal of Hospital Medicine looks forward to reviewing these articles from the Palliative Care Task Force and invites additional submissions relevant to the practice, teaching, or study of palliative care in the hospital setting.

References

Meier DE.Palliative care in hospitals.J Hosp Med.2006;1:21–28.
Pantilat SZ.Palliative care and hospitalists: a partnership for hope.J Hosp Med.2006;1:5–6.
Chittenden E,Clark S,Pantilat S.Discussing resuscitation preferences: challenges and rewards.J Hosp Med.2006;1:231–240.
Glasheen JJ,Youngwerth J,Johnson D.The effect of an intensive palliative care‐focused retreat on hospitalist faculty and resident palliative care knowledge and comfort/confidence.J Hosp Med.2006;1;S2:S9.

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Meier DE.Palliative care in hospitals.J Hosp Med.2006;1:21–28.
Pantilat SZ.Palliative care and hospitalists: a partnership for hope.J Hosp Med.2006;1:5–6.
Chittenden E,Clark S,Pantilat S.Discussing resuscitation preferences: challenges and rewards.J Hosp Med.2006;1:231–240.
Glasheen JJ,Youngwerth J,Johnson D.The effect of an intensive palliative care‐focused retreat on hospitalist faculty and resident palliative care knowledge and comfort/confidence.J Hosp Med.2006;1;S2:S9.

References

Meier DE.Palliative care in hospitals.J Hosp Med.2006;1:21–28.
Pantilat SZ.Palliative care and hospitalists: a partnership for hope.J Hosp Med.2006;1:5–6.
Chittenden E,Clark S,Pantilat S.Discussing resuscitation preferences: challenges and rewards.J Hosp Med.2006;1:231–240.
Glasheen JJ,Youngwerth J,Johnson D.The effect of an intensive palliative care‐focused retreat on hospitalist faculty and resident palliative care knowledge and comfort/confidence.J Hosp Med.2006;1;S2:S9.

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Who was Eddie and why would anyone want a piece of him? That was the question that troubled me for decades. “Bum bum baba bum bum bum bum … I want a piece of Eddie.” Every time I heard that song by The Ramones, it drove me to distraction. I couldn’t stand the band. It wasn’t their Proto-Punk cacophonic guitar jams or their dysfunctional family antics—it was Eddie. Why did they want a piece of him? It was a mystery I couldn’t solve.

Then last year I was listening to a radio piece on The Ramones when they mentioned that song. It turns out that the lyrics are actually, “I want to be sedated.” I want to be sedated? Not a piece of Eddie? How odd, and then how hilarious. Suddenly I was singing the song in my head. What a relief: There was no Eddie. It would be the prefect theme song for an anesthesiologist. I wanted to be sedated!

There is no specific term for medical malapropisms. Perhaps they should be called roaches, after the infamous “roaches in the liver” (cirrhosis).

Terms that sound alike are called homonyms; whole phrases are called oronyms. Some examples are stuffy nose and stuff he knows; pullet surprise and Pulitzer Prize; and delicate and delegate. There is an oronym poem that has circulated the Internet that goes, “Eye halve a spelling chequer, it came with my pea sea … ”

What Eddie and I had experienced was a mondegreen. This term was coined by Sylvia Wright in an article published in 1954 in Harper’s Magazine. It comes from a 17th-century ballad. Its line sounds like “And Lady Mondegreen,” but in fact it is “and laid him on the green.” The term refers specifically to song lyrics that are misunderstood. Here are some of my favorite examples; the mondegreen is followed by the actual lyric;

“There’s a bathroom on the right”/”There’s a bad moon on the rise” by Credence Clearwater Revival

“ ’Scuse me while I kiss this guy”/“ ’Scuse my while I kiss the sky” by Jimi Hendrix

“The girl with colitis goes by”/“The girl with kaleidoscope eyes” by The Beatles

“I’ll never leave your pizza burnin’ ”/“I’ll never be your beast of burden” by The Rolling Stones

“Oh, Louisa Brown”/“All the leaves are brown” by The Mamas and the Papas

“No ducks of Haslem in the classroom”/“No dark sarcasm in the classroom” by Pink Floyd

“Bring me an iron lung”/“Bring me a higher love” by Steve Winwood

“Midnight after you’re wasted”/“Midnight at the oasis” by Maria Muldaur

You get the idea.

The Ramones at their Rock and Roll Hall of Fame induction: Did they want a piece of Eddie? Or did they prefer sedation?

It is not always songs that get “misunderheard.” The complex lingo of medicine is also difficult for the neophyte or—worse—the patient to comprehend. When I started medical school, the most practical advice given to me was from my friend Jon’s father, who worked in the related profession of alcohol distribution. He told me to learn the buzzwords. I took his advice to cardia.

So there I was on rounds, a third-year medical student. A patient had an Na of 116. I wisely stroked my beard, and said that we should watch out for central pontoon myelinolysis. I guess they weren’t listening too carefully to what I had exactly said. For the next 14 years, I uttered dire warnings about central pontoon myelinolysis, until a first-year medical student corrected me. Oh, pontine, the pons—now that makes more sense!

I had made a malapropism, which comes from the character Mrs. Malaprop in an 18th-century play. (The name came from mal a propros, or French for “inappropriate”).

There is no specific term for medical malapropisms, or mondegreens. However, I call them roaches, after the famous “roaches in the liver” (cirrhosis). We have all seen these lists of roaches, whether generated by patients or bad dictation skills. Some examples are:

The patient was treated for Paris Fevers (paresthesias);

It was a non-respectable (unresectable) tumor;

A debunking (debulking) procedure was performed;

Nerve testing was done using a pink prick (pinprick) test;

I had smiling mighty Jesus (spinal meningitis);

She used an IOU (IUD) and still got pregnant;

He has very close veins (varicose);

She had postmortem (post partum) depression;

Heart populations and high pretension (palpitations and hypertension);

A case of headlights (head lice);

Sick as hell anemia (sickle cell anemia); and

The blood vessels were ecstatic (ectatic).

These roaches are generally amusing. They are certainly not anything a hospitalist would ever say or hear, though. Our patients are well informed, and our communications skills are flawless. We all know the medical malpractice risk of poor communication, and all of our patients are medically savvy and sesquepedalinistically erudite (whatever that means).

The next time you tell a patient they have a PE, remember they may be wondering what their medical condition has to do with monkey (an APE) and why you need to spell it out, or how their dyspnea is related to a high-school gym class (PE). You will have to excuse me now, I’ve got another hyponatremic patient and have to go hypertonic sailing. TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

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There is no specific term for medical malapropisms. Perhaps they should be called roaches, after the infamous “roaches in the liver” (cirrhosis).

“There’s a bathroom on the right”/”There’s a bad moon on the rise” by Credence Clearwater Revival

“ ’Scuse me while I kiss this guy”/“ ’Scuse my while I kiss the sky” by Jimi Hendrix

“The girl with colitis goes by”/“The girl with kaleidoscope eyes” by The Beatles

“I’ll never leave your pizza burnin’ ”/“I’ll never be your beast of burden” by The Rolling Stones

“Oh, Louisa Brown”/“All the leaves are brown” by The Mamas and the Papas

“No ducks of Haslem in the classroom”/“No dark sarcasm in the classroom” by Pink Floyd

“Bring me an iron lung”/“Bring me a higher love” by Steve Winwood

“Midnight after you’re wasted”/“Midnight at the oasis” by Maria Muldaur

You get the idea.

The Ramones at their Rock and Roll Hall of Fame induction: Did they want a piece of Eddie? Or did they prefer sedation?

I had made a malapropism, which comes from the character Mrs. Malaprop in an 18th-century play. (The name came from mal a propros, or French for “inappropriate”).

The patient was treated for Paris Fevers (paresthesias);

It was a non-respectable (unresectable) tumor;

A debunking (debulking) procedure was performed;

Nerve testing was done using a pink prick (pinprick) test;

I had smiling mighty Jesus (spinal meningitis);

She used an IOU (IUD) and still got pregnant;

He has very close veins (varicose);

She had postmortem (post partum) depression;

Heart populations and high pretension (palpitations and hypertension);

A case of headlights (head lice);

Sick as hell anemia (sickle cell anemia); and

The blood vessels were ecstatic (ectatic).

There is no specific term for medical malapropisms. Perhaps they should be called roaches, after the infamous “roaches in the liver” (cirrhosis).

“There’s a bathroom on the right”/”There’s a bad moon on the rise” by Credence Clearwater Revival

“ ’Scuse me while I kiss this guy”/“ ’Scuse my while I kiss the sky” by Jimi Hendrix

“The girl with colitis goes by”/“The girl with kaleidoscope eyes” by The Beatles

“I’ll never leave your pizza burnin’ ”/“I’ll never be your beast of burden” by The Rolling Stones

“Oh, Louisa Brown”/“All the leaves are brown” by The Mamas and the Papas

“No ducks of Haslem in the classroom”/“No dark sarcasm in the classroom” by Pink Floyd

“Bring me an iron lung”/“Bring me a higher love” by Steve Winwood

“Midnight after you’re wasted”/“Midnight at the oasis” by Maria Muldaur

You get the idea.

The Ramones at their Rock and Roll Hall of Fame induction: Did they want a piece of Eddie? Or did they prefer sedation?

I had made a malapropism, which comes from the character Mrs. Malaprop in an 18th-century play. (The name came from mal a propros, or French for “inappropriate”).

The patient was treated for Paris Fevers (paresthesias);

It was a non-respectable (unresectable) tumor;

A debunking (debulking) procedure was performed;

Nerve testing was done using a pink prick (pinprick) test;

I had smiling mighty Jesus (spinal meningitis);

She used an IOU (IUD) and still got pregnant;

He has very close veins (varicose);

She had postmortem (post partum) depression;

Heart populations and high pretension (palpitations and hypertension);

A case of headlights (head lice);

Sick as hell anemia (sickle cell anemia); and

The blood vessels were ecstatic (ectatic).

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The Obesity Problem in U.S. Hospitals

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The Obesity Problem in U.S. Hospitals

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Sheri Polley

The United States is growing. That is, its individual inhabitants are getting bigger. Depending on the source, anywhere from 30% to 50% of the American population is now obese.1-3 By all accounts, the percentage of obese adults in our country has risen considerably over the past two decades and continues to rise.

When asked about challenges in treating the obese patient, many medical professionals will expound on bariatric treatments and surgeries—programs designed to help patients lose weight. Addressed far less frequently are the challenges faced by physicians—specifically hospitalists—in treating the obese patient for a routine or emergency medical problem or traumatic injury.

Complicating Factors

Obesity is a contributing factor to a myriad of medical problems. The American Heart Association lists obesity as one of several modifiable independent risk factors for cardiovascular disease.4 Overweight individuals are also at higher risk for a long list of other diseases, including high blood pressure, high cholesterol, type 2 diabetes, stroke, gallbladder disease, arthritis, sleep disturbances and problems breathing, and certain types of cancers.5 There is also growing evidence that obesity may be a risk factor for asthma.6

Obese patients may delay seeking medical care for a number of reasons, including self-consciousness about their weight, fear of negative comments from physicians and staff, or past negative experiences with hospitals or staff.2 When patients delay seeking appropriate preventive care, they are more likely to end up in the emergency department or be admitted to the hospital and, consequently, under the care of a hospitalist.

The Transport Conundrum

Furniture, equipment, medical supplies, and everything else commonly used in the hospital are designed to accommodate the average-size adult. In fact, for many morbidly obese patients, the difficulty begins immediately upon arrival at (or even before reaching) the hospital.

When a patient suffers an acute illness or traumatic injury, the logical reaction in many cases is to call an ambulance for transport to the hospital. For a large person, this can create the first dilemma in receiving care. Many ambulance companies now have stretchers with weight ratings of up to 700 pounds. However, moving a stretcher loaded with several hundred pounds of patient can be quite a challenge for ambulance personnel—even with extra crew members available.

If the patient is not ambulatory, the crew must find a way to place the patient onto the stretcher and then to move the stretcher into their ambulance. They can face the difficulty of not only lifting and moving such a heavy load, but also moving through doorways, down stairs, and across uneven surfaces. Simply dealing with the logistics of moving the patient safely can be time-consuming and can cause a delay in administering emergency care to the patient.

Upon arrival at the hospital, the same dilemmas will arise in transferring the patient from the ambulance stretcher to a hospital bed. Many devices designed to aid in lifting and moving patients are not rated for use with the morbidly obese patient. There must be sufficient staff on hand to facilitate transfer of the patient, and the staff must be well educated in lifting and moving techniques safe for staff and patient.

The issues regarding the lifting and moving of obese patients present significant safety implications for hospital employees. Michael Allswede, DO, residency program director for Emergency Medicine Residency at Conemaugh Health Systems in Johnstown, Pa., says that this particular issue is compounded by the fact that many hospital employees are overweight themselves. “You basically have obese people trying to lift obese people,” he says.

In a Novation survey of VHA member hospitals released in December 2004, 28% of respondents reported an increase in workplace injuries—primarily back injuries—related to lifting obese patients.7 The National Council of Compensation estimates the average cost per healthcare worker injury to be $8,400.8 This increase in worker’s compensation claims clearly has a significant financial impact on hospitals.

Basic vital signs can be difficult to obtain. With several layers of fat between the arteries and skin surface, pulses can be difficult, if not impossible, to palpate. Blood pressure cuffs must be large enough to avoid obtaining false readings.

Diagnosis Made Difficult

Once the patient is situated, the medical staff faces the challenge of how to best assess the patient as accurately as possible. Basic vital signs can be difficult to obtain. With several layers of fat between the arteries and skin surface, pulses can be difficult—if not impossible—to palpate. Blood pressure cuffs must be large enough to avoid obtaining false readings. It can be difficult to auscultate lung sounds and cardiac rhythms; it may also be impossible to assess the abdomen by typical hands-on examination techniques. Even visualizing the entire skin surface can be difficult and time-consuming.

Obtaining diagnostic studies presents yet another challenge: Needles used for drawing blood may not be long enough to reach a vein through the layers of fat. CT and MRI images may not be possible if the gantry does not have a high enough weight rating, and there is also the possibility that the patient simply will not fit into the machine. Because body fat basically places a pillow between internal organs and the sensoring unit, ultrasound images may be impossible to obtain. Even something as simple as a chest X-ray may be difficult to interpret because of the difficulty of trying to diagnose the density difference between infected lung lobes versus the chest around it.

Dr. Allswede says that with the usual preferred diagnostic tools often rendered useless doctors have only two choices: “We can watch and wait, or we can perform invasive procedures.”

When an invasive procedure is necessary, Dr. Allswede cautions, physicians cannot rely on normal body landmarks to aid in location of underlying organs. Procedures such as placement of central lines, chest tubes, and peritoneal lavage can become a guessing game for the physician. “The normal body markings don’t align with body cavities,” he explains. “It becomes more difficult to do landmark locating for procedures.”

ABCs of Treating Obese Patients

Even the most basic medical management can be made difficult by obesity. Management of airway, breathing, and circulation is generally straightforward, and the protocols and procedures are standard; however, in the extremely obese patient problems can arise that are generally unseen in the average patient.

Morbidly obese patients desaturate more quickly than other adults. This can make it even more imperative than usual that a patent airway be obtained and maintained. Obesity makes it more difficult for the physician to visualize the laryngeal structures when attempting to intubate. Further, ventilation is made more difficult because of reduced pulmonary compliance, increased chest wall resistance, increased airway resistance, abnormal diaphragmatic position, and increased upper airway resistance.3

These patients have increased blood volumes, increased cardiac output, increased left ventricular volume, and lowered systemic vascular resistance. They may display atypical cardiac rhythms. Obtaining venous access can be extremely difficult in obese patients.3

Some of these problems can be solved by patient positioning, but some may require improvised techniques and/or specialized equipment.

Drug dosages must be modified for a morbidly obese patient; however, this is not simply a matter of larger body equaling larger dose. The physician must differentiate between fat-soluble and water-soluble medications, and obtain an estimate of the patient’s weight and body mass index to determine the proper dose of any given medication. Having a quick reference chart available for the most commonly used medications may be somewhat helpful, but it would be impossible to anticipate every possible drug-dosing dilemma. Figuring the proper dose can take some time, time that is not always available in a life-threatening situation.

Costly Solutions

Rising costs of caring for obese patients results in increased costs for everybody. The Centers for Disease Control estimates that the cost of caring for an overweight or obese patient is an average of 37% more than the cost of caring for a person of normal weight. This adds an average of $732 annually to the medical bill of every patient.8

In an effort to provide quality medical care to larger patients, many hospitals must purchase specialized equipment and supplies. There are hundreds of products available designed to help facilitate medical care of obese patients. Some hospitals are investing a great deal of money in caring for obese individuals, from lifting and moving equipment such as stretchers, wheelchairs, and lifts, to furniture such as beds and chairs, to medical equipment, including blood pressure cuffs, longer needles, and retractors.

Some facilities are making structural changes, such as widening doorways and hallways, to accommodate the passage of the larger equipment loaded with the larger patient. The 2004 Novation survey reported the mean estimated cost of new supplies to be $43,015. The mean cost of renovations in 2004 was $22,000 (compared with $15,250 in 2003).7

Conclusion

There is no doubt that the treatment of obese patients presents unique, sometimes expensive, challenges to hospitals and hospitalists. Hospitals have a responsibility to have the necessary diagnostic and treatment equipment available. Hospitalists have a responsibility to be familiar with the ways they can modify existing procedures and techniques to achieve a more desirable outcome in the obese patient. Above all, every effort must be expended to ensure that the obese patient is given the same respect and the same quality of care as every other patient. TH

Sheri Polley is based in Pennsylvania.

References

Weight Loss & Obesity Resource Center. Medical Care for Obese Patients. Available at: http://weightlossobesity.com/obesity/medical-care-for-obese-patients.html. Last accessed May 17, 2006.

Weight Control Information Network. Medical Care for Obese Patients. Available at: http://win.niddk.nih.gov/publications/medical.htm. Last accessed May 17, 2006.

Brunette DD. Resuscitation of the morbidly obese patient. Am J Emerg Med. 2004 Jan;22(1):40-47.

Criqui MH. Obesity, risk factors, and predicting cardiovascular events. Circulation. 2005 Apr 19;111 (15):1869-1870. Available online at: http://circ.ahajournals.org/cgi/content/full/111/15/1869. Last accessed May 17, 2006.

New York Office for the Aging 2001–2004. Overweight & Obesity. Available at: www.agingwell.state.ny.us/prevention/overweight.htm. Last accessed May 22, 2006.

Medical News Today. Is obesity a risk factor for asthma? Available at: www.medicalnewstoday.com/medicalnews.php?newsid=24118. Last accessed May 17, 2006.

VHA. 2004 obese patient care survey market research report. Available at: www.vha.com/portal/server.pt/gateway/PTARGS_0_2_1534_234_0_43/http%3B/remote.vha.com/public/research/docs/obestpatientcare.pdf. Last accessed May 6, 2006.

Akridge J. Bariatrics products help hospitals serve growing market. Healthcare Purchasing News. 2004 Mar. Available at: www.highbeam.com/library/docfree.asp?DOCID=1G1:124790587&num=1&ctrlInfo=Round20%3AMode20a%3ASR%3AResult&ao=&FreePremium=BOTH&tab=lib. Last accessed July19, 2006.

Classic Literature

1903 Article Introduces Early Electrocardiogram

By Jamie Newman, MD FACP

Einthoven's string galvanometer

Einthoven W. The galvanometric registration of the Human Electrocardiogram, likewise a review of the use of the capillary electrometer in physiology. Pfluger’s Arch.1903;99:472-480.

This landmark article represents one of the greatest achievements in the diagnosis of diseases of the heart. In tandem with the work of Werner Forssman and the first cardiac catheterization, it is the basis for modern cardiology.

Willem Einthoven was Dutch and served as the chair of physiology and histology at the University of Leiden, the Netherlands, for four decades. He based his work on the prior efforts of Luigi Galvani, Carlo Matteucci, and—most importantly—A.D. Waller, who showed that “leads” placed externally could measure the electric activity of the heart, using a capillary electrometer. (See Figure 1.) This device used a column of mercury, which responded to electric current but was inexact and not clinically useful.

In 1903, Einthoven used a galvanometer to measure this current. In this article he describes the physical principles of the electrocardiogram, as well as some early tracings. (See Figure 2.)

In 1924, he was awarded the Nobel Prize in physiology or medicine.

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Author(s)

Complicating Factors

The Transport Conundrum

Diagnosis Made Difficult

Dr. Allswede says that with the usual preferred diagnostic tools often rendered useless doctors have only two choices: “We can watch and wait, or we can perform invasive procedures.”

ABCs of Treating Obese Patients

Some of these problems can be solved by patient positioning, but some may require improvised techniques and/or specialized equipment.

Costly Solutions

Conclusion

Sheri Polley is based in Pennsylvania.

References

Weight Loss & Obesity Resource Center. Medical Care for Obese Patients. Available at: http://weightlossobesity.com/obesity/medical-care-for-obese-patients.html. Last accessed May 17, 2006.

Weight Control Information Network. Medical Care for Obese Patients. Available at: http://win.niddk.nih.gov/publications/medical.htm. Last accessed May 17, 2006.

Brunette DD. Resuscitation of the morbidly obese patient. Am J Emerg Med. 2004 Jan;22(1):40-47.

Criqui MH. Obesity, risk factors, and predicting cardiovascular events. Circulation. 2005 Apr 19;111 (15):1869-1870. Available online at: http://circ.ahajournals.org/cgi/content/full/111/15/1869. Last accessed May 17, 2006.

New York Office for the Aging 2001–2004. Overweight & Obesity. Available at: www.agingwell.state.ny.us/prevention/overweight.htm. Last accessed May 22, 2006.

Medical News Today. Is obesity a risk factor for asthma? Available at: www.medicalnewstoday.com/medicalnews.php?newsid=24118. Last accessed May 17, 2006.

VHA. 2004 obese patient care survey market research report. Available at: www.vha.com/portal/server.pt/gateway/PTARGS_0_2_1534_234_0_43/http%3B/remote.vha.com/public/research/docs/obestpatientcare.pdf. Last accessed May 6, 2006.

Akridge J. Bariatrics products help hospitals serve growing market. Healthcare Purchasing News. 2004 Mar. Available at: www.highbeam.com/library/docfree.asp?DOCID=1G1:124790587&num=1&ctrlInfo=Round20%3AMode20a%3ASR%3AResult&ao=&FreePremium=BOTH&tab=lib. Last accessed July19, 2006.

Classic Literature

1903 Article Introduces Early Electrocardiogram

By Jamie Newman, MD FACP

Einthoven's string galvanometer

Einthoven W. The galvanometric registration of the Human Electrocardiogram, likewise a review of the use of the capillary electrometer in physiology. Pfluger’s Arch.1903;99:472-480.

In 1903, Einthoven used a galvanometer to measure this current. In this article he describes the physical principles of the electrocardiogram, as well as some early tracings. (See Figure 2.)

In 1924, he was awarded the Nobel Prize in physiology or medicine.

Complicating Factors

The Transport Conundrum

Diagnosis Made Difficult

Dr. Allswede says that with the usual preferred diagnostic tools often rendered useless doctors have only two choices: “We can watch and wait, or we can perform invasive procedures.”

ABCs of Treating Obese Patients

Some of these problems can be solved by patient positioning, but some may require improvised techniques and/or specialized equipment.

Costly Solutions

Conclusion

Sheri Polley is based in Pennsylvania.

References

Weight Loss & Obesity Resource Center. Medical Care for Obese Patients. Available at: http://weightlossobesity.com/obesity/medical-care-for-obese-patients.html. Last accessed May 17, 2006.

Weight Control Information Network. Medical Care for Obese Patients. Available at: http://win.niddk.nih.gov/publications/medical.htm. Last accessed May 17, 2006.

Brunette DD. Resuscitation of the morbidly obese patient. Am J Emerg Med. 2004 Jan;22(1):40-47.

Criqui MH. Obesity, risk factors, and predicting cardiovascular events. Circulation. 2005 Apr 19;111 (15):1869-1870. Available online at: http://circ.ahajournals.org/cgi/content/full/111/15/1869. Last accessed May 17, 2006.

New York Office for the Aging 2001–2004. Overweight & Obesity. Available at: www.agingwell.state.ny.us/prevention/overweight.htm. Last accessed May 22, 2006.

Medical News Today. Is obesity a risk factor for asthma? Available at: www.medicalnewstoday.com/medicalnews.php?newsid=24118. Last accessed May 17, 2006.

VHA. 2004 obese patient care survey market research report. Available at: www.vha.com/portal/server.pt/gateway/PTARGS_0_2_1534_234_0_43/http%3B/remote.vha.com/public/research/docs/obestpatientcare.pdf. Last accessed May 6, 2006.

Akridge J. Bariatrics products help hospitals serve growing market. Healthcare Purchasing News. 2004 Mar. Available at: www.highbeam.com/library/docfree.asp?DOCID=1G1:124790587&num=1&ctrlInfo=Round20%3AMode20a%3ASR%3AResult&ao=&FreePremium=BOTH&tab=lib. Last accessed July19, 2006.

Classic Literature

1903 Article Introduces Early Electrocardiogram

By Jamie Newman, MD FACP

Einthoven's string galvanometer

Einthoven W. The galvanometric registration of the Human Electrocardiogram, likewise a review of the use of the capillary electrometer in physiology. Pfluger’s Arch.1903;99:472-480.

In 1903, Einthoven used a galvanometer to measure this current. In this article he describes the physical principles of the electrocardiogram, as well as some early tracings. (See Figure 2.)

In 1924, he was awarded the Nobel Prize in physiology or medicine.

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While Residents Rest

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While Residents Rest

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Gretchen Henkel

In the three years since the Accreditation Council for Graduate Medical Education (ACGME) instituted duty hour standards, academic and community-based internal medicine (IM) residency programs have had to change the way they do business. Although several surveys have documented residents’ satisfaction with reduced duty hours, some program directors and medical directors are concerned that complying with the standards can contribute to faculty burnout, affect continuity of patient care, and diminish residents’ educational opportunities. In recent interviews, IM program directors and medical directors of hospital medicine services shared their challenges of complying with the standards.

Who Takes Care of Patients?

The major provisions of the ACGME Common Duty Hour Standards, which took effect July 1, 2003, call for a weekly work limit of 80 hours, averaged over four weeks; a 24-hour limit on continuous duty time, with an additional period of as many as six hours to allow for continuity of care and educational activities, referred to as the “30-hour rule”; one day in seven free from all patient care; in-house call no more than once every three nights; and a 10-hour rest period between duty periods and in-house call. For more information on the new standards, visit www.acgme.org.

By instituting decreased duty hours, the council aimed to ensure that residents would be well rested, medical errors would be reduced, and patient safety would be improved. Tom Baudendistel, MD, associate residency program director at California Pacific Medical Center, a community-based hospital in San Francisco operated by Sutter Health, believes, however, that at the administrative level, the standards create “a potential for residency programs to be at odds with hospitals’ missions. Residency is making less money for the hospitals: For the same amount of dollars, they are receiving less coverage. So, hospitals hire additional attending physicians and physician extenders, which are a lot more expensive.”

With residents less available for extended duty hours, one of the largest challenges is to “figure out who’s going to take care of the patients,” notes Daniel Dressler, MD, MSc, director of the Hospital Medicine Service at Emory University Hospital, Atlanta. “At least in our institution, hospital medicine has stepped in to provide that care for many of the patients. We cannot get any additional house staff, and because their hours have been cut—reasonably so—we’re having to fill in the necessary gaps.”

The same phenomenon has occurred at Virginia Commonwealth University, Richmond, where Alan Dow, MD, MSHA, is assistant professor of Internal Medicine and director of the Academic Hospitalist Service. “My group has gone from two physicians four years ago, to now having 15 physicians,” he said recently. “We’ve grown, in large part, because we’re making up for the residency caps, but also because we’ve found other roles for ourselves in the health system to contribute and help.”

Another effect of decreased duty hours has been to contribute to the advent of non-teaching services, notes Dr. Baudendistel and Arpana R. Vidyarthi, MD, assistant professor of medicine and director of Quality-General Inpatient Medicine, University of California, San Francisco. At a recent panel she conducted at the SHM annual meeting, Dr. Vidyarthi said the main reason panelists cited for instituting non-teaching services was to reduce workloads for residents and comply with duty hours standards.

As duty-hour decreases have changed the nature of the academic hospitalist’s job, this leaves less and less time to do not just the things that you may enjoy and find intellectually satisfying, but also the things that are expected for getting promoted—a necessary part of life as an academic hospitalist.

—Arpana R. Vidyarthi, MD

Maintain Continuity of Care

The resident work hour caps have created a kind of mismatch with daily hospital routines, says Dr. Dow. In the ideal world, residents could admit patients at 7 or 8 a.m., allowing ample time to perform a comprehensive history and physical, review patients’ tests results, synthesize all the information in an educational way, and then be able to leave at 5 or 6 p.m. that evening. “Unfortunately,” he says, “patients show up at 4 or 5 p.m., until about 8 or 10 p.m., depending on the day. Ideally, we would have the same person admit and discharge the patient, but that just isn’t feasible because of the work hour caps.”

At Virginia Commonwealth, Dr. Dow’s hospitalist group has found that assigning admitting duties and ongoing patient care to separate teams allows for better patient care. Designated admitting physicians handle the admitting work in the late afternoons and evenings when most patients come up to the floor. All of the patient care is then transferred to another group of physicians who work during the day, ordering tests, speaking with consultants, and talking with families and social workers.

“What we’ve done is try to focus on continuity from that second day of hospitalization until discharge,” says Dr. Dow, “because I think the most critical point for errors in care is at discharge. We want to make sure that by the time patients go home, the discharging physician and the rest of the group have a really good idea of what is going on with those patients: What kind of home situation are they going to? What kind of follow-up do they have? What kind of medications are they going to be on? What kind of home services will they need?”

Dr. Dow has also noticed that reduced resident hours have resulted in the necessity for faculty to be more “available and present, and to focus on making the team more efficient. For my group of hospitalists, this is not a problem because our clinical venue is the hospital. But for people who are active researchers or who need to go to other clinical venues, this can be very difficult because their obligations in the hospital are more than they were five years ago.”

Casualties of Caps

No one argues that decreased duty hours are a bad idea. As a consequence, however, more work has fallen to faculty. Because residents have to be out of the hospital at designated cut-off points, attendings must stay up-to-speed with nuances of paperwork and electronic medical records. Sources agreed that they have observed faculty members working harder and harder, and many worry about issues with potential burnout among the faculty.

“As duty-hour decreases have changed the nature of the academic hospitalist’s job, this leaves less and less time to do not just the things that you may enjoy and find intellectually satisfying, but also the things that are expected for getting promoted—a necessary part of life as an academic hospitalist,” says Dr. Vidyarthi.

Other program directors voiced concerns that certain provisions of the duty standards might foster less connection to both the treatment team and to patients. “I think the fear I have as an educator,” says Dr. Baudendistel, “is the erosion of the continuity and the professionalism that is a byproduct of the work hours decrease, with the implicit hand-offs that occur in care. This is a paradigm shift. When I was a resident, this was my patient because I didn’t have too many days off. I saw my patient through the long hospitalization.”

But with changes in the duty hours, he says, now “the residents with reduced work hours and mandated days off might only admit the patient. Then three other house staff will see the patients and discharge them, and it’s not their patient any more. Who’s there to provide the continuity? It’s the attendings. So then the residents can abdicate responsibility to the senior residents and the attendings because they are only at the hospital for, say, a 12-hour shift.

“I think that shift work mentality is a definite threat to professionalism,” he concludes. “And that mentality is not good for patient care.”

Studies of Standards’ Effects

Few studies have been published specific to the hospital medicine experience with the reduced duty hours. Lin, et al., conducted four focus groups of internal medicine residents at the Washington University School of Medicine (St. Louis, Mo.), and found concerns about the effects of the duty hour restrictions on patient care and medical education.1 A study published this January in Academic Medicine by Dr. Vidyarthi and colleagues at UCSF asked 164 internal medicine residents to rate the value of their educational activities, frequency of administrative tasks interfering with education, and their educational satisfaction after duty hours were reduced.2 Dr. Vidyarthi and her coauthors did not see an increase in educational satisfaction, which was one of the expected outcomes of the new duty hour restrictions. She believes that for educational satisfaction among residents to increase, additional structural changes also must be put in place.

“If this is really an educational endeavor, then we need to make it such,” she says. “Duty hour decreases are here, so let’s make this amount of time that [the residents] are spending in the hospital as educationally valuable as possible.”

Can Less Be More?

One effect of reduced resident availability is that hospital medicine programs must become more thoughtful about the content of the educational experience for residents. If residents will see fewer patients because of fewer hours on duty, how might the remaining patient contacts be maximized for their educational opportunities?

“I think that there is much room for making their time in the hospital as educationally valuable as possible,” asserts Dr. Vidyarthi, “from pedagogical ways of thinking about medicine, to decreasing the number of tasks that they do that are not educational in value.”

Dr. Dressler agrees. “By reducing the resident work hours, we definitely reduce the amount of patient contact by residents,” he says. “Now, whether or not that will dramatically affect the amount of education the residents receive would be difficult to measure. Potentially, down the road, the American Board of Internal Medicine or some other governing board may decide that residency programs need to be longer. Medical training programs have instituted a comprehensive programmatic change [with the new work hours], will attempt to evaluate all the potential downsides as well as the value of this change, and, ultimately, will have to address problems or unexpected results in the new system in order to optimize patient care as well as physician trainee education.”

At California Pacific Medical Center’s residency program, “there are certain components we have had to re-analyze, and consider. [For example,] what is our core educational mandate that we’re trying to achieve? ” asks Dr. Baudendistel. Examining residents’ rotations, he says, has led to decisions to take residents off certain rotations, such as transplant nephrology, in favor of less esoteric rotations.

Hospitalists to the Rescue?

The question remains whether the reduced duty hours are better from the patient’s point of view. “The number of sign-outs that we’re seeing due to the duty hour decreases is significant. Interns will sign out approximately 300 times in a month, which is more than the number of patients they’ll see in the course of a year and, in fact, more often than they will eat in a month,” says Dr. Vidyarthi. “So, the challenge for the safety of patients [one of the impetuses for the decreased duty hours] is being balanced against having better rested, potentially better educated, happier residents. It’s really a Faustian bargain. Are we making this bargain [for better-rested residents] such that patients will, in fact, not be safer, because of the sign outs?”

Concerns about continuity of care under the new standard are “reasonable and legitimate,” says Dr. Dressler. “From a hospital medicine standpoint, that is how we practice: We are frequently handing off care. We understand that there is an inherent potential risk of doing that, and we like to be able to teach and train residents and students to understand how to do that effectively as part of their practice. Because hospitalists do this daily, we have an understanding of how to train people to optimally handoff patients to other clinicians and/or transition patients to other care settings or the outpatient arena.”

Dr. Dow views his hospitalist group as a sort of a “free safety,” taking care of patients that residents may not be able to take care of. “I view hospitalists as problem-solvers. Whether it’s a specific patient with a medical or social need, or a system problem, our big role is in filling those needs,” he says. “When patients need to be admitted and no other group is available, my hospitalist group is ready to care for folks.” TH

Gretchen Henkel is based in California.

References:

Lin GA, Beck DC, Garbutt JM. Residents’ perceptions of the effects of work hour limitations at a large teaching hospital. Acad Med. 2006 Jan;81(1):63-67.

Vidyarthi AR, Katz PP, Wall SD, et al. Impact of reduced duty hours on residents’ educational satisfaction at the University of California, San Francisco. Acad Med. 2006 Jan;81(1):76-81.

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Who Takes Care of Patients?

—Arpana R. Vidyarthi, MD

Maintain Continuity of Care

Casualties of Caps

“I think that shift work mentality is a definite threat to professionalism,” he concludes. “And that mentality is not good for patient care.”

Studies of Standards’ Effects

Can Less Be More?

Hospitalists to the Rescue?

Gretchen Henkel is based in California.

References:

Lin GA, Beck DC, Garbutt JM. Residents’ perceptions of the effects of work hour limitations at a large teaching hospital. Acad Med. 2006 Jan;81(1):63-67.

Vidyarthi AR, Katz PP, Wall SD, et al. Impact of reduced duty hours on residents’ educational satisfaction at the University of California, San Francisco. Acad Med. 2006 Jan;81(1):76-81.

Who Takes Care of Patients?

—Arpana R. Vidyarthi, MD

Maintain Continuity of Care

Casualties of Caps

“I think that shift work mentality is a definite threat to professionalism,” he concludes. “And that mentality is not good for patient care.”

Studies of Standards’ Effects

Can Less Be More?

Hospitalists to the Rescue?

Gretchen Henkel is based in California.

References:

Lin GA, Beck DC, Garbutt JM. Residents’ perceptions of the effects of work hour limitations at a large teaching hospital. Acad Med. 2006 Jan;81(1):63-67.

Vidyarthi AR, Katz PP, Wall SD, et al. Impact of reduced duty hours on residents’ educational satisfaction at the University of California, San Francisco. Acad Med. 2006 Jan;81(1):76-81.

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Larry Beresford

When Karie Praszek, MD, a hospitalist at the University of Texas Health Center at Tyler (UTHCT) found out this past fall that she was being considered for the position of medical director of the hospital’s planned hospice inpatient unit, she went home after work and cried. These were tears of happiness because she was finally going to be able to combine her two loves as a physician: hospital medicine and hospice care. “It was like coming full circle,” she explains.

The seven-bed hospice unit at UTHCT opened in partnership with Hospice of East Texas in Tyler in November, following renovations to create more comfortable and spacious rooms. It is one of a growing number of collaborations between hospitals and community hospice programs to provide institutional beds for terminally ill, hospice-enrolled patients in need of short-term inpatient care for symptom management.

In many hospitals, hospitalists are well positioned to provide planning, leadership, hospice referrals, or medical management of hospice units in the hospital. But few of them will follow a path like Dr. Praszek’s to the medical leadership of the hospice unit.

The Needs of End-of-Life Patients

Dr. Praszek’s commitment to the needs of patients facing the end of their lives took her from Texas to Oklahoma to Oregon and back to Texas. She has been a practicing hospitalist at UTHCT since 2004, but medicine wasn’t her first career. In the 1980s, as a computer expert for the U.S. Postal Service, she helped to automate postal facilities. She was well paid, she says, but something was missing in her life.

Wanting to make a meaningful contribution, Dr. Praszek became a volunteer candy striper at a hospital in Dallas. She learned about hospice while assigned to the oncology floor.

“When I started doing hospice care, I fell in love with it, and used volunteer work to hone my skills,” she says. She quit her job and moved to Oklahoma to attend a seminary with a specialized curriculum in death, dying, and grief counseling, all the while volunteering with hospice patients.

“They even trained me to be a certified nurse’s aide,” she says. “I just wanted to do whatever they needed—to do what no one else wanted to do.”

As a volunteer nurse’s aide she cleaned bedpans, changed diapers, and gave bed baths to hospice patients. “I didn’t mind it because it meant I could have more time to talk with the patients,” explains Dr. Praszek.

A turning point came while she was on a hospice wing of a nursing home, working with a patient who had metastatic prostate cancer and was in excruciating pain. “You could hear this gentleman moaning when you entered the building,” she recalls.

The nurses on the unit turned to Dr. Praszek and asked her to call the patient’s physician for an order for more pain medications. “I said, ‘I’m just a volunteer,’ but they told me, ‘You’re our last hope,’ ” recounts Dr. Praszek. “So I called the doctor, and he said he wouldn’t order any more pain medications because he didn’t want the terminally ill patient to become an addict. Then he said, ‘I’m the doctor and you’re not,’ and hung up on me. I thought, well, you so-and-so. I’ll go to medical school instead of nursing school, which I had been considering, so that nobody can ever pull this kind of thing on me again.”

Dr. Praszek completed her pre-med courses, but put off applying because she was afraid that she was too old or not smart enough. Finally, with her husband’s encouragement, she applied to Oregon Health Sciences University and, on her 40th birthday in 1996, received notification of acceptance. Looking for students with significant life experience, the medical school offered Dr. Praszek a full scholarship. She graduated at the head of her class.

After completing her internal medicine residency, she couldn’t find a hospice-related position, but she had learned to appreciate the pace and complexity of hospital medicine. After doing locum tenens (temporary assignments), she landed in the hospitalist position at UTHCT. The 100-bed facility began as a tuberculosis hospital housed in a former U.S. Army base in 1949, and in 1977 it became part of the University of Texas health system.

Today Dr. Praszek heads a three-person hospital medicine department, with another physician and a physician’s assistant and the backup of 10 clinic physicians for after-hours coverage. Her job combines both clinical and administrative responsibilities, including risk assessments, protocol development, and the ethics committee. Roughly 10% of her time is devoted to patients on the hospice unit.

Providing Necessary Care

Hospice is an approach to the care of patients with life-limiting illnesses and their families, emphasizing the relief of pain and other symptoms, maximizing quality of life and support for the emotional and spiritual issues that come up at this time of life. Under the Medicare Hospice Benefit (introduced in 1983) Medicare-certified hospice programs are responsible for providing essentially all of the care needed to manage their enrolled patients, who have a life expectancy of six months or less. Medicare pays the hospice a daily packaged rate for its services—all-inclusive except for attending or consulting physicians, who are able to bill separately. Although the hospice benefit is primarily intended as a service in the patient’s home or other place of residence, such as a nursing home, often terminally ill patients require inpatient care for short periods to bring their medical symptoms under control.

To fill this need, hospice programs can open their own freestanding inpatient facilities, as Hospice of East Texas did with its 28-bed HomePlace, or else contract with a hospital for inpatient beds, as the hospice did with UTHCT. Those involved in planning the hospice unit at UTHCT emphasize that at the rate Medicare pays for inpatient hospice care ($562.69 per day, regionally adjusted), neither partner is likely to derive a profit from it. Instead the unit reflects a true commitment by both to meeting the needs of terminally ill patients in the hospital.

“This hospice unit was the right thing to do,” says UTHCT’s Chief Medical Officer Steven Brown, MD. “It’s an opportunity to educate our medical staff about end-of-life care, introduce the concept of hospice into the hospital, and improve utilization,” by changing the focus of treatment for those who choose the hospice approach.

The unit also provides an opportunity to concentrate palliative care training for nurses on the floor, which includes neuro-restorative and tuberculosis beds as well as non-dedicated hospice beds. Many patients are simultaneously referred to the unit and to Hospice of East Texas, while others may receive hospice care at home at the time of their placement on the unit.

Bring Inpatient Care Closer to Families

Marjorie Ream, CEO of Hospice of East Texas, explains that the origins of the hospice unit at UTHCT are in response to her agency’s family satisfaction surveys. Some families in the northeastern corner of the agency’s 13-county service area said they drove too far to visit loved ones at its HomePlace inpatient facility.

“We looked at our mission statement and started to explore how to make inpatient care available closer to the folks we serve,” says Ream. “I started a dialogue with Dr. Kirk Calhoun, the hospital’s president.”

Coincidentally, Dr. Calhoun had attended a hospital conference where he learned about a collaboration between a public charity hospital and a hospice in Atlanta that had received recognition from the American Hospital Association.

Their first meeting to discuss collaborating was in August 2005, and by November 15 the renovated unit was in operation, with two-room suites large enough to allow the patient’s family members to stay overnight on pullout sofas. Dr. Praszek’s name entered the dialogue after she gave a hospital lecture on end-of-life care and code status. “When we talked with her and she shared her career journey, we could see that she was a logical fit,” explains Ream. “And she really wanted to do this.

“My impression is that Dr. Praszek has a true ‘hospice heart.’ She really understands the interdisciplinary team. She’s an expert clinician, and she understands the differences in treating terminally ill patients. She has a real sense of the patient and family as people,” says Ream. “Nurses love her commitment and enthusiasm and are proud to be her colleagues.”

Dr. Praszek’s first concern is keeping people healthy. “To be a hospitalist on a hospice unit, you have to know how to change your focus from cure to caring,” she says. “It takes someone who is not afraid of confronting their patients’—or their own—mortality. When we first opened the unit, there was a sharp learning curve for physicians in the hospital. But it’s been a pretty smooth transition overall, except for one or two who still have a hard time recognizing when their patient is dying. Most physicians at this institution are learning how to look at the entire lifespan of their patients.”

Dr. Praszek tries to see every patient on the hospice unit each day she is on service. She also works closely with the interdisciplinary team at Hospice of East Texas. Routine care on the unit is provided by hospital staff, while the hospice team provides care management and oversight. Hospice care generally involves fewer intensive medical procedures and more intensive nursing care and comfort measures.

A Deeper Commitment

“My life today is the way it is because I really love my work,” says Dr. Praszek. She brings a lot of it home at night. In fact, Dr. Brown says he occasionally worries about the long hours she works. “But we try to make sure she gets the support she needs.”

“My door is always open,” adds Dr. Praszek. “I’m still learning from the nurses, and I’ve had housekeeping staff give me advice. When they find out my background [as a nurse’s aide], they always say, ‘Oh, that’s why we get along so well.’ ” TH

Larry Beresford wrote about hospitalists who work as administrators in the July issue.

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The Needs of End-of-Life Patients

Wanting to make a meaningful contribution, Dr. Praszek became a volunteer candy striper at a hospital in Dallas. She learned about hospice while assigned to the oncology floor.

“They even trained me to be a certified nurse’s aide,” she says. “I just wanted to do whatever they needed—to do what no one else wanted to do.”

Providing Necessary Care

Bring Inpatient Care Closer to Families

A Deeper Commitment

Larry Beresford wrote about hospitalists who work as administrators in the July issue.

The Needs of End-of-Life Patients

Wanting to make a meaningful contribution, Dr. Praszek became a volunteer candy striper at a hospital in Dallas. She learned about hospice while assigned to the oncology floor.

“They even trained me to be a certified nurse’s aide,” she says. “I just wanted to do whatever they needed—to do what no one else wanted to do.”

Providing Necessary Care

Bring Inpatient Care Closer to Families

A Deeper Commitment

Larry Beresford wrote about hospitalists who work as administrators in the July issue.

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Risky Business II: A Whole New Category of Risk

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Five years ago, it was clearly recognized that malpractice law associated with hospitalist systems was an emerging phenomenon.1 But today this is rapidly changing, says Linda Greenwald, RN, MS, the editor of Risk Management Publications at the ProMutual Insurance Group, Boston, who keeps an eye on emerging trends related to medical malpractice litigation.

“There’s a whole new category of risk coming up,” she says, “because it’s a whole new specialty that kind of exploded on the scene, and some time needs to be spent defining the role of hospitalists.”

The 2006 winter issue of the company’s newsletter, Perspectives on Clinical Risk Management, was devoted to the subject of hospitalists.2 Patient safety concerns and communication, particularly as they relate to post-discharge communication, were the two overriding issues Greenwald identified connecting malpractice risk and hospitalists. (An upcoming issue of The Hospitalist will address the topic of post-discharge communication.) From her research, Greenwald gathered that hospitalists were considered “like the residents of yore,” expected to “cover the entire house,” to be everything and do everything for everyone.

The newsletter issue advises hospitalists to explain to patients and families who you are and what your role is, and to ask them pointedly whether they have concerns about that. Many patients feel abandoned by their primary care physicians; they don’t understand the new system, and they need to be reassured about the continuity of care. In a larger sense, ProMutual also suggests that institutions provide some type of public forum in their community for the public and providers both, to openly discuss ways to make the hospitalist system work for them all.

How do we all sleep at night thinking it’s a good thing that between 92%-98% of people who are injured by our negligence don’t get compensated?

—Meg Gaines, JD, LLM

That Dollar Sign

Accumulating evidence shows that some of the contributory causes of rising healthcare-related litigiousness include patients’ higher expectations, poor provider-patient communication, and society’s adversarial legal stance.3

What is really to blame for the rising malpractice costs? “The medical system in our country is grounded in money,” says Meg Gaines, JD, LLM, clinical professor of law at the University of Wisconsin Law School, Madison. “It’s grounded in profit or, at the least, fiscal survival, depending on the institution. … In the bottom line equation, one of the variables is a dollar sign.”

Therefore, she says, anyone working in the hospital needs to recognize that, to a great extent, their working life revolves around that equation.

“The press has made this connection between [the number and amounts of payouts for] lawsuits and rising malpractice costs,” says Professor Gaines. “[It’s not] that there isn’t a connection. But what we do know, and what there is ample research to show, is that malpractice rates are much more linked to the rise and fall of the stock market.”4-10

To an insurance provider, she explains, the premiums are basically a loss leader; that is, a product sold below cost. “They don’t make money on premiums,” says Professor Gaines. “They make money investing premiums. You can see the correlation between rates and stock market performance over time.”

Professor Gaines says that the media has led the public to believe that the high cost of healthcare is due to skyrocketing medical malpractice awards. “Many of the states that put caps on their awards for malpractice torts are doing fine, but so are many states without caps,” she says. “It behooves the press to pit wicked lawyers against angelic doctors, or vice versa,” but it’s a lot more complicated than that. “And that rhetoric takes away from the real point, which is this: Nobody disagrees that too many patients are injured through negligence. But the number of patients injured through documented negligence who actually sue is somewhere between 2%-8%,” which is a very small percentage. Maybe too small.

Bad things happen to good people, and not everybody sues; it’s the people who feel that they’re cared for that tend not to sue. The documentation for this is increasing daily.

“Patients who have good, communicative relationships with their doctors don’t sue,” says Professor Gaines. “We generally don’t sue people we love or who love us.” And that’s a good thing, she speculates. “But it is important for doctors to think about this: So your patients don’t sue you, but you do make mistakes, right? And sometimes you cause injury. So how does that work for you that you have malpractice insurance that covers you for injury that you cause, but your patients won’t sue you because they love you?” she asks. “How do we all sleep at night thinking it’s a good thing that between 92%-98% of people who are injured by our negligence don’t get compensated?”

The Value of Litigation

With respect to the issue of patient safety, says George J. Annas, JD, MPH, Edward R. Utley professor of health law and the chairman of the Department of Health Law, Bioethics, and Human Rights at Boston University School of Public Health, rather than doctors and lawyers viewing each other as “predator and prey,” it would be far more beneficial for them to see each other as “natural allies.”11 He suggests that we recall the intended purpose of litigation and its value for society.

Professor Gaines concurs: “We live in this world where on the medical side people are so litigation-phobic that we really aren’t able to see the value of litigation anymore.” Healthcare itself can be viewed as a patient that might be healthier if required to pay the price of unhealthy practices: namely, failing to engage in communication and safety practices that would reduce error and injury. Shaking up that system might lead to better healthcare.11

In fact, the claim that the malpractice system is fraught with frivolous litigation has been called “overblown” and not substantiated in the literature.12 The malpractice system is effective in separating claims without merit from those with merit and compensating the latter. In an analysis of outcomes and claims costs from 1,452 closed malpractice claims from five liability insurers, “three-quarters of the litigation outcomes were concordant with the merits of the claim.”12

“Some of the most excellent doctors I know have said to me on the QT, ‘I’m sure glad you lawyers are around because if you weren’t I don’t know how we’d ever get rid of the scary doctors.’ ” says Professor Gaines. “And if the rate of malpractice claims for merited negligence “is only 2%-8%,” she says, “we’re probably not doing a great job of it.”

What makes doctors scary to patients? Or, rather, what makes a good doctor? When patients and physicians were both asked this question (pertaining to outpatient physicians), more patients than doctors considered the exchange of health-related information to be an essential aspect of their healthcare. Physicians placed it far lower on their list.13 These kinds of differences in perception may influence the quality of interactions between physicians and patients, the study concluded.

Professor Gaines, who has consulted with hundreds of physicians and nurses in her role as director of the Center for Patient Partnerships at the University of Wisconsin, encourages them to spend time in meaningful communication with their patients. “Their argument usually is: I don’t have time.” she says. “My answer is: You don’t have time not to.”

Communication and Patient Safety Concerns

The needs for superb patient safety and optimal healthcare communication are intertwined. In research on quality of care, patient safety is now specifically named as a factor and is distinguished from effectiveness.4 Malpractice litigation is often pursued when patients experience an adverse outcome coupled with a lack of empathy from and a withholding of essential information by physicians.14 Senators Hillary Clinton (D-NY) and Barack Obama (D-IL) cite documentation for this when they advocate for patient safety to be the centerpiece of medical liability reform.

As careful as hospitalists might be to protect their patients from safety hazards and errors, however, they alone cannot protect themselves and their institutions from wrongdoing or the risk of litigation.

“In hospital care, the challenge is to reform corporate governance to make hospital boards take their responsibility for patient safety at least as seriously as they take the hospital’s financial condition,”11 writes Professor Annas, who’s affiliated with both Boston University’s School of Law and School of Medicine. “Hospitals that do not take specific actions to improve safety should be viewed as negligent and be subject to malpractice lawsuits when a violation of the right to safety results in injury.”

It is also the hospital’s obligation, he says, to maintain a safe environment for healthcare providers. And hospitalists and other providers who “live” in hospitals have an ethical obligation to advance the connection of patient safety and communication in hospital-medicine-led quality improvement as well as whole-hospital initiatives.3,11,15,16 That means that staffing, technologies, and facilities must all be up to par so providers can work with the assurance that available resources will support their efforts to provide the best care for their patients.11

Those objectives were taken on by the University of Michigan (Ann Arbor) in a program launched in 2002 to reduce litigation costs, accelerate provision of compensation to patients, and increase the numbers of patients who are compensated for their injuries. The link between the medical liability environment and patient safety was well illustrated in their results. The program involved three strategic components:

Acknowledge cases in which a patient was hurt because of medical error and compensate these patients quickly and fairly;

Aggressively defend cases that the hospital considers to be without merit; and

Study all adverse events to determine how procedures could be improved.

Whereas the organization had approximately 260 claims and lawsuits pending at any given time prior to August 2001, by August 2005 the number had dropped to 114. The average time from the filing of a claim to its resolution was reduced by 11 months, and annual litigation costs dropped from about $3 million to $1 million.14

This program clearly connected the dots between responsibility, compensation for merited negligence, systems quality improvement, and communication across the board. Senators Rodham Clinton and Obama infused their bill with the sensibility that these humane criteria are particularly important.14 When healthcare providers, administrators, and regulators around the world are being advised that a “post-event communication-cum-mediation framework” is the key national strategy for resolving malpractice disputes,3 the need for empathy, apology, and responsibility are implied. (See “I’m Sorry,” June 2006, p.25.)

“When I talk about patient safety, I imagine hospitalists are particularly attuned to this,” says Professor Gaines, “I am talking about what a physician could do in 15 seconds if every single patient is actively engaged in their [own] care.” It’s a no-brainer and “the easiest thing in the world if patients are invited and made to feel welcome as full members of the team.”

Inattention to little things can cause the risky miscommunications that lead to serious problems, both medically and legally. And yet, says Professor Gaines, the remedy is sometimes as easy as “having an informed patient partner as the final check.”

The Bottom Line for Hospitalists

When asked what she wants to say to hospitalists from her personal experience as a hospital inpatient as well as that of her extensive professional background as a criminal defense lawyer, law professor, and patient advocate, Professor Gaines began with her own expression of empathy. “First, in many ways you’re being asked to do an impossible job,” she says. “And patients like me, critics, and commentators will say, ‘Hey! You’re not doing it as well as you could.’ ”

Hospitalists, she says, might be prone to say, “ ‘Leave me alone. I’m doing the best I can.” You’re doing what may be an untenable job, you’ve got specialists leaning on you from one angle, patients and families … wailing on you from another level, and you’re … stuck in between: a utility player, the one everyone loves to boo off the field when you’re having a bad day.”

On the other hand, she says, “Every day I am carving another little bit of my epitaph, and what it says at the end is of my making. And if you can’t carve in these circumstances, then change them or do something about it. But when the bell tolls for thee, the fact that you worked in a busy hospital and had a bunch of overqualified guys breathing down your neck and under-informed patients blaming you for things that aren’t really your fault—that’s going to be footnote material. Carve out your ground, stand it, and do the job you can be proud of. And nobody and nothing gets you off the hook for that.”

Conclusion

The rising costs of medical malpractice litigation are far more a function of the fluctuations of the economy, among other factors, than of the number and size of malpractice claims payouts. Data show that the vast majority of expenditures that go toward litigation are not due to frivolous claims or unmerited compensation. In fact, litigation may hold value in serving to remind hospitals and providers that the best means of warding off lawsuits is to invest resources in patient safety, including prioritizing communication with patients, families, and colleagues. TH

Andrea Sattinger wrote “Risky Business I” in the Feb. 2006 issue (p. 1).

References

Alpers A. Key legal principles for hospitalists. Am J Med. 2001;111:5-9S.

Greenwald L, ed. Hospitalists. Perspectives on Clinical Risk Management. Winter 2006.

Harold TK. Minimizing medical litigation, part 2. J Med Pract Manage. 2006 Mar-Apr;21(5):257-261.

Brennan TA, Gawande A, Thomas E, et al. Accidental deaths, saved lives, and improved quality. N Engl J Med. 2005 Sep 29;353(13):1405-1409.

Brennan TA, Mello MM. Patient safety and medical malpractice: a case study. Ann Intern Med. 2003 Aug 19;139(4):267-273.

Brennan TA, Sox CM, Burstin HR. Relation between negligent adverse events and the outcomes of medical-malpractice litigation N Engl J Med. 1996 Dec 26;335(26):1963-1967.

Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991 Feb 7;324(6):370-376.

Harvard Medical Practice Study. Patients, doctors, and lawyers: medical injury, malpractice litigation, and patient compensation in New York. Report of the Harvard Medical Practice Study to the state of New York. Cambridge, Mass: President and Fellows of Harvard College; 1990: www.nysl.nysed.gov/scandoclinks/OCM21331963.htm. Last accessed July 11, 2006.

Localio AR, Lawthers AG, Brennan TA et al. Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III. N Engl J Med. 1991 Jul 25;325(4):245-251.

Mills DH, ed. California Medical Association and California Hospital Association Report on the Medical Insurance Feasibility Study. San Francisco, Calif: Sutter Publications; 1977.

Annas GJ. The patient's right to safety—improving the quality of care through litigation against hospitals. N Engl J Med. 2006 May 11;354(19):2063-2066.

Studdert DM, Mello MM, Gawande AA, et al. Claims, errors, and compensation payments in medical malpractice litigation. N Engl J Med. 2006 May 11;354(19):2024-2033.

Laine C, Davidoff F, Lewis CE, et al. Important elements of outpatient care: a comparison of patients' and physicians' opinions. Ann Intern Med. 1996 Oct 15;125(8):640-645.

Clinton HR, Obama B. Making patient safety the centerpiece of medical liability reform. N Engl J Med. 2006;354:2205-2208.

Studdert DM, Mello MM, Brennan TA. Medical malpractice. N Engl J Med. 2004;350:283-292.

Delbanco TL. Quality of care through the patient's eyes. BMJ. 1996;313:832-833.

A Wild Ride

Referring to her course of treatment for the diagnosis of ovarian cancer she received in 1994, Meg Gaines, JD, LLM, says: “I had a healthcare experience that included everything from bona fide negligent medical error to brilliant risk-taking that saved my life, and everything in between.” Professor Gaines gave TH a summary of the incidents that spurred her to co-found the Center for Patient Partnerships at the University of Wisconsin in Madison.

When I was initially examined my gynecologist, she thought she felt an ovarian cyst. She scheduled a laparoscopy, but the cyst burst during surgery. That’s probably how I wound up with a tumor in my liver.

My surgeon and second gynecologist didn’t tell me this. First they said it was not cancer; then they said it was borderline tumor. Then I had the pathology reread and there were two different ovarian cancer cell types.

Next, my primary care physician missed that there were blood clots metastasizing. He put me on pain meds and, ultimately, crutches before I wound up in the hospital with pulmonary emboli. I was put on such a high dose of anticoagulants by my medical oncologist that he couldn’t reduce them quickly enough so that my blood could clot and they could perform a biopsy. An IV infusion of vitamin K, given to me too quickly, put me in anaphylactic shock.

When my liver was able to be biopsied, the pathologists found ovarian cancer. Very shortly after the biopsy result, one of my oncologists scheduled me to get a port put in for my chemotherapy. When I woke up from that procedure, I had this strange feeling like I’d had when I’d had the pulmonary emboli and went into shock: I couldn’t breathe. The surgeon who put the port in had been summoned emergently as my left lung had collapsed; he had punctured it trying to install the port in the left side. Four days later, with a still-not-fully-inflated left lung, the cardiologist opined that the chest tube was too small and recommended installing a larger one, removing the smaller one first. So the surgeons had to do an emergency intubation.

And it goes on from there.

That’s the bad side of it. I got quite an education. But my story’s not unusual, and people shouldn't think that it is.

The amazingly wonderful part of my journey included a powerful, respectful, and wonderful relationship with my gynecologic oncologist (my third oncologist) in Madison, who served as both my medical oncologist and surgeon. I’d had some great care and some not so great care along the way, by a number of different physicians and surgeons.

I went to Los Angeles for a consult with someone else because I wanted to “hit the long ball,” to take a chance on cure and not settle for an extended remission. It was a huge risk, but on the other hand, there wasn't a lot that standard treatment had to offer me at that point. Though I had found a chemo that was incredibly effective, I didn't want to rely on chemotherapy. I wanted to have surgery plus effective chemotherapy. I felt it was my best shot at a home run.

The surgeon in Los Angeles thought I had 12 tumors, and although I had “failed” chemotherapy, he agreed to open me up and “cryo” my liver. When he did … he discovered that I had only ever had one tumor in my liver and he froze it out. … This guy took a huge risk on me—this 38-year-old woman, mother of two little kids. And he saved my life. There are no words for the gift he gave me.

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How do we all sleep at night thinking it’s a good thing that between 92%-98% of people who are injured by our negligence don’t get compensated?

—Meg Gaines, JD, LLM

That Dollar Sign

Therefore, she says, anyone working in the hospital needs to recognize that, to a great extent, their working life revolves around that equation.

Bad things happen to good people, and not everybody sues; it’s the people who feel that they’re cared for that tend not to sue. The documentation for this is increasing daily.

The Value of Litigation

Communication and Patient Safety Concerns

Acknowledge cases in which a patient was hurt because of medical error and compensate these patients quickly and fairly;

Aggressively defend cases that the hospital considers to be without merit; and

Study all adverse events to determine how procedures could be improved.

The Bottom Line for Hospitalists

Conclusion

Andrea Sattinger wrote “Risky Business I” in the Feb. 2006 issue (p. 1).

References

Alpers A. Key legal principles for hospitalists. Am J Med. 2001;111:5-9S.

Greenwald L, ed. Hospitalists. Perspectives on Clinical Risk Management. Winter 2006.

Harold TK. Minimizing medical litigation, part 2. J Med Pract Manage. 2006 Mar-Apr;21(5):257-261.

Brennan TA, Gawande A, Thomas E, et al. Accidental deaths, saved lives, and improved quality. N Engl J Med. 2005 Sep 29;353(13):1405-1409.

Brennan TA, Mello MM. Patient safety and medical malpractice: a case study. Ann Intern Med. 2003 Aug 19;139(4):267-273.

Brennan TA, Sox CM, Burstin HR. Relation between negligent adverse events and the outcomes of medical-malpractice litigation N Engl J Med. 1996 Dec 26;335(26):1963-1967.

Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991 Feb 7;324(6):370-376.

Harvard Medical Practice Study. Patients, doctors, and lawyers: medical injury, malpractice litigation, and patient compensation in New York. Report of the Harvard Medical Practice Study to the state of New York. Cambridge, Mass: President and Fellows of Harvard College; 1990: www.nysl.nysed.gov/scandoclinks/OCM21331963.htm. Last accessed July 11, 2006.

Localio AR, Lawthers AG, Brennan TA et al. Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III. N Engl J Med. 1991 Jul 25;325(4):245-251.

Mills DH, ed. California Medical Association and California Hospital Association Report on the Medical Insurance Feasibility Study. San Francisco, Calif: Sutter Publications; 1977.

Annas GJ. The patient's right to safety—improving the quality of care through litigation against hospitals. N Engl J Med. 2006 May 11;354(19):2063-2066.

Studdert DM, Mello MM, Gawande AA, et al. Claims, errors, and compensation payments in medical malpractice litigation. N Engl J Med. 2006 May 11;354(19):2024-2033.

Laine C, Davidoff F, Lewis CE, et al. Important elements of outpatient care: a comparison of patients' and physicians' opinions. Ann Intern Med. 1996 Oct 15;125(8):640-645.

Clinton HR, Obama B. Making patient safety the centerpiece of medical liability reform. N Engl J Med. 2006;354:2205-2208.

Studdert DM, Mello MM, Brennan TA. Medical malpractice. N Engl J Med. 2004;350:283-292.

Delbanco TL. Quality of care through the patient's eyes. BMJ. 1996;313:832-833.

A Wild Ride

And it goes on from there.

That’s the bad side of it. I got quite an education. But my story’s not unusual, and people shouldn't think that it is.

How do we all sleep at night thinking it’s a good thing that between 92%-98% of people who are injured by our negligence don’t get compensated?

—Meg Gaines, JD, LLM

That Dollar Sign

Therefore, she says, anyone working in the hospital needs to recognize that, to a great extent, their working life revolves around that equation.

Bad things happen to good people, and not everybody sues; it’s the people who feel that they’re cared for that tend not to sue. The documentation for this is increasing daily.

The Value of Litigation

Communication and Patient Safety Concerns

Acknowledge cases in which a patient was hurt because of medical error and compensate these patients quickly and fairly;

Aggressively defend cases that the hospital considers to be without merit; and

Study all adverse events to determine how procedures could be improved.

The Bottom Line for Hospitalists

Conclusion

Andrea Sattinger wrote “Risky Business I” in the Feb. 2006 issue (p. 1).

References

Alpers A. Key legal principles for hospitalists. Am J Med. 2001;111:5-9S.

Greenwald L, ed. Hospitalists. Perspectives on Clinical Risk Management. Winter 2006.

Harold TK. Minimizing medical litigation, part 2. J Med Pract Manage. 2006 Mar-Apr;21(5):257-261.

Brennan TA, Gawande A, Thomas E, et al. Accidental deaths, saved lives, and improved quality. N Engl J Med. 2005 Sep 29;353(13):1405-1409.

Brennan TA, Mello MM. Patient safety and medical malpractice: a case study. Ann Intern Med. 2003 Aug 19;139(4):267-273.

Brennan TA, Sox CM, Burstin HR. Relation between negligent adverse events and the outcomes of medical-malpractice litigation N Engl J Med. 1996 Dec 26;335(26):1963-1967.

Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991 Feb 7;324(6):370-376.

Harvard Medical Practice Study. Patients, doctors, and lawyers: medical injury, malpractice litigation, and patient compensation in New York. Report of the Harvard Medical Practice Study to the state of New York. Cambridge, Mass: President and Fellows of Harvard College; 1990: www.nysl.nysed.gov/scandoclinks/OCM21331963.htm. Last accessed July 11, 2006.

Localio AR, Lawthers AG, Brennan TA et al. Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III. N Engl J Med. 1991 Jul 25;325(4):245-251.

Mills DH, ed. California Medical Association and California Hospital Association Report on the Medical Insurance Feasibility Study. San Francisco, Calif: Sutter Publications; 1977.

Annas GJ. The patient's right to safety—improving the quality of care through litigation against hospitals. N Engl J Med. 2006 May 11;354(19):2063-2066.

Studdert DM, Mello MM, Gawande AA, et al. Claims, errors, and compensation payments in medical malpractice litigation. N Engl J Med. 2006 May 11;354(19):2024-2033.

Laine C, Davidoff F, Lewis CE, et al. Important elements of outpatient care: a comparison of patients' and physicians' opinions. Ann Intern Med. 1996 Oct 15;125(8):640-645.

Clinton HR, Obama B. Making patient safety the centerpiece of medical liability reform. N Engl J Med. 2006;354:2205-2208.

Studdert DM, Mello MM, Brennan TA. Medical malpractice. N Engl J Med. 2004;350:283-292.

Delbanco TL. Quality of care through the patient's eyes. BMJ. 1996;313:832-833.

A Wild Ride

And it goes on from there.

That’s the bad side of it. I got quite an education. But my story’s not unusual, and people shouldn't think that it is.

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Uncertain Prognosis

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They’ve already been in the hospital three or four times, and now they’re back,” says Howard Epstein, MD, an internal medicine-trained hospitalist and the medical director of the palliative care program at Regions Hospital, St. Paul, Minn., describing patients who have acute exacerbations of their life-threatening chronic illnesses. “It’s a challenge we face all the time.”

Hospitalists spend a good deal of their time caring for dying patients, and data show that, by many accounts, they do it well.1 But just how near these patients are to death is often uncertain, especially for patients with diagnoses such as advanced heart and lung failure. Despite their slow decline, during any episode in which they are hospitalized, they may indeed die.

“As hospitalists, we encounter these situations regularly, maybe even daily,” wrote Steve Pantilat, MD, SHM past president, in his column in The Hospitalist (July/August 2005, p. 4): “We are the physicians who care for the seriously ill and the dying. The question is not whether we will take care of these patients; rather, when we do, will we be ready and able?”

End of life and palliative care are areas that hospitalists consider important but feel their training is generally inadequate.2 The conversations with patients and families can be challenging and take time, yet the time is worth the investment and they are a critical part of quality care. “We can learn how to conduct these discussions better,” wrote Dr. Pantilat, “and can practice phrases that will help them go more smoothly.”1,3-14 (See “Practice Phrases,” p. 34.)

Is there a difference in the way hospitalists treat those acute exacerbations if they come from or are attempting to return to their homes in the community or in long-term care? Not really, says Dr. Epstein. The exceptions may be in determining what kind of assistance a patient is getting or not getting outside the hospital (e.g., they’ll return home to a “supercaregiver spouse” versus returning to an assisted or skilled nursing facility). A patient in long-term care usually has multiple comorbidities, or their functional state has declined to the point where they need more assistance, palliative care only, or referral to hospice.

When a patient who has chronic obstructive pulmonary disease (COPD) comes in with an acute exacerbation, he says, it’s a good example of when you need to ask those clarifying questions. “If they’re deteriorating and you can paint that broad picture and help them to see that and that they’re going toward some inexorable decline,” says Dr. Epstein, “then they might make different decisions with that information.”

One study shows that even if patients with cancer requested survival estimates, doctors provide a frank estimate only 37% of the time and provide no estimate, a conscious overestimate, or a conscious underestimate most of the time.

What’s Good in a Good Death?

Phrases such as “good death” and “dying with dignity” bear some interpretation, says Eva Chittenden, MD, a hospitalist with the University of California at San Francisco and a faculty member of its Palliative Care Leadership Center. Most palliative care experts might further define this to mean dying with appropriate respect for who that person is or who that person has been up until this point. A good death, she says, might better be referred to as a death that is “as good as possible.

“People say they want to die at home, but on the other hand, they also want to live forever,” says Dr. Chittenden. The reality is that most people die in acute-care hospitals while receiving invasive therapies.5-6,15 “We want a peaceful death, we want a pain-free death, we want a death where we’re surrounded by our families,” she says, “but at the same time we want to delay that forever. And those two things come into extreme conflict.7,9

“If you have cancer, maybe you don’t want to talk with your oncologist about death and dying because you want them to save your life. So you don’t even want to go there. And then you’re admitted to the hospital you’re told, ‘You’re extremely sick; you have pneumonia, but if we intubate you, we might be able to turn this situation around versus, if we don’t intubate you, you will surely die.’ And people don’t want to make that decision, because they’re not ready to die, even if ideally they’d want to have that good death,” says Dr. Chittenden, noting that not all providers have come to terms with how to use the available medical technology, when to stop using it, and how to talk about prognosis.

Even though providers, patients, and families may have already had conversations about advanced care planning, a patient’s change in health status might herald the need for a new conversation.

Talking about Prognosis

“In no case of serious illness … is predicting the future straightforward or meaningless,” writes Nicholas Christakis, in Death Foretold: Prophecy and Prognosis in Medical Care.16 “Part of the problem is that even formulating, much less communicating, a prediction about death is unpleasant, so physicians are inclined to refrain from it. But when they are able to formulate a prediction and fail to do so, the quality of care that patients receive may suffer.”

According to Dr. Epstein, you have to practice the conversations. “It’s a skill set, just like doing a bedside procedure … something that you have to do over and over and get comfortable doing,” he explains. “And it shocks people out of their seats when they actually hear the ‘D word.’ ” But part of meeting your responsibility to patients and their families requires speaking the truth.

Dr. Epstein says there are numerous resources available to help hospitalists overcome their discomfort and fears about being incorrect about how long the patient has to live. “I think it is OK to also say, ‘Look, I’m not God and I don't have a crystal ball, but I have seen lots of people in your situation and having watched them go through this point in their life, this is my expert opinion … ,’ ” he advises.

This involves telling the patient, “These are your chances of making a full recovery to the point where you might appreciate the quality of life you would have.” You don’t have to give numbers; you can use words such as good, bad, or poor.

For those with advanced systemic failure, you might discuss prognoses in words that patients can better understand by making a comparison to someone has a cancer diagnosis. For instance, “I’ll say, ‘Your chances for living for a year are about as good as someone living with metastatic lung cancer,’ ” says Dr. Epstein. “I think that’s something that patients grasp a lot easier.”

In addition to the fear of being incorrect in prognosticating, physicians often don’t want their patients to lose hope. “Whereas in truth people are already thinking about these things, and there are studies that show people want their doctors to bring it up,” says Dr. Chittenden.7

A number of these studies were conducted by Dr. Christakis and Elizabeth Lamont, MD, a medical oncologist now practicing at Massachusetts General Hospital Cancer Center and assistant professor of medicine and health care policy at Harvard Medical School.15,17-19 Their findings have shown that doctors’ inaccuracies in their prognoses for terminally ill patients are systematically optimistic and that this may adversely affect the quality of care given to patients near the end of life.17

In their study of 326 patients in five hospices in Chicago, Drs. Christakis and Lamont showed that even if patients with cancer requested survival estimates, doctors would provide a frank estimate only 37% of the time and would provide no estimate, a conscious overestimate, or a conscious underestimate most of the time (63%).18 This, they concluded, may contribute to the observed disparities between physicians’ and patients’ estimates of survival.

Dr. Lamont’s interest in prognosis at end of life and the subject of advanced care planning arose from her experiences as a resident when she was cross-covering the oncology services. “I would be called to see [for example] a 35-year-old woman with widely metastatic breast cancer including brain metastases who was clearly at the end of life,” she says. “She became acutely short of breath, and my concern was that she was having a pulmonary embolism. … I was trying to decide whether to send her to the ICU. I was trying to inform her about the risks of anticoagulation … and I asked, ‘Have you talked about whether or not you’d want to go to the intensive care unit, whether or not you’d want your heart restarted, whether or not you’d want to be put on a ventilator if you couldn’t be breathe on your own; have you talked about these kinds of things with your oncologist?’ [Her answer was,] ‘Oh, no!’ ” Dr. Lamont figured that if she would have these conversations anyway, it would make more sense to have them as part of the admission history and physical. The study she subsequently designed and conducted involved 111 newly admitted patients with cancer whom she interviewed about (among other things) whether they had advanced care preferences (ACP) and whether they had discussed advanced directives with their medical oncologists. Only 9% of patients said that they had advanced directives, although 69% of patients had discussed their ACP with someone else (such as family).19 (See “ACP among Hospitalized Cancer Patients,” below.) However, 58% of patients approved of the option of being offered a discussion about advanced care planning with medical house staff as part of the admission history.

In other words, for the population of patients at high risk for dying during their current hospitalization, more than half would be open to discussing ACP with those whom they do not know well—such as hospitalists.

Practice Phrases

Dr. Epstein says certain words or phrases serve as tools for the hospitalist to use when talking about whether to sustain acute care or change the course of treatment. Though an individual hospitalist might personalize these phrases, the following are tried and true.

What have the doctors told you?

How do you think things are going?

What do you expect to happen?

What do you hope to get out of this hospitalization?

What do you hope to get out of all the treatment that we’re offering you?

What do you think will happen to you in the next month? Three months? Six months?

Do you think you are getting better this time in the hospital? Do you think you are getting worse?

Do you think after you leave the hospital this time you’ll like the quality of life you have or do you think you’ll feel it is not improving and you’ll want to move to supportive care?

Advance Care Planning

A study just published in Archives of Internal Medicine suggests that elderly people who suffer from terminal illnesses become increasingly more willing to accept a life-preserving treatment, resulting in further physical disability or more pain if they were already diminished in those domains.20 Terri Fried, MD, an associate professor of internal medicine at Yale, and her colleagues studied 226 older men and women with advanced cancer, congestive heart failure (CHF), or COPD. In the course of in-home interviews conducted over two years, the investigators explored whether the participants would accept life-prolonging treatment if it resulted in one of four diminished health states: mild physical disability, severe physical disability, mental disability, or moderately severe daily pain.

Results showed that the likelihood of a treatment resulting in mild or severe functional disability rating as acceptable increased with each month of participation in the study. More than half of the patients had prepared living wills, and these individuals were more likely to prefer death to disability, but preferences could also change. These findings suggest that even though providers, patients, and families may have already had conversations about advance care planning, a patient’s change in health status might herald the need for a new conversation.

Dr. Lamont says there are two major areas in which hospitalists can politically advocate for changes that could facilitate better advance care planning. The first is to adopt the model proposed in her study, whereby patients are queried regarding advanced directives as part of the admission history.19 Patients for whom this could be added as a new data field would include, for example, those with advanced cancer, metastatic solid tumors, relapsed leukemia, relapsed lymphoma, or with acute exacerbations of illnesses such as CHF or COPD. The second area where hospitalists could advocate for change is national healthcare policy. Like a number of others, Dr. Lamont believes CMS should begin reimbursing for high-quality end-of-life care discussions, the measures of which would be determined at both local and national levels.

Existential Issues: Alternative Ways to Communicate

David Solie, MS, PA, clinician, educator and author of How to Say It to Seniors: Closing the Communication Gap with Our Elders, was working with a patient whom Solie predicted had two to three days to live.22 Solie asked the patient’s wife whom he might call for her. She said her husband had a brother who was estranged, and though conflicted over it, the patient had vowed he would never talk to him again.

With the wife’s permission, Solie contacted the brother. When Solie came to work the next day, the brother was sitting by the patient’s bed. “As a provider,” says Solie, “it was an overwhelming experience for me. I was so caught off guard that, at this last growth phase of life, as people sort out their life and how they want to be remembered, there were chances for all kinds of reconciliations and … conclusions.”

The patient was a man in his late 40s. He’d been married and divorced and had three children in that marriage. Then he had another relationship in which he’d had two children who were quite young. The children from the second marriage were about three and six years old. His wish was to see his younger children before he died, and his mother and father and brother had hoped to help with his reconciliation—to try to get the ex-girlfriend to bring in the two children—but she had refused. So I asked, “Well, can I call?”

[I did and] I explained that he was dying and this was literally his last wish, and the next day she brought the children. It was wonderful. There was reconciliation not just with the children and the father, but with this woman. And I think he died more peacefully because of that. … I would say to other hospitalists, just use your common sense and your humanity, and also your creativity. It’s thinking outside the box. It’s not thinking in the medical model.—Eva Chittenden, MD

We had a man in his 60s who was dying of bladder cancer. He had a bowel obstruction, … a nasogastric tube, and he was terribly depressed. We spent lots of time working with him and his family, and they ended up having some good time together. It helped that once we got his nausea under control, he had a little bit of an appetite. So we asked him what he wanted to eat and he said, “peach gelato with mocha Frappuccino.” His family [felt great] because they could go out and do something. … He could eat it and taste it, and then it just got sucked back out the tube.—Eva Chittenden, MD

Communication Training

“The more hospital medicine training gets incorporated into internal medicine residency,” says Dr. Epstein, “the greater the opportunity to train new hospitalists to have these difficult conversations: how to have a family meeting, to identify the issues, to see if there are any ethical issues involved, any legal issues, and how to negotiate a reasonable plan of care based on the patient’s goals.”2,8,21

In addition to helping with control of physical symptoms, such as pain and nausea control, physicians facilitate decision-making. “We try to address a lot of the existential and reconciliation and legacy issues,” says Dr. Chittenden. Because of the number of situations in which the patient is a woman or man in their 40s or 50s who have young children, she says, “we help the parents come to terms with this and get our child-life specialist involved to help the parents think about how to talk with the kids.”

Because of the growth of the palliative care movement, the training is beginning to improve. “The LCME [Liaison Committee on Medical Education], the licensure group for medical schools, mandates that there be some end-of-life care exposure,” says Dr. Chittenden. “And the ACGME [Accreditation Council for Graduate Medical Education], which licenses the residency programs, strongly suggests that there be opportunities to learn about this. … Slowly but surely we are realizing this needs to happen, but we are far from doing it well.”

What would be ideal? A two-week rotation for residents in a palliative care service? “That would be wonderful,” says Dr. Epstein. “As more palliative care services pop up across the country, the chance of that happening would increase. … And even if you’re not in palliative care and you’re a hospitalist and you do these kinds of things well, the residents should be watching you have those kinds of conversations.”

Explaining that he is paraphrasing Mark Leenay, MD, the former program director at Fairview-University, Minnesota, and the physician who spearheaded the development of a clinical team that comprehensively addresses the multiple aspects of suffering from life-threatening illness, Dr. Epstein says: “I can train anybody to do symptom management in hospice, but how to walk into a room and understand … and negotiate the family dynamics and the patient’s plan of care … to communicate on different levels with different people with … their own agendas, and all the pieces of information … [and different interpretations] … to take it all in and digest it for that meeting and spit it out in a way [in which] everyone can relate and come to some sort of consensus, hopefully, at the end of the meeting? That’s the art. And that takes practice.”

Conclusion

Patients with life-threatening chronic illnesses are often admitted to the hospital multiple times in the course of the period that could be considered the end of life. Important nonmedical issues for hospitalists to address at each new admission include communication regarding prognosis and advance care planning, and addressing existential issues greatly contributes to the quality of care. TH

Resources

The Hastings Center is involved in bioethics and other issues surrounding end-of-life care (www.thehastingscenter.org/default.asp). The Special Report listed in “References” is downloadable from their Web site.23

Education in Palliative and End-of-Life Care (EPEC) curriculum (www.epec.net).

The American Board of Hospice and Palliative Medicine (www.abhpm.org).

The American Association of Hospice and Palliative Medicine (www.aahpm.org).

Harvard’s Center for Palliative Care offers courses that emphasize teaching (www.hms.harvard.edu/cdi/pallcare/).

The Center to Advance Palliative Care (CAPC), Mount Sinai School of Medicine, New York, serves as a resource for hospital-based palliative care program development. CAPC supports six regional Palliative Care Leadership Centers (www.capc.org).

The following Web sites include models for advance directives.

Five Wishes: www.agingwithdignity.org

Individual decisions: www.newgrangepress.com

Respecting choices at end of life: www.gundersenlutheran.com/eolprograms

Physician orders for life-sustaining treatment: www.polst.org

References

Auerbach AD, Pantilat SZ. End-of-Life care in a voluntary hospitalist model: effects on communication, processes of care, and patient symptoms. Am J Med. 2004 May 15;116(10):669-675.

Plauth WH, Pantilat SZ, Wachter RM, et al. Hospitalists' perceptions of their residency training needs: result of a national survey. Am J Med. 2001;111(3):247-254.

Lo B, Quill TE, Tulsky J. Discussing palliative care with patients. ACP--ASIM End-of-Life Care Consensus Panel. American College of Physicians--American Society of Internal Medicine. Ann Intern Med. 1999 May 4;130(9):744-749.

Quill TE. Initiating end-of-life discussions with seriously ill patients: addressing the "elephant in the room." JAMA. 2000 Nov 15;284(19):2502-2507.

Kaufman SR. And a Time to Die: How American Hospitals Shape the End of Life. New York: Scribner; 2005.

Kaufman SR. A commentary: hospital experience and meaning at the end of life. Gerontologist. 2002 Oct;42 Spec No. 3:34-39.

Pantilat SZ. End-of-life care for the hospitalized patient. Med Clin North Am. 2002 Jul;86(4):749-770.

Tulsky JA. Beyond advance directives: importance of communication skills at the end of life. JAMA. 2005 Jul 20;294(3):359-365.

Heyland DK, Dodek P, Rocker G, et al. What matters most in end-of-life care: perceptions of seriously ill patients and their family members. CMAJ. 2006 Feb 28;174(5):627-633.

Barbato M. Caring for the dying: the doctor as healer. MJAust. 2003 May 19;178(10):508-509.

Fallowfield LJ, Jenkins VA, Beveridge HA. Truth may hurt but deceit hurts more: communication in palliative care. Palliat Med. 2002 Jul;16(4):297-303.

Fins JJ, Miller FG, Acres CA, et al. End-of-life decision-making in the hospital: current practice and future prospects. J Pain Symptom Manage. 1999 Jan;17(1):6-15.

Kalish RA. Death, grief and caring relationships. Belmont, California: Brooks/Cole; 1985.

Lynn J, Schuster JL, Kabcenell A. Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians. New York: Oxford University Press; 2000.

Lamont EB. A demographic and prognostic approach to defining the end of life. J Palliat Med. 2005;8 Suppl 1:S12-21.

Christakis NA. Death Foretold: Prophecy and Prognosis in Medical Care. Chicago: University of Chicago Press; 2001.

Christakis NA, Lamont EB. Extent and determinants of error in doctors' prognoses in terminally ill patients: prospective cohort study. BMJ. 2000 Feb;320(7233):469-472.

Lamont EB, Christakis NA. Prognostic disclosure to patients with cancer near the end of life. Ann Intern Med. 2001 Jun 19; 134 (12):1096-1105.

Lamont EB, Siegler M. Paradoxes in cancer patients' advance care planning. J Palliat Med. 2000 Spring;3(1):27-35.

Fried TR, Byers AL, Gallo WT, et al. Prospective study of health status preferences and changes in preferences over time in older adults. Arch Intern Med. 2006 Apr 24;166(8):890-895.

McPhee SJ, Rabow MW, Pantilat SZ, et al. Finding our way--perspectives on care at the close of life. JAMA. 2000 Nov 15;284(19):2512-2513.

Solie D. How to Say It to Seniors: Closing the Communication Gap with Our Elders. New York: Prentice Hall Press; 2004.

Jennings B, Kaebnick GE, Murray TH. Improving End of Life Care: Why Has It Been So Difficult? Hastings Center Special Report. 2005;35.

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What’s Good in a Good Death?

Even though providers, patients, and families may have already had conversations about advanced care planning, a patient’s change in health status might herald the need for a new conversation.

Talking about Prognosis

Practice Phrases

What have the doctors told you?

How do you think things are going?

What do you expect to happen?

What do you hope to get out of this hospitalization?

What do you hope to get out of all the treatment that we’re offering you?

What do you think will happen to you in the next month? Three months? Six months?

Do you think you are getting better this time in the hospital? Do you think you are getting worse?

Do you think after you leave the hospital this time you’ll like the quality of life you have or do you think you’ll feel it is not improving and you’ll want to move to supportive care?

Advance Care Planning

Existential Issues: Alternative Ways to Communicate

David Solie, MS, PA, clinician, educator and author of How to Say It to Seniors: Closing the Communication Gap with Our Elders, was working with a patient whom Solie predicted had two to three days to live.22 Solie asked the patient’s wife whom he might call for her. She said her husband had a brother who was estranged, and though conflicted over it, the patient had vowed he would never talk to him again.

With the wife’s permission, Solie contacted the brother. When Solie came to work the next day, the brother was sitting by the patient’s bed. “As a provider,” says Solie, “it was an overwhelming experience for me. I was so caught off guard that, at this last growth phase of life, as people sort out their life and how they want to be remembered, there were chances for all kinds of reconciliations and … conclusions.”

The patient was a man in his late 40s. He’d been married and divorced and had three children in that marriage. Then he had another relationship in which he’d had two children who were quite young. The children from the second marriage were about three and six years old. His wish was to see his younger children before he died, and his mother and father and brother had hoped to help with his reconciliation—to try to get the ex-girlfriend to bring in the two children—but she had refused. So I asked, “Well, can I call?”

[I did and] I explained that he was dying and this was literally his last wish, and the next day she brought the children. It was wonderful. There was reconciliation not just with the children and the father, but with this woman. And I think he died more peacefully because of that. … I would say to other hospitalists, just use your common sense and your humanity, and also your creativity. It’s thinking outside the box. It’s not thinking in the medical model.—Eva Chittenden, MD

We had a man in his 60s who was dying of bladder cancer. He had a bowel obstruction, … a nasogastric tube, and he was terribly depressed. We spent lots of time working with him and his family, and they ended up having some good time together. It helped that once we got his nausea under control, he had a little bit of an appetite. So we asked him what he wanted to eat and he said, “peach gelato with mocha Frappuccino.” His family [felt great] because they could go out and do something. … He could eat it and taste it, and then it just got sucked back out the tube.—Eva Chittenden, MD

Communication Training

Conclusion

Resources

The Hastings Center is involved in bioethics and other issues surrounding end-of-life care (www.thehastingscenter.org/default.asp). The Special Report listed in “References” is downloadable from their Web site.23

Education in Palliative and End-of-Life Care (EPEC) curriculum (www.epec.net).

The American Board of Hospice and Palliative Medicine (www.abhpm.org).

The American Association of Hospice and Palliative Medicine (www.aahpm.org).

Harvard’s Center for Palliative Care offers courses that emphasize teaching (www.hms.harvard.edu/cdi/pallcare/).

The Center to Advance Palliative Care (CAPC), Mount Sinai School of Medicine, New York, serves as a resource for hospital-based palliative care program development. CAPC supports six regional Palliative Care Leadership Centers (www.capc.org).

The following Web sites include models for advance directives.

Five Wishes: www.agingwithdignity.org

Individual decisions: www.newgrangepress.com

Respecting choices at end of life: www.gundersenlutheran.com/eolprograms

Physician orders for life-sustaining treatment: www.polst.org

References

Auerbach AD, Pantilat SZ. End-of-Life care in a voluntary hospitalist model: effects on communication, processes of care, and patient symptoms. Am J Med. 2004 May 15;116(10):669-675.

Plauth WH, Pantilat SZ, Wachter RM, et al. Hospitalists' perceptions of their residency training needs: result of a national survey. Am J Med. 2001;111(3):247-254.

Lo B, Quill TE, Tulsky J. Discussing palliative care with patients. ACP--ASIM End-of-Life Care Consensus Panel. American College of Physicians--American Society of Internal Medicine. Ann Intern Med. 1999 May 4;130(9):744-749.

Quill TE. Initiating end-of-life discussions with seriously ill patients: addressing the "elephant in the room." JAMA. 2000 Nov 15;284(19):2502-2507.

Kaufman SR. And a Time to Die: How American Hospitals Shape the End of Life. New York: Scribner; 2005.

Kaufman SR. A commentary: hospital experience and meaning at the end of life. Gerontologist. 2002 Oct;42 Spec No. 3:34-39.

Pantilat SZ. End-of-life care for the hospitalized patient. Med Clin North Am. 2002 Jul;86(4):749-770.

Tulsky JA. Beyond advance directives: importance of communication skills at the end of life. JAMA. 2005 Jul 20;294(3):359-365.

Heyland DK, Dodek P, Rocker G, et al. What matters most in end-of-life care: perceptions of seriously ill patients and their family members. CMAJ. 2006 Feb 28;174(5):627-633.

Barbato M. Caring for the dying: the doctor as healer. MJAust. 2003 May 19;178(10):508-509.

Fallowfield LJ, Jenkins VA, Beveridge HA. Truth may hurt but deceit hurts more: communication in palliative care. Palliat Med. 2002 Jul;16(4):297-303.

Fins JJ, Miller FG, Acres CA, et al. End-of-life decision-making in the hospital: current practice and future prospects. J Pain Symptom Manage. 1999 Jan;17(1):6-15.

Kalish RA. Death, grief and caring relationships. Belmont, California: Brooks/Cole; 1985.

Lynn J, Schuster JL, Kabcenell A. Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians. New York: Oxford University Press; 2000.

Lamont EB. A demographic and prognostic approach to defining the end of life. J Palliat Med. 2005;8 Suppl 1:S12-21.

Christakis NA. Death Foretold: Prophecy and Prognosis in Medical Care. Chicago: University of Chicago Press; 2001.

Christakis NA, Lamont EB. Extent and determinants of error in doctors' prognoses in terminally ill patients: prospective cohort study. BMJ. 2000 Feb;320(7233):469-472.

Lamont EB, Christakis NA. Prognostic disclosure to patients with cancer near the end of life. Ann Intern Med. 2001 Jun 19; 134 (12):1096-1105.

Lamont EB, Siegler M. Paradoxes in cancer patients' advance care planning. J Palliat Med. 2000 Spring;3(1):27-35.

Fried TR, Byers AL, Gallo WT, et al. Prospective study of health status preferences and changes in preferences over time in older adults. Arch Intern Med. 2006 Apr 24;166(8):890-895.

McPhee SJ, Rabow MW, Pantilat SZ, et al. Finding our way--perspectives on care at the close of life. JAMA. 2000 Nov 15;284(19):2512-2513.

Solie D. How to Say It to Seniors: Closing the Communication Gap with Our Elders. New York: Prentice Hall Press; 2004.

Jennings B, Kaebnick GE, Murray TH. Improving End of Life Care: Why Has It Been So Difficult? Hastings Center Special Report. 2005;35.

What’s Good in a Good Death?

Even though providers, patients, and families may have already had conversations about advanced care planning, a patient’s change in health status might herald the need for a new conversation.

Talking about Prognosis

Practice Phrases

What have the doctors told you?

How do you think things are going?

What do you expect to happen?

What do you hope to get out of this hospitalization?

What do you hope to get out of all the treatment that we’re offering you?

What do you think will happen to you in the next month? Three months? Six months?

Do you think you are getting better this time in the hospital? Do you think you are getting worse?

Do you think after you leave the hospital this time you’ll like the quality of life you have or do you think you’ll feel it is not improving and you’ll want to move to supportive care?

Advance Care Planning

Existential Issues: Alternative Ways to Communicate

David Solie, MS, PA, clinician, educator and author of How to Say It to Seniors: Closing the Communication Gap with Our Elders, was working with a patient whom Solie predicted had two to three days to live.22 Solie asked the patient’s wife whom he might call for her. She said her husband had a brother who was estranged, and though conflicted over it, the patient had vowed he would never talk to him again.

With the wife’s permission, Solie contacted the brother. When Solie came to work the next day, the brother was sitting by the patient’s bed. “As a provider,” says Solie, “it was an overwhelming experience for me. I was so caught off guard that, at this last growth phase of life, as people sort out their life and how they want to be remembered, there were chances for all kinds of reconciliations and … conclusions.”

The patient was a man in his late 40s. He’d been married and divorced and had three children in that marriage. Then he had another relationship in which he’d had two children who were quite young. The children from the second marriage were about three and six years old. His wish was to see his younger children before he died, and his mother and father and brother had hoped to help with his reconciliation—to try to get the ex-girlfriend to bring in the two children—but she had refused. So I asked, “Well, can I call?”

[I did and] I explained that he was dying and this was literally his last wish, and the next day she brought the children. It was wonderful. There was reconciliation not just with the children and the father, but with this woman. And I think he died more peacefully because of that. … I would say to other hospitalists, just use your common sense and your humanity, and also your creativity. It’s thinking outside the box. It’s not thinking in the medical model.—Eva Chittenden, MD

We had a man in his 60s who was dying of bladder cancer. He had a bowel obstruction, … a nasogastric tube, and he was terribly depressed. We spent lots of time working with him and his family, and they ended up having some good time together. It helped that once we got his nausea under control, he had a little bit of an appetite. So we asked him what he wanted to eat and he said, “peach gelato with mocha Frappuccino.” His family [felt great] because they could go out and do something. … He could eat it and taste it, and then it just got sucked back out the tube.—Eva Chittenden, MD

Communication Training

Conclusion

Resources

The Hastings Center is involved in bioethics and other issues surrounding end-of-life care (www.thehastingscenter.org/default.asp). The Special Report listed in “References” is downloadable from their Web site.23

Education in Palliative and End-of-Life Care (EPEC) curriculum (www.epec.net).

The American Board of Hospice and Palliative Medicine (www.abhpm.org).

The American Association of Hospice and Palliative Medicine (www.aahpm.org).

Harvard’s Center for Palliative Care offers courses that emphasize teaching (www.hms.harvard.edu/cdi/pallcare/).

The Center to Advance Palliative Care (CAPC), Mount Sinai School of Medicine, New York, serves as a resource for hospital-based palliative care program development. CAPC supports six regional Palliative Care Leadership Centers (www.capc.org).

The following Web sites include models for advance directives.

Five Wishes: www.agingwithdignity.org

Individual decisions: www.newgrangepress.com

Respecting choices at end of life: www.gundersenlutheran.com/eolprograms

Physician orders for life-sustaining treatment: www.polst.org

References

Auerbach AD, Pantilat SZ. End-of-Life care in a voluntary hospitalist model: effects on communication, processes of care, and patient symptoms. Am J Med. 2004 May 15;116(10):669-675.

Plauth WH, Pantilat SZ, Wachter RM, et al. Hospitalists' perceptions of their residency training needs: result of a national survey. Am J Med. 2001;111(3):247-254.

Lo B, Quill TE, Tulsky J. Discussing palliative care with patients. ACP--ASIM End-of-Life Care Consensus Panel. American College of Physicians--American Society of Internal Medicine. Ann Intern Med. 1999 May 4;130(9):744-749.

Quill TE. Initiating end-of-life discussions with seriously ill patients: addressing the "elephant in the room." JAMA. 2000 Nov 15;284(19):2502-2507.

Kaufman SR. And a Time to Die: How American Hospitals Shape the End of Life. New York: Scribner; 2005.

Kaufman SR. A commentary: hospital experience and meaning at the end of life. Gerontologist. 2002 Oct;42 Spec No. 3:34-39.

Pantilat SZ. End-of-life care for the hospitalized patient. Med Clin North Am. 2002 Jul;86(4):749-770.

Tulsky JA. Beyond advance directives: importance of communication skills at the end of life. JAMA. 2005 Jul 20;294(3):359-365.

Heyland DK, Dodek P, Rocker G, et al. What matters most in end-of-life care: perceptions of seriously ill patients and their family members. CMAJ. 2006 Feb 28;174(5):627-633.

Barbato M. Caring for the dying: the doctor as healer. MJAust. 2003 May 19;178(10):508-509.

Fallowfield LJ, Jenkins VA, Beveridge HA. Truth may hurt but deceit hurts more: communication in palliative care. Palliat Med. 2002 Jul;16(4):297-303.

Fins JJ, Miller FG, Acres CA, et al. End-of-life decision-making in the hospital: current practice and future prospects. J Pain Symptom Manage. 1999 Jan;17(1):6-15.

Kalish RA. Death, grief and caring relationships. Belmont, California: Brooks/Cole; 1985.

Lynn J, Schuster JL, Kabcenell A. Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians. New York: Oxford University Press; 2000.

Lamont EB. A demographic and prognostic approach to defining the end of life. J Palliat Med. 2005;8 Suppl 1:S12-21.

Christakis NA. Death Foretold: Prophecy and Prognosis in Medical Care. Chicago: University of Chicago Press; 2001.

Christakis NA, Lamont EB. Extent and determinants of error in doctors' prognoses in terminally ill patients: prospective cohort study. BMJ. 2000 Feb;320(7233):469-472.

Lamont EB, Christakis NA. Prognostic disclosure to patients with cancer near the end of life. Ann Intern Med. 2001 Jun 19; 134 (12):1096-1105.

Lamont EB, Siegler M. Paradoxes in cancer patients' advance care planning. J Palliat Med. 2000 Spring;3(1):27-35.

Fried TR, Byers AL, Gallo WT, et al. Prospective study of health status preferences and changes in preferences over time in older adults. Arch Intern Med. 2006 Apr 24;166(8):890-895.

McPhee SJ, Rabow MW, Pantilat SZ, et al. Finding our way--perspectives on care at the close of life. JAMA. 2000 Nov 15;284(19):2512-2513.

Solie D. How to Say It to Seniors: Closing the Communication Gap with Our Elders. New York: Prentice Hall Press; 2004.

Jennings B, Kaebnick GE, Murray TH. Improving End of Life Care: Why Has It Been So Difficult? Hastings Center Special Report. 2005;35.

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