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Advance directives may lower costs, increase compassionate care

Monday, August 18, 2014   (0 Comments)
Posted by: Kelly Hekler
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Advance directives may lower costs, increase compassionate care


By Susan Schooleman, MGMA staff writer

The need for patients to have advance directives was underscored when MGMA member Keith Rapp, MD, CMD, of Geriatric Associates of America PA, Houston, successfully resuscitated a 95-year-old man while Rapp was a medical student in 1978. Advance directives are generally defined as a written statement of a person's wishes regarding medical treatment, made to make sure those steps are taken by another if the person is unable to communicate them to a doctor.
 
“The patient told me, ‘You know, if that ever happens again, do not do that again. Do not ever put me through that again.’ That individual event kind of struck a heart-chord in me that there are things worse than death, and I think having a prolonged suffering phase at the end of one’s life is one of them,” Rapp says.
 
Rapp has long recognized the need for patients to put their own advance directives in place before they’re not able to make the decision themselves. Often when family members have to make end-of-life decisions for their loved ones, they become emotional and opt for costly heroic measures that add little value, as documented in a recent National Public Radio Planet Money broadcast.
 
Thus, when Rapp started his geriatric practice in 1996, his group put an incentive in place – 3% of provider salaries is tied to whether providers meet 10 quality measures that were developed specifically for the practice. One of these measures is that the provider must ask any new patient about any advance directive wishes.
 
In addition to frequently only extending patient suffering, end-of-life care can be extremely costly because rather than opt for the natural course of one’s life end, which is less expensive – and usually selected by a patient as part of an advance directive – patients’ families will opt for more aggressive measures even though many times this is only prolonging a suffering stage of one’s life.
 
Ideally, it would be beneficial if providers introduce advance directives while patients are still healthy, says Alex Binder, MGMA member, chief operating officer, Visiting Physician Services, Eatontown, N.J.
“I think it’s good to talk about them when everyone is healthy, but too many of us are ‘in denial.’
I mean I don’t even have an advance directive! … do you?” he says.
 
The reality: most providers should talk to a patient and his or her family when there is “some type of deterioration in the patient’s condition,” he says.
 
“The process usually starts by our providers assessing the patient’s family’s awareness of the ‘next phase.’ We ask the family, ‘What are your expectations for your father over the next six months?’ Or we might ask, ‘Would you be surprised if his condition worsened, or if he were to pass in the next few months?’ That allows us to start the discussion from their perspective,” Binder says.
 
In addition to the advance directive form, Rapp recommends a “do not attempt to resuscitate” order rather than a “do not resuscitate” order. Adding the word “attempt” is important because it underscores that if an elderly patient is successfully resuscitated – and many times that does not happen – he or she may not return to full capacity, Rapp says.
 
Both Binder and Rapp believe ensuring patients have advance directives must be part of a more comprehensive end-of-life care discussion with patients and their family members.

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