Survey reveals barriers to end-of-life, advance care planning discussions

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Although almost all physicians who treat Medicare beneficiaries think end-of-life and advance care planning conversations are important, many of them report significant barriers to having these discussions with those for whom they care, and 46% report that they frequently or sometimes feel unsure of what to say, according to the results of a new national poll.

In January, the Centers for Medicare & Medicaid Services began reimbursing doctors and other professionals for having such discussions. The benefit covers multiple conversations and is not limited to people who are close to death.

The new poll finds that 95% of physicians support the new benefit, although only 14% report they have billed Medicare for an advance care planning conversation since reimbursement began.

The survey was commissioned by The John A. Hartford Foundation, the California Health Care Foundation and Cambia Health Foundation, and it includes responses from 736 primary care and specialist physicians (oncologists, pulmonologists and cardiologists) in 50 states.

Although the long-term effect of the new Medicare benefit remains unclear, 75% of survey participants predicted that it will make them more likely to talk with older adults about advance care planning. And 87% of them believe that such conversations could reduce unwanted hospitalizations at the end of life.

The survey findings mesh with the opinions of members of the Assisted Living Committee of AMDA–The Society for Post-Acute and Long-Term Care Medicine, who recently identified rehospitalizations as one of the top three issues on which assisted living providers should focus. The provision of care, including end-of-life care, was identified as an important area as well.

At a session during the 2016 Spring Investment Forum of the National Investment Center for Seniors Housing & Care, Brookdale Chief Medical Officer Kevin O'Neil, M.D., who chairs the AMDA committee, said that advance care and end-of-life planning could prevent unnecessary hospitalizations and rehospitalizations of assisted living residents and other older adults.

“So many of the folks we're sending bouncing back and forth, back and forth, are those who would've been much better served by palliative and/or hospice care,” he said. “They're at the end of a disease trajectory.”

Healthcare professionals must have discussions with those for whom they care to understand their health goals, and they also must educate older adults about their health statuses, O'Neil said. “I think if more people understood what the prognosis was, they'd probably be less inclined to subject themselves to very burdensome, intrusive interventions which, truthfully, are often very futile” as well as expensive, he added.

So why aren't these conversations occurring? The physicians responding to the new survey identified several barriers:

  • 48% said they didn't want an advance care planning conversation to cause those in their care to feel they were “giving up” on them, and 46% said they didn't want those in their care to “give up hope.”
  • Only 29% reported that their practice or healthcare system has a formal system for assessing patients' end-of-life wishes and goals of care.
  • Only 29% reported having had any formal training specifically on talking with people and their families about end-of-life care.
  • 24% said there is no place in their electronic health record to indicate whether someone has an advance care plan; for those doctors whose EHRs do contain advance care plan information, only 54% said they can access those plans.

A second phase of the polling project will conduct focus groups with physicians, nurse practitioners and others on the healthcare team to explore these and related barriers in more detail.

The good news is that physicians who said they had been trained in end-of-life conversations are more likely (46%) to find conversations about end-of-life care to be rewarding than those who have not (30%), and also said they feel unsure about what to say in these conversations “rarely or not too often” (60%) compared with those who have not had explicit training (52%).

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