Showing posts with label negotiation. Show all posts
Showing posts with label negotiation. Show all posts
Thursday, January 15, 2009
Pallimed Case Conferences (cases.pallimed.org) is closed to comments and new posts as of April 25, 2013.
This site will stay online as an archived source, but will no longer be updated.
For active posts on these cases and new cases go to www.pallimed.com.
By Linda A. King, MD and Nicole Fowler, MHSA
Originally posted at the Institute to Enhance Palliative Care, University of Pittsburgh Medical Center
Vol 1, No. 8 - March 2002
(Original PDF)
(Original PDF)
Case:
A 67-year-old man with end-stage congestive heart failure presented to the hospital with worsening respiratory distress and was intubated in the emergency room. Despite a week of intensive efforts, he could not be weaned from the ventilator and remained dependent on intravenous dobutamine for blood pressure support. The ICU staff met with the patient and family to discuss the medical situation and options for care including withdrawal of life support. The patient did not want to continue on long-term ventilatory support nor did he want to die in the hospital. The patient expressed to the care team a strong desire to leave the hospital and to die at home.
A palliative care consultation was initiated to support the patient and family and to assist with a discharge to home. The patient, family, ICU team and palliative care team discussed potential options for discharge and decided on a plan to transport the patient home with ongoing mechanical ventilation and inotropic support. This option allowed the patient to be comfortable at home with his family before removing the ventilator and providing medications for comfort that would likely be sedating. Efforts to carry out this plan were hindered by the reluctance of home care and hospice agencies to participate in this “unusual” and expensive plan that provided little or no reimbursement (i.e. withdrawal of life-support in the home setting while the patient continued on Dobutamine).
Following hours of coordination and planning, the physician from the Palliative Care service and a nurse from the ICU rode home in the ambulance with the patient where they were met by many of the patient’s family and friends and a private duty nurse to support the patient and family. After a few hours of visiting with his loved ones, the patient indicated that he was ready for the ventilator to be withdrawn. Intravenous morphine and ativan were administered until the patient was comfortable, then the endotracheal tube was removed. Additional medication was administered intermittently to maintain adequate comfort and the patient died comfortably at home a few days later. The family expressed their gratitude that the patient’s wish to die at home was achieved.
Discussion
For many patients facing a life-threatening illness, death at home is viewed as a desirable and even essential element of a “good death.” Patients in the hospital expected to die imminently after the withdrawal of life-support do not typically have this option because of the obstacles and lack of payment incentives for coordinating this type of care. Withdrawal of life support in the home can provide patients and families with the opportunity to achieve their goal of dying in the familiar setting of their own home at a lower cost than the average cost of care in an ICU.
However, in our current care system it requires extenuating circumstances and significant coordination and planning to assure that patients and families are well supported and the patient’s comfort is maintained. When the goals of care shift for seriously ill patients from a disease-specific and curative approach to an approach that focuses on comfort, symptom management and other personal preferences for care (such as wanting to die at home), the health care system is often inadequate and discontinuous. One reason, as in our highlighted case, is that “ownership” for this type of coordination does not exist and few providers (home care and others) are willing to assume this role because most insurance programs (such as Medicare) will not pay. Since most care is reimbursed according to location, it is difficult to provide comprehensive services that meet the changing goals of patients as their disease progresses.
Public policies and financial incentives that encourage and reward hospitals, home care agencies, nursing homes and hospices for seamless care need to be established. Surely to compliment our modern care system and life prolonging technologies we should be able to develop a reliable and sustainable system that also relieves symptoms, honors preferences and supports patients and their families at the end of life.
References:
1. Lynn, J. Serving patients who may die soon and their families. JAMA 2002;285: pp. 925-932.
A 67-year-old man with end-stage congestive heart failure presented to the hospital with worsening respiratory distress and was intubated in the emergency room. Despite a week of intensive efforts, he could not be weaned from the ventilator and remained dependent on intravenous dobutamine for blood pressure support. The ICU staff met with the patient and family to discuss the medical situation and options for care including withdrawal of life support. The patient did not want to continue on long-term ventilatory support nor did he want to die in the hospital. The patient expressed to the care team a strong desire to leave the hospital and to die at home.
A palliative care consultation was initiated to support the patient and family and to assist with a discharge to home. The patient, family, ICU team and palliative care team discussed potential options for discharge and decided on a plan to transport the patient home with ongoing mechanical ventilation and inotropic support. This option allowed the patient to be comfortable at home with his family before removing the ventilator and providing medications for comfort that would likely be sedating. Efforts to carry out this plan were hindered by the reluctance of home care and hospice agencies to participate in this “unusual” and expensive plan that provided little or no reimbursement (i.e. withdrawal of life-support in the home setting while the patient continued on Dobutamine).
Following hours of coordination and planning, the physician from the Palliative Care service and a nurse from the ICU rode home in the ambulance with the patient where they were met by many of the patient’s family and friends and a private duty nurse to support the patient and family. After a few hours of visiting with his loved ones, the patient indicated that he was ready for the ventilator to be withdrawn. Intravenous morphine and ativan were administered until the patient was comfortable, then the endotracheal tube was removed. Additional medication was administered intermittently to maintain adequate comfort and the patient died comfortably at home a few days later. The family expressed their gratitude that the patient’s wish to die at home was achieved.
Discussion
For many patients facing a life-threatening illness, death at home is viewed as a desirable and even essential element of a “good death.” Patients in the hospital expected to die imminently after the withdrawal of life-support do not typically have this option because of the obstacles and lack of payment incentives for coordinating this type of care. Withdrawal of life support in the home can provide patients and families with the opportunity to achieve their goal of dying in the familiar setting of their own home at a lower cost than the average cost of care in an ICU.
However, in our current care system it requires extenuating circumstances and significant coordination and planning to assure that patients and families are well supported and the patient’s comfort is maintained. When the goals of care shift for seriously ill patients from a disease-specific and curative approach to an approach that focuses on comfort, symptom management and other personal preferences for care (such as wanting to die at home), the health care system is often inadequate and discontinuous. One reason, as in our highlighted case, is that “ownership” for this type of coordination does not exist and few providers (home care and others) are willing to assume this role because most insurance programs (such as Medicare) will not pay. Since most care is reimbursed according to location, it is difficult to provide comprehensive services that meet the changing goals of patients as their disease progresses.
Public policies and financial incentives that encourage and reward hospitals, home care agencies, nursing homes and hospices for seamless care need to be established. Surely to compliment our modern care system and life prolonging technologies we should be able to develop a reliable and sustainable system that also relieves symptoms, honors preferences and supports patients and their families at the end of life.
References:
1. Lynn, J. Serving patients who may die soon and their families. JAMA 2002;285: pp. 925-932.
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Thursday, January 15, 2009
Monday, May 12, 2008
Pallimed Case Conferences (cases.pallimed.org) is closed to comments and new posts as of April 25, 2013.
This site will stay online as an archived source, but will no longer be updated.
For active posts on these cases and new cases go to www.pallimed.com.
By Elizabeth Chaitin, MSW, MA, DHCE
Originally posted at the Institute to Enhance Palliative Care, University of Pittsburgh Medical Center
Vol 8, No. 1 - February 2008
(Original PDF)
Case:(Original PDF)
Mr. James Martin is 74-year-old man admitted to an outside hospital with a two-month history of shortness of breath, edema, and recent difficulty ambulating. He has a history of an aortic aneurysm, hypertension, cellulitis of his lower extremities, chronic obstructive pulmonary disease from years of heavy smoking, as well as ischemic cardiomyopathy and congestive heart failure. Mr. Martin had worsening renal functioning upon admission and was found to have two masses, one on each adrenal gland. He was scheduled for surgery and an ethics consult was called because the patient “didn’t seem mentally right.” The ethics consultant interviewed the patient and family and discovered that Mr. Martin was “mentally slow” and was illiterate. He never attended school and was raised and cared for by family until his adult years when he rented a small apartment near his sister Debbie with whom he is quite close. The consultant recommended that his sister sign for consent for the surgery for she felt Mr. Martin was neither able to comprehend the severe nature of his current condition nor could he comprehend the risks undertaken with the recommended surgery. The sister consented to bilateral adrenalectomies.
In this case there were two different stories or viewpoints present, which could have been conflictual in nature depending on the approach taken by the Palliative Care and Ethics Team. In Story One, the attending believed strongly that it was possible the patient could “get well” with more time and encouraged the family to consider the placement of a feeding tube. In Story Two, the Palliative Care and Ethics Team was certain that the patient was dying and believed that the placement of a feeding tube would not add to the longevity or quality of the patient’s life.
1. Douglas Stone, Bruce Patton and Sheila Heen. “Difficult Conversations: How to Discuss What Matters Most.” Penguin Books, 1999.
2. Roger Fisher, William Ury and Bruce Patton. Getting to Yes: Negotiating Agreement Without Giving In.” Penguin Books, 1991. (Wikipedia Link)
2. Roger Fisher, William Ury and Bruce Patton. Getting to Yes: Negotiating Agreement Without Giving In.” Penguin Books, 1991. (Wikipedia Link)
(Edit: (6/16) Added missing fragment "...consultant believed that the patient was dying and spoke with...)
Monday, May 12, 2008
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