Skip to main content

Give patients end-of-life options

By Joan M. Teno, Special to CNN
updated 11:20 AM EDT, Fri March 15, 2013
A massage therapist embraces a terminally ill patient at a Colorado hospice.
A massage therapist embraces a terminally ill patient at a Colorado hospice.
STORY HIGHLIGHTS
  • Joan Teno asks: Why do doctors continue to test and treat patients who are clearly dying?
  • She says instead they should be helping very sick patients weigh quality of life against quantity
  • Teno: Hospice care doubles, but patients still in ICU until last 3 days of life. Do they want this?
  • Teno: Intervention lucrative for medical industry; this wars with patient-centered end-of-life care

Editor's note: Joan M. Teno is a physician and professor of health systems, policy and practice at the Warren Alpert School of Medicine of Brown University.

(CNN) -- The urban dictionary defines "cheech" as a verb used among physicians in training that refers to the act of ordering every conceivable radiological and laboratory test for a patient, often to diagnose a condition that once diagnosed is untreatable. Thirty years ago, the macabre joke during my three-month stint as an intern in the medical ICU was first cheech, then death.

I remember sitting at the bedside of a frail, older woman with dementia dying of septic shock. A litany of subspecialists had rounded earlier in the day, but no one said what was so obvious. She was dying. Instead, I sat at her bedside at 4:30 a.m. watching the sun rise over Narragansett Bay, increasing vasopressors to try to maintain her blood pressure.

Joan Teno
Joan Teno

Instead of being surrounded by her family and loved ones, the only person at her bedside was an exhausted intern who had never met the woman in bed No. 2 until the night before. This was simply wrong. Why were we rearranging the deck chairs on the Titanic instead of ensuring that her death was peaceful and that she was surrounded by her family?

Intensive Care Units save some patients and play an important role in our health care system. But the overarching concern is, "Are we talking to frail, older patients and their families at the right time about when to stop (or avoid) ICU care and recurrent hospitalizations?" Decisions about hospitalizations and ICU admission must weigh the quality vs. the quantity of life.

Opinion: End-of-life planning eases suffering

These decisions must reflect a patient's informed wishes and goals for care, be based on what the patient and/or family understand about the medical condition -- their hopes and goals -- and educate them about the prognosis and treatment options to arrive at a care plan that honors realistic patient goals of care.

Our research published in the February 8 edition of JAMA finds that hospice is now part of mainstream medical care, with nearly half of older Medicare beneficiaries receiving hospice services. However, that's only half the story. More than a quarter (28.4%) of these people had the benefit of hospice for three days or less, and nearly half (40.3%) were in an ICU immediately before.

Become a fan of CNNOpinion
Stay up to date on the latest opinion, analysis and conversations through social media. Join us at Facebook/CNNOpinion and follow us @CNNOpinion on Twitter. We welcome your ideas and comments.



Indeed, contrasting end of life care in 2000 vs. 2009, in spite of a doubling of hospice use, we found more ICU care, more repeat hospitalizations and more patient transfers from hospital to another health care setting in the last three days of life. Does this pattern of care reflect the informed wishes of dying patients and their families? Our research does not provide the answer to this important question. But it is something we really need to know.

On the face of it, our research findings should not be surprising. You get what you pay for. All the financial incentives in fee-for-service Medicare are aligned to induce more hospitalizations, more ICU care and late hospice referrals. As we try to reform our health care system to provide care that is patient centered and care that improves the health of our population, we need to do a better job of paying for quality rather than simply paying for another day in the ICU, particularly if it does not change the inevitable.

Where dying kids' lives are celebrated
Dedicated to caring for the dying

Yet during the debate over health-care reform, a proposal to pay health-care providers for advance care planning was eliminated from the legislation based on the mistaken argument that promoting shared decision making with the goals of honoring patient wishes was equivalent to creating a "death panel."

The key is that decisions be based upon discussions that weigh the quantity vs. the quality of life reflect informed patient preferences. The evidence to date suggests we are falling short of that goal. We've previously shown that 11.6% of family members felt pressured by a physician to put a feeding tube in a dying patient with advanced dementia, and about 10% reported that no one discussed that decision with them.

A recent study of two ICUs that differed on the aggressiveness of care provided found contrasting decision-making styles: a futility based decision-making process where one talks to the patient only when death is certain in the aggressive ICU vs. a shared decision making model where physicians work with patients and families early in the ICU stay to arrive at a decision that is consistent with the patient's prognosis and goals of care in the ICU.

We must have publicly reported data on the degree in which our health care system delivers on the promise of patient centered care -- that health care providers are informing patients and their families of the expected prognosis and treatment options, helping them in making these difficult decisions, and that patients are provided the right care at the right time, in the right place, and consistent with their informed wishes. We must hold our health care system accountable to the goal that medical decisions should reflect patient informed goals and values.

Follow us on Twitter @CNNOpinion.

Join us on Facebook/CNNOpinion.

The opinions expressed in this commentary are solely those of Joan M. Teno

ADVERTISEMENT
Part of complete coverage on
updated 8:21 AM EDT, Mon September 1, 2014
Carlos Moreno says atheists, a sizable fraction of Americans, deserve representation in Congress.
updated 12:25 PM EDT, Sun August 31, 2014
Julian Zelizer says Democrats and unions have a long history of mutual support that's on the decline. But in a time of income inequality they need each other more than ever
updated 12:23 AM EDT, Sun August 31, 2014
William McRaven
Peter Bergen says Admiral William McRaven leaves the military with a legacy of strategic thinking about special operations
updated 12:11 PM EDT, Fri August 29, 2014
Leon Aron says the U.S. and Europe can help get Russia out of Ukraine by helping Ukraine win its just war, sharing defense technologies and intelligence
updated 1:24 PM EDT, Fri August 29, 2014
Timothy Stanley the report on widespread child abuse in a British town reveals an institutional betrayal by police, social services and politicians. Negligent officials must face justice
updated 9:06 PM EDT, Fri August 29, 2014
Peter Bergen and David Sterman say a new video of an American suicide bomber shows how Turkey's militant networks are key to jihadists' movement into Syria and Iraq. Turkey must stem the flow
updated 11:54 AM EDT, Mon September 1, 2014
Whitney Barkley says many for-profit colleges deceive students, charge exorbitant tuitions and make false promises
updated 10:34 AM EDT, Fri August 29, 2014
Mark O'Mara says the time has come to decide whether we really want police empowered to shoot those they believe are 'fleeing felons'
updated 10:32 AM EDT, Thu August 28, 2014
Bill Frelick says a tool of rights workers is 'naming and shaming,' ensuring accountability for human rights crimes in conflicts. But what if wrongdoers know no shame?
updated 10:43 PM EDT, Thu August 28, 2014
Jay Parini says, no, a little girl shouldn't fire an Uzi, but none of should have easy access to guns: The Second Amendment was not written to give us such a 'right,' no matter what the NRA says
updated 1:22 PM EDT, Sat August 30, 2014
Terra Ziporyn Snider says many adolescents suffer chronic sleep deprivation, which can indeed lead to safety problems. Would starting school an hour later be so wrong?
updated 9:30 AM EDT, Fri August 29, 2014
Peggy Drexler says after all the celebrity divorces, it's tempting to ask the question. But there are still considerable benefits to getting hitched
updated 2:49 PM EDT, Fri August 29, 2014
The death of Douglas McAuthur McCain, the first American killed fighting for ISIS, highlights the pull of Syria's war for Western jihadists, writes Peter Bergen.
updated 6:42 PM EDT, Tue August 26, 2014
Former ambassador to Syria Robert Ford says the West should be helping moderates in the Syrian armed opposition end the al-Assad regime and form a government to focus on driving ISIS out
updated 9:21 AM EDT, Wed August 27, 2014
Ruben Navarrette says a great country does not deport thousands of vulnerable, unaccompanied minors who fled in fear for their lives
updated 9:19 AM EDT, Wed August 27, 2014
Robert McIntyre says Congress is the culprit for letting Burger King pay lower taxes after merging with Tim Hortons.
updated 7:35 PM EDT, Tue August 26, 2014
Wesley Clark says the U.S. can offer support to its Islamic friends in the region most threatened by ISIS, but it can't fight their war
updated 4:53 PM EDT, Tue August 26, 2014
America's painful struggle with racism has often brought great satisfaction to the country's rivals, critics, and foes. The killing of Michael Brown and its tumultuous aftermath has been a bonanza.
updated 3:19 PM EDT, Tue August 26, 2014
Rick Martin says the death of Robin Williams brought back memories of his own battle facing down depression as a young man
updated 11:58 AM EDT, Tue August 26, 2014
David Perry asks: What's the best way for police officers to handle people with psychiatric disabilities?
updated 3:50 PM EDT, Mon August 25, 2014
Julian Zelizer says it's not crazy to think Mitt Romney would be able to end up at the top of the GOP ticket in 2016
updated 4:52 PM EDT, Mon August 25, 2014
Roxanne Jones and her girlfriends would cheer from the sidelines for the boys playing Little League. But they really wanted to play. Now Mo'ne Davis shows the world that girls really can throw.
updated 5:04 PM EDT, Mon August 25, 2014
Kimberly Norwood is a black mom who lives in an affluent neighborhood not far from Ferguson, but she has the same fears for her children as people in that troubled town do
updated 5:45 PM EDT, Fri August 22, 2014
It apparently has worked for France, say Peter Bergen and Emily Schneider, but carries uncomfortable risks. When it comes to kidnappings, nations face grim options.
ADVERTISEMENT
ADVERTISEMENT
ADVERTISEMENT
ADVERTISEMENT