To Reduce Futile Care, Build Trust
To Reduce Futile Care, Build Trust
My institution, like many around the country, has spent substantial time and resources bolstering its palliative care infrastructure. Our academic health center has multiple hospitals, including a large, comprehensive pediatric hospital, so this has been no small undertaking. It has seemed to me all along that the leadership’s motivations for doing this have flowed from their desire to do the right thing for patient care, and not because of calculations about cost savings or the role of palliative care in the Accountable Care Organization that we have just become.
I and several of my colleagues were just asked to make brief presentations to a large group of leaders within the organization about end-of-life care in conjunction with the hospital system’s board subcommittee meetings. The goal of this invitation was to make sure that our organization’s leaders understood that excellent end-of-life care was among several important institutional priorities. My topic was non-beneficial treatment, sometimes also referred to as “futile” treatment, a subject that I have spent at least 15 years thinking about. This topic is far too protean to cover in a single blog post; however, it is clearly a topic on many people’s minds of late: think of the all the attention paid to it in both the lay and professional media, its importance to the subject of cost savings in the new healthcare financing environment, and the perennial conundrum encountered by cancer clinicians who are faced with patients and families who request further cancer-directed treatment even in the face of advanced cancers clearly unresponsive to therapy.
In examining the myriad contributors to the problem of such non-beneficial treatments, and in summarizing the long list of factors that have shaped our healthcare environment in which so much non-beneficial treatment is both requested and provided, it struck me that most of the factors were not issues over which we have much control. For example, we cannot alter the fact that we are a “death-denying society.” Years ago, there was a sort of “movement” to take on the challenge of the death-denying society. I would argue that efforts to change this have been largely unsuccessful. Advance directives have been another strategy for which the evidence is overwhelming that they have not positively affected the amount of non-beneficial treatment we provide. The factors that contribute to the problem of non-beneficial treatment over which we do have some control all came down to issues involving communication between clinicians and patients and families: how do we compassionately convey the limits of medicine? How do we communicate about prognosis so that people will believe us? How do we overcome the gaps in communication that are a seemingly inevitable part of complex care?
I have come to the conclusion that a successful systematic approach to earlier transitions from disease-directed cancer therapy to end-of-life and palliative care can only come from better communication in the context of more trusting relationships. People will only accept that further disease-directed treatment will not help them if they trust the person telling them. Moreover, our national conversation about limiting treatments of many kinds will inevitably intensify in the next two or three years, no matter what the outcome of November’s election, and this will heighten some patients’ sense that we physicians—and the institutions of which we are a part—intend to take things away in order to extract cost savings from the system. But they will not feel like saying this about those they implicitly trust. The relational aspects of trust building and maintenance with patients and families have therefore never been more important.