Commentary
Getting it right at the end of life
Now, most dying hospitalized patients are cared for by hospitalists who may be meeting the patient for the first time.
With the number of aging Americans projected to grow dramatically in the next several years, the need for primary palliative care and advance care planning (ACP) is more important than ever. Patients and their families want and expect palliative care when needed, but initial conversations about ACP can be difficult for them. Appropriate timing in raising this subject and clear communication can give patients the opportunity, while they are still independent, to set their goals for medical care.
For the past several decades, political decisions and judicial cases have shaped palliative care as we know it today. And its shape is still evolving. In support of ACP, advocacy groups at a national level are developing models that practitioners can use to engage patients in setting goals. And Medicare is now reimbursing primary care providers for this work that they have been doing for years (although many still may not be billing for the service).
Finally, the busy primary care office may have its own set of challenges in addressing ACP. Our aim in this review is to identify the barriers we face and the solutions we can implement to make a difference in our patients’ end-of-life care planning.
Landmark events have defined advance care planning today
In 1969, Luis Kutner, an Illinois attorney, proposed the idea of a “living will,” envisioned as a document specifying the types of treatment a person would be willing to receive were they unable at a later time to participate in making a decision.1 In 1976, California became the first state to give living wills the power of the law through the Natural Death Act.2
Throughout the 1970s and '80s, several high-profile court cases brought this idea into the national spotlight. In 1975, the New Jersey Supreme Court granted the parents of 21-year-old Karen Ann Quinlan the right to discontinue the treatment sustaining her in a persistent vegetative state. Ms. Quinlan was removed from the ventilator and lived 9 more months before dying in a nursing home.
A few years later, Nancy Cruzan, a 32-year-old woman involved in a 1983 motor vehicle accident, was also in a persistent vegetative state and remained so until 1988 when her parents asked that her feeding tube be removed. The hospital refused, indicating that it would lead to her death. The family sued and the case eventually went to the US Supreme Court in 1989.
In a 5-to-4 decision, the Supreme Court ruled that a state was legally able to require “clear and convincing evidence” of a patient’s wish for removal of life-sustaining therapies. Cruzan’s family was able to provide such evidence and her artificial nutrition was withheld. She died 12 days later.
The Cruzan case was instrumental in furthering ACP, leading to the passage of the Patient Self Determination Act (PSDA) by Congress in 1990. All federally funded health care facilities were now required to educate patients of their rights in determining their medical care and to ask about advance directives.3 The ACP movement gained additional momentum from the landmark SUPPORT study that documented shortcomings in communication between physicians and patients/families about treatment preferences and end-of-life care in US hospitals.4
In the Terri Schiavo case, the patient’s husband disagreed with the life-sustaining decisions of his wife’s parents given her persistent vegetative state and the fact that she had no chance of meaningful recovery. After a prolonged national debate, it was ultimately decided that the husband could elect to withhold artificial nutrition. (She died in 2005.) The Schiavo case, as well as the Institute of Medicine’s report on “Dying in America,”5 influenced Congress in 2016 to pass legislation funding ACP conversations.