Tag Archives: shared decision making

Emanuel: New “independent entity” would save federal dollars by convincing patients to forgo treatments

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In an article just published in the New England Journal of Medicine, former Obama adviser Ezekiel Emanuel (infamous for his “complete lives system”) and Emily Oshima Lee of the Center for American Progress have an idea on how to cut costs:  “share” in patients’ decisions to request expensive treatments by providing patients with “certified” decision aids.  Lee and Emanuel write:

Section 3506 of the ACA aims to facilitate shared decision making. Primarily, it funds an independent entity that would develop consensus-based standards and certify patient decision aids for use by federal health programs and other interested parties.

Not surprisingly, “shared decision making” (as opposed to ordinary decision making), is proven to cut costs:

In 2008, the Lewin Group estimated that implementing shared decision making for just 11 procedures would yield more than $9 billion in savings nationally over 10 years.

The authors suggest that HHS can bypass Congress in making the tools mandatory:

For approaches that provide savings or improve quality of care, implementation can be mandated throughout Medicare without additional legislation.

Lee and Emanuel do not offer specific examples of patient decision aids, but one that comes to mind is a video tool that made news in 2009.  Researchers affiliated with Harvard Medical School, Massachusetts General, and Boston University created a video of a woman with advanced dementia who could not talk or eat.  After viewing the video, almost all dementia patients (96%) declined life-saving treatment, while in the control group (decision-making without the video) only 86% chose to forgo life-saving measures. (Read about the study: Video Images of Advanced Dementia Help Patients Plan Care.  The study and video are online:  Volandes, Angelo E et al. “Video Decision Support Tool for Advance Care Planning in Dementia: Randomised Controlled Trial.” BMJ 2009;338:b2159)

Don’t worry; CMS can get started even without the independent entity in place.  International guidelines are available:

The Department of Health and Human Services could quickly launch pilot programs for shared decision making while it works to standardize and certify decision aids. The International Patient Decision Aid Standards Collaboration has developed evidence-based guidelines for certification indicating that decision aids should include questions to help patients clarify their values and understand how those values affect their decisions . . .

The Center for American Progress urges immediate action.

Care Transitions in Akron, OH

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Poor people “over the age of 60 who are living with one of 9 life-limiting conditions” are being subjected to an ongoing experiment in care transitions in the Akron, Ohio, region.

Medicaring.org gave the project a very favorable review just a few months ago.  The study is called the “PEACE Trial (Promoting Effective Advanced Care for Elders), a project involving Summa Health, the Area Agency on Aging (AAA), University of Akron, Kent State University, and the Northeastern Ohio Universities of College of Medicine and Pharmacy.

It’s all very scientific.  As Medicaring.org explains:

The randomized controlled pilot study features a geri-palliative care case management intervention for Ohio consumers who are participants in the state’s long-term care Medicaid waiver program, PASSPORT.  Frequently, these elders have not documented their advance care preferences, and so arrive in the hospital, where family members are left to make critical decisions for which they are unprepared.

In other words, a social worker or nurse from the Area Agency on Aging will follow the patient home, and later to the physician’s office, to coach the patient on how to take medications and, more importantly, to coach the patient on “appropriate” care and end-of-life decisions:

The PEACE Trial [focuses] on health coaching and patient activation for self management, while promoting advance care planning discussions with primary care providers.

. . . Care managers make two home visits, for example, centered on symptom assessment and advance care planning. They review findings with an interdisciplinary team, which makes appropriate recommendations for the patient and the primary care provider. The care manager next accompanies the consumer to one visit with the primary care provider to discuss advance care goals. Following this, the care manager and the palliative care nurse supervisor make an additional home visit to begin to implement the care plan.

Because Summa has a history of running the PEACE Trial and other case management projects, Medicare and Medicaid (CMS) announced last November that Akron would be awarded funding as a test site for the Center for Innovation’s CCTP project (see Care Transitions in Akron in this AOA presentation, beginning at slide 41.)

PEACE Trial is funded by the National Palliative Care Research Center (NPCRC) in New York City.  NPCRC was established in 2005 with a $3 million grant from the Kornfeld Foundation to Sean Morrison, MD.  Dr. Morrison was known to be sympathetic to physician-assisted suicide; several years earlier he had co-authored with Timothy Quill an article in New England Journal of Medicine that surveyed how physicians can and do assist suicides.  The Kornfeld Foundation had funded a similar NEJM article in 1989.  Kornfeld’s objective was clear.  As they stated in their Form 990 for the IRS, their mission was to support “the right of the individual to choose the time and manner of his or her death, without undue interference by doctors, hospitals, courts, churches, families or society.”

Let’s be clear:  the PEACE Trial is not about physician-assisted suicide.  It is not about barbiturate overdosing or gas inhaling in the manner of Timothy Quill or Jack Kevorkian.  The PEACE Trial is all about  coaching people on making end-of-life decisions.

Co-investigator for the PEACE Trial is Steven “Skip” Radwany. MD.  Dr. Radwany is a professor of medicine at Northeastern Ohio Universities Colleges of Medicine and Pharmacy, and medical director for Summa Health System’s Palliative Care and Hospice Services.

Dr. Radwany gained credentials with the death with dignity crowd in 2003 when he called for the withdrawal of nutrition and hydration from Gerald Carpenter, an elderly man who had suffered a stroke in a nursing home.

The death-with-dignity viewpoint on the story is related in a book by assisted-suicide advocate Alan Meisel (here).  The news stories concerning the Carpenter case are no longer available online, so we have posted online here the full text, showing the URLs for where the stories were posted eight years ago

Carpenter could open his eyes and move his arms and legs, but he could not eat.  A nurse at the nursing home said that Carpenter had said he would want life-sustaining treatment. Carpenter’s son hadn’t visited the father in so many months that it was difficult for the nursing home to locate him.  When he was finally contacted, he wanted his father’s feeding tube removed. Dr. Radwany agreed.

Dr. Radwany decided that Mr. Carpenter would not improve, and was therefore “terminal” and should not have hydration and nourishment:

Radwany said it was in Carpenter’s “best interest to discontinue all invasive, life-sustaining measures….” 

“It is the consensus among the physicians that he will not improve from this state,” Radwany testified. “He is terminal.”

 

Bottom line:  It’s all about the coaching.