Monday, June 1, 2015

End-of-Life Care: The Long Conversation

California palliative care specialist, author, and consultant Ira Byock, MD, calls the issues surrounding end-of-life care “a public health crisis.” But he says many of the same solutions to improving the health care system overall — shared decisionmaking, advancements in medical education, and better payment and delivery structures — apply equally to this area of medical care. “Part of the achievable goals of health care should be to help people die well,” he says.

Texas Medicine spoke to Dr. Byock before his keynote address during the Opening General Session of the Texas Medical Association's annual meeting, TexMed 2015. Below is a synopsis of the interview. Read the full interview in Texas Medicine and watch his TexMed presentation below.

“People are dying badly,” Dr. Byock says. “People are dying in ways they would not have wanted, in places they would not have wanted to die if anyone had asked them. But of course, we don’t ask them.”

Dr. Byock says, however, that this is one national crisis we can solve, and physicians can lead the way.

“Physicians are so well-positioned to assert not only clinical leadership, but also cultural leadership. We’ve yet to make even one person immortal, so our commitment to giving the best care possible to every patient has to extend to making sure that their comfort and quality of life is as good as it can be, that their family is as well-supported as they can be, and on their own terms.”

The “secret sauce” that Dr. Byock says will fix this crisis lies in what he calls “shared decisionmaking.”

“Nowadays, we recognize that patients come to the doctor-patient relationship already expert in their values, preferences, and priorities. Together, in shared fashion, we can apply the best medical science and technology consistent with the values, preferences, and priorities of each person in service of achievable goals of health care.”

End-of-life decisionmaking is not just the domain of palliative care specialists, Dr. Byock says. Physicians of all specialties should talk with their adult patients about their final decisions.

“Sometimes young, healthy people become suddenly seriously ill. They ought to have a chance to have spoken for themselves, at least in naming someone they trust to speak for them, but also in expressing their values.”

Dr. Byock says he worries physicians are not learning enough about end-of-life care in medical school. “In a four-year curriculum, we teach 20 hours or less of palliative and hospice medicine — even though the large majority of physicians contribute to the care of seriously ill and dying patients.”

And it’s not just the medical community that could do with more knowledge on end-of-life care. Everybody needs more education, says Dr. Byock, from patients, to physicians, to society as a whole.

“This is not about rationing, or giving up, or any of that. It is about using the best of our technology in service of protecting and preserving life, while acknowledging that at some point in time, more treatment is not better care, and that part of the achievable goals of health care should be to help people die well. I have the remarkable experience of witnessing and, at times, helping people achieve a sense of well-being during the last months, weeks, even days of their lives. And I have to say, that's the most clinically exciting thing I've ever been part of. And it is the highest health outcome I could ever hope for a patient.”

Read the full interview.

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