The Morality of Using Mortality as a Financial Incentive

[herring_RN, ASN, BSN]

That is the title of a new opinion in the Journal of the American Medical Association (JAMA)

http://jama.jamanetwork.com/article.aspx?articleID=1693897

The author wrote, "Because hospitals will be held accountable for outcomes, physicians may be under pressure to be highly selective when recommending inpatient services for patients whose 30-day mortality risk is higher than average, although not certain."

His opinion is, in part that, "... clinicians are be placed between the desires of the patients and families for more time vs the pressures of the system."

He writes, "One potential solution would be to extend the 24-hour rule so that patients who are transitioned to hospice shortly after admission are excluded from the mortality measure. This could alleviate the pressures to rapidly triage the sickest patients to hospice care and allow the process to be less influenced by financial incentives for either the hospital or the physician."

Here is an article regarding the JAMA piece:

Hospitals Fear of 30-Day Penalties may Speed Hospice Admissions

An exception to federal 30-day mortality measures may incent hospitals to prematurely push patients into hospice care, says one critic, who calls it an unintended consequence of healthcare reform. ...

... Kupfer, a practicing cardiologist, doesn't stop there with his concern."My question really is, are incentives constructed around physician behavior morally ethical? ...

http://www.healthleadersmedia.com/print/QUA-292985/Hospitals-Fear-of-30Day-Penalties-May-Speed-Hospice-Admissions

What are your thoughts?

[tewdles, RN]

I think that this will heighten the discussions of hospice with patients that we all know should be considering that option for care. There are unequivocally, too many patients with no hope of meaningful survival being run through the medical procedure mill when they should be seeking quality of life and good palliation of symptoms.

Hopefully, these discussions will grow palliative care programs within acute care and primary care settings.

[Susie2310]

While I respect tewdles right to her opinion in her post above, I do not believe the patient or their family should be pushed into hospice discussions in primary care or acute care settings unless they initiate the discussion or express clear interest in the subject. As nurses and doctors, it is not for us to generalize about the value of our patients lives or what constitutes meaningful survival to them, and we (doctors and nurses) cannot accurately predict patient outcomes. Why remove the option of curative treatment? I did not read the article in JAMA as it required subscription, but the second article in HealthLeadersMedia heightened my intention to be very alert as to the care my older family members are receiving in all settings, from primary care through hospitalization. I do not doubt there are financial incentives on the part of the health care industry to try to move patients in to hospice as early as possible.

[marcopollo]

No more on this subject please ...

[herring_RN, ASN, BSN]

While I respect tewdles right to her opinion in her post above, I do not believe the patient or their family should be pushed into hospice discussions in primary care or acute care settings unless they initiate the discussion or express clear interest in the subject. As nurses and doctors, it is not for us to generalize about the value of our patients lives or what constitutes meaningful survival to them, and we (doctors and nurses) cannot accurately predict patient outcomes. Why remove the option of curative treatment? I did not read the article in JAMA as it required subscription, but the second article in HealthLeadersMedia heightened my intention to be very alert as to the care my older family members are receiving in all settings, from primary care through hospitalization. I do not doubt there are financial incentives on the part of the health care industry to try to move patients in to hospice as early as possible.

When my 90 year old aunt was diagnosed with pancreatic cancer and had to be told her odds of surviving the office nurse, an LPN asked her if she knew about hospice. She said she only knew a little but would like to know more.

She signed up for home hospice care a few days later.

Her six kids and as many nieces and nephews made a schedule so someone would always be with her. I took my vacation to spend a week with her.

We talked and looked at scrap books. I learned so much about her young life. From the time I was little she was a Mom. I remember cherishing one on one time with her as I handed her clothespins while she hung the wash on the line.

The good thing was that at first she was walking around the house, going to church, and such. She could hardly believe she was able to stay in her own house. She takled with my daughter just hours before she died. She laughed ans said, "I'm just in bed all the time now." then told her of all the family that was with her.

I was so impressed by the hospice nurse and the coung CNA who came to bathe her.

It is a wonderful program for people who choose it.

If I'm ever terminal I will choose hospice. If my family can't care for me I'll choose in-patient hospice.

(But may just have a CVA or get hit by a truck)

I do NOT think the topic should be brought up during a crisis. It takes time for patients and their loved ones to make decisions.

[traumaRUs, MSN, APRN]

I work with chronically ill hemodialysis pts. All of my pts are palliative care pts by the definition.

Should we discuss end of life decisions with ALL my pts (yes, even including the teens and young adults)? Yep, I do. Hospice, end of life, code status should and MUST be discussed prior to imminent demise.

We (providers) should be re-thinking our offers of "we can cure everything" and "of course, everyone can live to be 100".

This is not realistic.

Rather, we should be discussing quality over quantity.

[tewdles, RN]

While I respect tewdles right to her opinion in her post above, I do not believe the patient or their family should be pushed into hospice discussions in primary care or acute care settings unless they initiate the discussion or express clear interest in the subject. As nurses and doctors, it is not for us to generalize about the value of our patients lives or what constitutes meaningful survival to them, and we (doctors and nurses) cannot accurately predict patient outcomes. Why remove the option of curative treatment? I did not read the article in JAMA as it required subscription, but the second article in HealthLeadersMedia heightened my intention to be very alert as to the care my older family members are receiving in all settings, from primary care through hospitalization. I do not doubt there are financial incentives on the part of the health care industry to try to move patients in to hospice as early as possible.

Perhaps I can give you reason to consider another perspective.

A large part of our professional responsibility is to provide our patients with health information relevant to their health concerns.

If/when we withhold information because we are not comfortable with the information/options/philosophy/procedure/treatment/etc, we are denying our patients the information they REQUIRE to make informed decisions about their care, their lives, and their goals.

It is not up to us to decide that a patient will be in hospice.

It is our job to help our patients achieve their health goals.

We have already demonstrated what happens when we wait for patients and families to initiate these conversations...that would be a continuation of an already failed practice. People often do not know what they do not know. We want them to be hopeful, to be forward looking...so it is not surprising that they do not initiate those discussions and that is actually okay. It is more appropriate for us to take that huge step...to initiate those difficult conversations.

I agree completely that these conversations should not be held during crisis. However, our current practices in acute care often accomplish just that, first time difficult discussions in times of great stress/crisis.