Resistance It’s not just for patients….. MAPP Workshop 4/27/2012 Janis B. Petzel, M.D., DFAPA
Why Do Doctors Resist Death, Documents and Data?
Death • Self-selection and training • Military model “death warrior” • Reaction to our own helplessness? • Fear?
Documents • Informed Consent • Advance Directives
Source of Resistance? • Surface: • Time-sucking • Don’t help but hurt if done wrong • Less Obvious: • Forced on us by legal system • Make us confront our mistakes and limitations • Ideas?
Data • Historic • Numerous examples • PSA • Failure to monitor for metabolic syndrome in patients on antipsychotic medication • Improved longevity on with palliative care, but low referral rates
Why? • Many times, data is not “stable” over time • Aging out of current knowledge? • Clinical experience does not match data? • We believe ourselves more than we believe data? • Economics? • “Don’t just do something, stand there” has been trained out of us? • Ideas?
Feeding Tubes in Dementia Is it all about money? Hand feeding takes time, Poorly reimbursed
Utilization of Nasogastric Feeding Tubes in a Group of Chronically Ill, Elderly Patients in a Community HospitalTimothy E. Quill, MD Arch Intern Med. 1989;149(9):1937-1941. Results: Conclusions: Not effective: only 2% NG removed due to patient improvement 8:1 ratio of biomedical reason for insertion rather than quality of life • 2/51 had informed consent documented • 1/7 surrogates consulted took patient wishes into account • 35/55 died in hospital, including 90% who had asked for comfort-oriented treatment • 53% restraints
Tube Feedings in Elderly PatientsIndications, Benefits, and Complications Jerry O. Ciocon, MD; Felix A. Silverstone, MD; L. Michael Graver, MD; Cornelius J. Foley, MD Arch Intern Med. 1988;148(2):429-433. Outline of study: Reason for Tube Feeding: 50% Refusal to swallow 47% Dysphagia, no obstruction 3% Esophageal Obstruction • 11 months • 70 patients • 65-95 years old • 69 patients initially had NG, of these, 15 later got G Tube
Tube Feedings in Elderly PatientsIndications, Benefits, and Complications Arch Intern Med. 1988;148(2):429-433. NG Tube Group G Tube Group Early Complications 56%aspiration pneumonia 50% tube dysfunction 49% agitation/extubation Late Complications 56%agitation/extubation 38% tube dysfunction • Early Complications • 67% agitation/extubation • 43% aspiration pneumonia • Late Complications • 44% aspiration pneumonia • 39% agitation/extubation 40% Mortality
From blog: “he received no support when he requested a feeding tube” for his wife
Why? • Money? • Feel we have to do something? • Trying to please family? • Force of habit? • Ideas?
Tube Feeding in Dementia: How Incentives Undermine Health Care Quality and Patient Safety. Finucane et al. doi:10.10161 j.jamda.2007.01.007 Perfect Storm? Reimbursement Regulations Tort • Nursing Home—fears of getting “ding-ed” for patient weight loss, negligence • Money • “reduced physical function”=hand feeding, takes 35+minutes/patient • “special care”=tube feeding reimbursed under Medicare
Clinical Correlates Low referral rates to hospice Futile care in CCU Poor ability to switch from acute care to palliative Poor ability to discuss prognosis accurately ?Poor ability to recognize our own needs