From my perspective as a physician for more than 40 years, I have witnessed the non-stop increase in the power of medicine, be it surgical procedures, drugs, chemotherapy or the application of mechanical devices.
It has enhanced our ability to cure and to extend life.
Even as the power of medicine has made so much more possible, multiple medical journal articles have documented the widespread lack of effective communication between patients and members of the healthcare team.
As just one example out of many, direct-observational studies have shown that only about a third of doctors actually stated the prognosis — at any time. Half of all patients with lung cancer have not heard any of their doctors use the word “hospice.”
How did we get to this sorry state of affairs?
The current approach to treatment is the problem. Our health-care system, including the education of our future health-care providers, has not kept up with the times. While our model of care is appropriate for active, robust otherwise healthy individuals with an acute illness, this approach for the steadily increasing number of chronically ill, frail, older patients is badly out of date.
For such patients, there is a great necessity for initiating “difficult conversations” prior to initiating medical interventions.
Recent evidence points the way to a co-ordinated, systematic model of advance care planning (British Medical Journal, 2010). This new model used trained facilitators to identify the patient’s wishes about their care. Conversations focused on values, beliefs and needs, as opposed to specific treatments.
The implications of this proposal are profound. The proposed change in approach would offer patients sufficient information, support and opportunity to make truly informed choices. The research demonstrated that such an approach improves care from the perspective of the patient and the family, and decreases the likelihood of stress, anxiety, and depression in surviving relatives.
It would improve access to hospital resources for those who need acute care. I wonder what quantity of resources is targeted at patients who may well have refused if they only received the opportunity to make a truly informed choice.
Here is the story of the pilot project at Health Sciences North that began in January of 2016.
The ward clerk identifies all patients 85 years old and greater on one of our medical wards. The meeting with the patient occurs early in the admission and tries to include a person who knows the patient well.
The information gathered is documented in the hospital chart. A copy is given to the patient. A process is being developed to store this information electronically, and with time, spread this initiative throughout the hospital and the health-care community.
The information will be released only to health-care providers authorized by the patient. Such a plan, once in operation, will be a powerful tool for the integration of the care provided to the patient.
In closing, here is a poem by Laura Leblanc, one of our experienced nurses involved in the program. It is all about asking, within a supportive environment, a series of questions. It is also about taking the time to listen to the answers.
Advance care planning is a unique way for those 85 and older to have their say.
It’s about knowing and sharing and how to discern.
It’s a conversation for us to talk and learn.
This interaction will give patients a voice.
A discussion about dying to allow them a voice.
What are they prepared to leave behind?
What kinds of things would give them piece of mind?
What are they willing to sacrifice?
What are their thoughts about end of life?
We’ll record a copy of this plan.
So their wishes will be known to their fellow man.
Bring to the surface their hopes and fears.
What are some wishes they’ve thought about over the years?
So write it down, record and review
So everyone will know what to do.
Advance care planning is about living life while you’re in it.
It’s about your last days and how you want to spend it.
There is a wonderful book on the subject, too, “Being Mortal,” by Atul Gawande.
Check out this website. You will find there the Sudbury Health Action Committee’s submission to the province: Our Call for Advance Care Planning. This column is based on that submission.
Dr. Peter Zalan is president of the medical staff at Health Sciences North. His monthly column tackles issues in health care from a local perspective. If you have a question for Dr. Zalan, email it to [email protected].
