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The future of palliative care - Issue #13

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"Are you willing to use whatever power and influence you have to create islands of sanity?" Meg Wheat
 

The future of palliative care

May 28 · Issue #13 · View online
In many respects, we've arrived. Yet what we know now won't get us to the next level. So I'm looking for signals from the future, & I'm curating them here.

“Are you willing to use whatever power and influence you have to create islands of sanity?” Meg Wheatley

1. ICU nurses can play a pivotal role in communication.
A beautifully designed and implemented stepped wedge randomized trial in 5 ICUs at the University of Pittsburgh led by Doug White shows that nurses can be trained in specific roles around family conferences–specifically, to prepare families before a conference, and debrief them after a conference. This ‘family-support’ intervention is really an application of a decision making model that explicitly involves responses to emotion cues. (It’s grown out of the work we’ve done at VitalTalk, & Bob Arnold led the communication training). Takeaway: decision making is a process whose boundaries extend outside the family meeting–we should invest in equipping nurses to contribute more.
A Randomized Trial of a Family-Support Intervention in Intensive Care Units | NEJM
2. Patients & physicians can be primed to discuss goals.
Please be patient: this is another study i’m involved with. Randy Curtis led a large randomized study of a intervention for early upstream goals conversations in outpatients at high risk that involved surveying patients, and then prompting physicians with a tailored communication tip just before a target visit. The goals of care documentation increased from 31% to 74% even though this intervention lacked an EMR component (that would make documentation easier, for example). I think of this Seattle study and the Pittsburgh study above as ‘second-gen’ interventions: they were both done in institutions that have had a lot of communication training for providers already–just not as part of these studies. Would a tip work for a physician who has zero real skill in communication? I’m doubtful, but we forgot to ask how much training participating physicians had. 
Effect of a Patient and Clinician Communication-Priming Intervention on Patient-Reported Goals-of-Care Discussions Between Patients With Serious Illness and Clinicians: A Randomized Clinical Trial | JAMA Internal Medicine
3. 'Alexa, what did the doctor say yesterday?'
Back in the ‘load cassette tape, press record’ day, a handful of careful studies showed that when patients received audiorecordings of their visits with their oncologists, their comprehension & recall improved. Now the technology has matured, and such recordings could become routine. Google says that they can transcribe medical conversations with reasonable accuracy already. As 33charts blogger Bryan Vartabedian relates, “parents [he’s a pediatric gastroenterologist] try to hide their recording for fear that it won’t be allowed.” But when these conversations all go directly to the cloud, who owns them?  
Patients are taking home recordings of doctor visits. Who else could listen?
4. In the wake of UC Davis's withdrawal from Medi-Cal...
Two years ago, UC Davis terminated all its Medi-Cal primary care contracts. Now, a ‘publish-ahead-of-print’ editorial in Academic Medicine describes the consequences: “Despite being a non-profit, state-designated, public health hospital, UC Davis Health no longer accepts Medi-Cal patients in most of its ambulatory care clinics. And while Medi-Cal beneficiaries account for nearly 40% of hospital discharges, UC Davis Health now provides…fewer Medi-Cal emergency visits than all three of its local competitors.” The authors, all UC Davis faculty, one a friend, gamely try to talk about the responsibility of academic health centers to 'innovate.’ But they don’t mention the moral calculus. They’re putting lipstick on a pig.
Academic Health Centers and Medicaid: Advance or Retreat? : Academic Medicine
5. Is decision making actually a social process?
This week, the New Yorker podcast reprises an interview with Malcolm Gladwell about school shooters. The new perspective he brings to this is sociological: this is not just about crazy adolescent boys with guns. As he wrote in a 2015 piece in the New Yorker: “Social processes are driven by our thresholds—which [Granovetter] defined as the number of people who need to be doing some activity before we agree to join them.” Granovetter is a sociologist who made mathematical models of riots. Gladwell writes: “what if the way to explain the school-shooting epidemic is to…use the Granovetterian model—to think of it as a slow-motion, ever-evolving riot, in which each new participant’s action makes sense in reaction to and in combination with those who came before?” This matters to palliative care because private decisions by people with serious illnesses are being made increasingly public. Barbara Bush started a discussion about ‘comfort care.’ Now John McCain is consciously, and publicly, leaving a legacy. How should we be trying to influence this?
Opinion | As He Lay Dying - The New York Times
This newsletter is made possible by the John A. Hartford Foundation. But the recommendations and opinions are mine alone. No algorithms, data-mining, or profiling!
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