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The future of palliative care - Issue #17


The future of palliative care

July 15 · Issue #17 · 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.

“If you want to change how a person thinks, give up. You cannot change how another person thinks. Give them a tool the use of which will gradually lead them to think differently.” –Buckminster Fuller

1. Doctors who know less spend more.
If you spend more on medical care at the end of life, shouldn’t get more? Well no, not if you live in the US. Spending varies widely, but outcomes don’t. Why would that be? In Health Affairs, Keating et al make an interesting observation: “Physicians in higher-spending areas reported less knowledge about and comfort with treating dying patients and less positive attitudes about hospice, compared to those in lower-spending areas.” You could call this a ‘duh’ insight. But it’s another empirical demonstration that we’re spending money on the wrong things. [If you need access, click here.]
Factors Contributing to Geographic Variation
2. The sociology of serious illness is changing.
In the Atlantic, Matthew Stewart makes an interesting case about the American elites–it’s not the 0.1% but the 9.9%, which includes me, and many of us trying to plan the future of serious illness care. “We are the people of good family, good health, good schools, good neighborhoods, and good jobs. We may want to call ourselves the ‘5Gs’ rather than the 9.9 percent.” The falling middle class faces a swath of illness that is increasingly determined by sociological factors, in what Princeton economists Case and Deaton called the ‘diseases of despair.“ They write: ”We find marked differences in mortality by race and education, with mortality among white non-Hispanics (males and females) rising for those without a college degree, and falling for those with a college degree.“ What are 'diseases of despair’? Mental illness and substance use. These are the new frontiers for serious illness care. 
Mortality and morbidity in the 21st century
“Deaths of despair” are surging in white America - Anne Case
3. Chasing professionals with sticks may not work.
A sobering evaluation from the RAND Corporation followed three school districts and four charter management organizations through a six-year effort (from 2010 to 2016) to implement reforms to improve teachers’ performance. Funded to the tune of $200 million by the Gates Foundation, these value-based reforms created ‘effectiveness ratings’ for individual teachers based on student tests, classroom observations, and parent surveys. But the data was inconsistently available, and the school principals, who were supposed to do the classroom observations and deliver feedback, weren’t trained to observe and didn’t have time to give feedback. So they were hesitant to give low scores because the stakes were high, and the process ‘undermined teacher morale.’ In a way, this is unsurprising: to build better professional performance, what you build is not a system of punishments, but a community of practice where rewards are given for excellence. Clinicians are no different than teachers. 
The Gates Foundation Spent $200M+ Trying to Improve Teacher Performance, and All It Got Was This Report | EdSurge News
4. A worldwide call to improve healthcare quality.
A new report, Delivering Quality Health Services: An Imperative for Universal Health Coverage, is the first global report co-authored by the three multilateral organizations [the World Health Organization (WHO), the World Bank Group and the Organization for Economic Cooperation and Development (OECD)]. From the report: ‘Building quality health services requires a culture of transparency, engagement, and openness about results…“ Their point is that improving access isn’t enough, and the report calls for "urgent action from governments, clinicians, patients, civil society, and the private sector”. What this means for the US, where our government currently wants to leave national strategy to the market, is that we need to self-organize. 
Delivering quality health services
5. What makes collective impact work.
As we think about cross-sector and cross-institution collaboration, there are valuable lessons other social sectors. In 2011, John Kania and Mark Kramer published an article in the Stanford Social Innovation Review laying out “collective impact” as an approach for solving social problems at scale. The first large scale evaluation examined 25 regional sites that addressed issues in health, poverty, and education, of which 20 showed population-level changes. For 8 sites, collective impact ‘undoubtedly’ contributed, and in these sites, “Key drivers of systems changes were most commonly early changes related to partnerships, including the deepening of the relationships, the expansion of the relationships, and the degree of commitment and engagement.” This report and approach serve as an important contrast to the Gates Foundation’s focus on a single metric, as described above. The successful collective impact projects all used data strategies but the data were broader, and utilized in building hypotheses about how change was occurring. 
When Collective Impact Has Impact: A Cross-Site Study of 25 Collective Impact Initiatives
6. Looking death straight in the eye.
Sallie Tisdale, whose previous books include a book entitled “Talk Dirty to Me: an Intimate Philosophy of Sex”, just wrote an awesome guide to death. Here’s how it starts: “One day when I was almost seven, my mother sat at the dinner table and cried all afternoon, even though it was almost Christmas. My father told me that my grandfather had died. I wasn’t sure what that meant. I liked grandpa a lot, who used to laugh a lot and take his dentures out at the dinner table to make the kids scream. My mother started packing a suitcase. She was going to the funeral, he said…"Can I go too? No, he said sharply. I was not allowed. No one explained and I never saw Grandpa again.” Our culture in a nutshell. As the NYT review noted, it’s a page-turner.
Advice for Future Corpses (and Those Who Love Them): A Practical Perspective on Death and Dying: Sallie Tisdale
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