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The future of palliative care - Issue #24

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"You cannot understand a system until you try to change it." Kurt Lewin
 

The future of palliative care

October 15 · Issue #24 · 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.

“You cannot understand a system until you try to change it.” Kurt Lewin

1. A myth we cling to: showing people data causes them to change.
In a new blog in Health Affairs, Shannon Brownlee, author of Overtreated, writes about the problem of getting physicians to stop recommending treatments after negative evidence emerges. “Even when new evidence is clearly negative, clinicians often resist abandoning a service they have believed in, and developed expertise in, especially when that service provides a significant portion of their livelihoods.” Like many observers–especially economists–her emphasis is on the possibility that physicians persist because of secondary gain. But to me, what she is missing is an understanding about how professionals learn: we learn from experience. So it’s not enough for us to just tell the surgeon to stop doing the endarterectomy (an example from her father’s care); we need to create an experience for the surgeon of the pathway that is better. That experience of better would equip the surgeon to counsel the patient and family about what would happen, and what is truly possible. Just no won’t do it.
Getting Physicians To Stop Delivering Low-Value Services
2. The old narratives that we tell, and retell.
A personal account, in the New England Journal of Medicine, from a resident about talking to a family about code status: “After nine grueling rounds, the health care team won the battle in a victory that bore a frightening resemblance to an ultimatum, and Ms. S.’s sons agreed to sign a do-not-resuscitate order for their 70-year old mother.” Ugly. But in another case, the senior resident turned to the family to say “'Tell me about Mr. M.’ It was such a simple question, yet it empowered the family, opening the door to a wealth of information…“ Part of me loves that a valuable, if basic, that the writer nails a fundamental iecommunication skill. But part of me also wonders about the constant retelling of a patient narrative that puts the physician in the role of hero. If the care ecosystem really worked to provide upstream discussions initiated by a variety of clinicians–well, we don’t know that story, so we don’t look for it.
A Seat at the Table | NEJM
3. Why is unlearning so hard?
Tim Harford is an British economist who writes for the Financial Times; in his blog he explains why changing mental models, as in the example above, is so hard. His examples are corporate–Sony, Xerox, BP–but they illustrate a phenomena important to the future of palliative care. These companies had employees with brilliant ideas that could have secured the sustainability and growth. But the brilliant ideas were never adopted. Why? Harford is hard on Clay Christensen’s notion of disruptive innovation–he thinks it’s too simplistic. He turns instead to another Harvard Business School professor, Rebecca Henderson, whose alternative theory is located in the organizations, not the innovators outside. “Dominant organisations are prone to stumble when the new technology requires a new organisational structure.” This is the issue we’re facing now: think of upstream serious illness care as a technology that locates much more outside the hospital. What are the new organizational structures we need?
Tim Harford — Article — Why big companies squander brilliant ideas
4. For 35% of us, where we live doesn't feel like home.
A New Era of Life at Home - Ikea
Every year, Ikea conducts a big, fascinating study; this year their question was “What gives people the feeling of home, and where they go to find it?” This year, their data collection included 22,000 respondents, 22 markets worldwide, and 12 in-home studies by anthropologists. What they found is a signal from the future to clinicians and systems that draw again and again on the rhetoric of home. To wit: 53% of young families don’t get a sense of belonging from their residential home. Almost half of Americans (45%) go to their car, outside of the home, to have a private moment to themselves. If the future of palliative care is at home, maybe we need to figure what home really means?
IKEA Life at Home 2018
5. What happens after your last meal.
Roxane Gay, whose memoir about her childhood abuse and subsequent obesity Hunger is like a case study from the Adverse Childhood Events study, just published in Medium a fascinating piece about having bariatric surgery. Her ‘last meal’ was a rib eye and all the fixings. But what was so instructive for me as a clinician was her account of what her body felt like afterwards. “My clothes are looser. My shoes are inexplicably loose. My ring is loose. I fit into my car in a way I never have. I fit into chairs better…. But I can’t believe that I am losing weight, despite all this evidence.” In an older, stunning memoir in Harper’s, David Wong Louie writes about life after treatment for head and neck cancer. “I am told that cancer has not changed the essential me. 'You’re still David,’ my wife says…as much as I love her for saying that she sees me past the wreckage, I think she’s lying, at least a little, because from in here things have changed…. Seeing food now doesn’t make me hungry; neither does reading about it or thinking about it. Drop a steak in front of me and what am I going to do? Will my mouth water or my blood pressure rise, my pleasure centers spark in my brain? None of this happens, because it can’t. A plate of rib eye might as well be behind the glass of a Hall of Mammals diorama.” [pdf here] I’m reminded of John Dewey: we learn by making sense of our experience.
Listen: Roxane Gay Reads "What Fullness Is"
This newsletter is made possible by The John A. Hartford Foundation, but the recommendations, views, and opinions are mine alone.
I’ll be at Grantmakers in Aging in Memphis this friday–stop by to say hello if you’re there! And my keynote from the C-TAC National Summit will be in this newsletter next week.
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