I guess it shouldn't surprise me, but when I looked at the information in the April, 2008 Dartmouth Atlas of Health Care, I was taken aback. The Atlas looked at the outcomes of chronic disease care and tracked these outcomes against the resources attached to them. It was found that when it comes to getting care for a chronic disease, geography matters. Depending on where they live and what hospital or health care organization they use, these patients receive very different care.
These variations in care appear not to be linked to how sick the patients are, and, it turns out that the places where more resources are available are not the places demonstrating better care and better health outcomes.
This article focuses on supply sensitive care for patients with severe chronic illness in the last 2 years of their life. Areas that had offered more resources actually had a slightly higher mortality rate (over a period of up to 5 years) for patients following acute myocardial infarction, hip fracture, and colorectal cancer diagnosis--with no difference in functional status. As well, in higher-resourced settings, patients reported worse access to care and greater waiting times, with no difference in patient-reported satisfaction with care.
Paul Batalden's quote is so appropriate: "Every system is perfectly designed to get the results it gets."
Monday, 24 November 2008
Sunday, 23 November 2008
Sunday, 16 November 2008
The Go-to Person for Legal Advice
Joan Rush is an expert in the legal field and a savvy researcher. She understands Advance Care Planning at so many levels. In her law practice, she consults in the areas of health law, corporate governance, insurance law, and legal issues relevant to health care providers and the financial services industry. Prior to establishing her consulting practice, Joan was Vice President and General Counsel of a Canadian life insurance company.
Joan is a member of the Board of Directors for Community Living B.C., and a former adjunct Professor at the Faculty of Law, University of British Columbia. Joan completed her LL.M. thesis in the area of health law and ethics in 2005 and received her Master of Laws degree from UBC in 2006. Her thesis focused on advance directives and the law.
Her comprehensive overview of the state of advance directives in Canada, was first published in the Canadian Journal of Medical Radiation Technology (now the Journal of Medical Imaging and Radiation Sciences ). Visit www.jmirs.org to access current and past issues of JMIRS, and coming soon, CJMRT.
Draw Me a Response
This great diagram is found in the article by Joanne Lynn and Nathan Goldstein (Advance Care Planning for Fatal Chronic Illness: Avoiding Commonplace Errors and Unwarranted Suffering) published in the May 20, 2003 Annals of Internal Medicine.
It captures the essential elements of ACP for individuals with eventually fatal chronic disease.
Friday, 14 November 2008
Check Out These CJMRT Articles
This article was first published in the Canadian Journal of Medical Radiation Technology (now the Journal of Medical Imaging and Radiation Sciences ). Visit www.jmirs.org to access current and past issues of JMIRS, and coming soon, CJMRT. 
The Airport Shuttle and the Fundraising Dinner
Advance Care Planning isn't just, or even primarily, about writing down wishes for future healthcare. It's about clear communication amongst patients, family members, friends, and healthcare providers. It's about listening, asking pertinent questions, and respecting each other. It's about goals for living well during health and sickness. It's about what gives life meaning. It's even about communicating worries and preventing medical errors. It's not surprising then, that Advance Care Planning issues can crop up all over the place--sometimes in hotel shuttle buses and sometimes at fundraising dinners.
In my other life, I volunteer with Hope International Development Agency—a grassroots, non-profit organization that focuses on providing basic human necessities (i.e., clean water) for the neediest of the needy in the developing world. Surprisingly, two conversations from the recent round of fundraising dinners in Alberta, BC, and Ontario, actually had Advance Care Planning written all over them.
The Airport Shuttle
She and I were both on the hotel shuttle to the airport—both heading for Toronto; she to go back home, and me to organize a silent auction at two Ontario fundraising dinners. When she asked if this was my full time job, I explained that my day job was teaching communication skills to healthcare providers. Her face lit up, and so began an animated conversation. She works for an insurance company—one that specializes in insuring municipalities and towns. I explained how crucial good communication skills are for healthcare providers and how often a lack of communication skills results in less than optimal outcomes in the healthcare sector. This got her thinking about the situation in her own business. “Wow,” she remarked, “I never thought of communication being a safety issue before, but it really is. We need to hear more about this in our business.” I wonder what she’ll do with this epiphany.
The Fundraising Dinner
She and I were both at the same dinner table; as we chatted she asked me if I was employed by Hope International Development Agency. I explained that I volunteered with Hope, but had my own business teaching communication skills, specifically, skills in facilitating Advance Care Planning conversations, to healthcare providers. Her immediate response was, “I have some physicians who need to attend your classes…want to hear my latest experience?” She proceeded to tell me about her recent ophthalmologist visit. She explained that she had a rare, progressive muscle disease that called for her to see an ophthalmologist on a yearly basis. “I went for my routine exam,” she began, “and minutes into the visit the doctor told me I wouldn’t be able to drive anymore. The visit went on for several minutes, but I heard NOTHING after he told me I wouldn’t be able to drive. I was stunned. All I could do was think about how my daily activities would be curtailed by this restriction. I went home in a daze. A few days later, still upset, I went to see my family physician. She encouraged me to call the ophthalmologist’s office and make a “consultation” appointment—an appointment to discuss the driving restriction and the reasons for it. I never knew this was an option, but I quickly followed her instructions. I’m so glad I did. I explained to him how I had not processed any of his comments after he told me I would not be able to drive. He was immediately concerned and listened intently to what I had to say. ‘Look over at that eye chart,’ he said after I had fully expressed my concerns. ‘Read as many letters as you can.’ He then checked my chart and said, ‘You know what, I think you WILL be able to drive. We can put a special lens in your right eye, and, yes, you’ll be able to drive.’ I walked out of that office on a cloud. I don’t know why he didn’t figure this out during the previous exam, but right now I don’t care. I’m just thrilled that I’ll be able to drive for a while longer. What would have happened if I hadn’t gone back to him to talk about things?”
In my other life, I volunteer with Hope International Development Agency—a grassroots, non-profit organization that focuses on providing basic human necessities (i.e., clean water) for the neediest of the needy in the developing world. Surprisingly, two conversations from the recent round of fundraising dinners in Alberta, BC, and Ontario, actually had Advance Care Planning written all over them.
The Airport Shuttle
She and I were both on the hotel shuttle to the airport—both heading for Toronto; she to go back home, and me to organize a silent auction at two Ontario fundraising dinners. When she asked if this was my full time job, I explained that my day job was teaching communication skills to healthcare providers. Her face lit up, and so began an animated conversation. She works for an insurance company—one that specializes in insuring municipalities and towns. I explained how crucial good communication skills are for healthcare providers and how often a lack of communication skills results in less than optimal outcomes in the healthcare sector. This got her thinking about the situation in her own business. “Wow,” she remarked, “I never thought of communication being a safety issue before, but it really is. We need to hear more about this in our business.” I wonder what she’ll do with this epiphany.
The Fundraising Dinner
She and I were both at the same dinner table; as we chatted she asked me if I was employed by Hope International Development Agency. I explained that I volunteered with Hope, but had my own business teaching communication skills, specifically, skills in facilitating Advance Care Planning conversations, to healthcare providers. Her immediate response was, “I have some physicians who need to attend your classes…want to hear my latest experience?” She proceeded to tell me about her recent ophthalmologist visit. She explained that she had a rare, progressive muscle disease that called for her to see an ophthalmologist on a yearly basis. “I went for my routine exam,” she began, “and minutes into the visit the doctor told me I wouldn’t be able to drive anymore. The visit went on for several minutes, but I heard NOTHING after he told me I wouldn’t be able to drive. I was stunned. All I could do was think about how my daily activities would be curtailed by this restriction. I went home in a daze. A few days later, still upset, I went to see my family physician. She encouraged me to call the ophthalmologist’s office and make a “consultation” appointment—an appointment to discuss the driving restriction and the reasons for it. I never knew this was an option, but I quickly followed her instructions. I’m so glad I did. I explained to him how I had not processed any of his comments after he told me I would not be able to drive. He was immediately concerned and listened intently to what I had to say. ‘Look over at that eye chart,’ he said after I had fully expressed my concerns. ‘Read as many letters as you can.’ He then checked my chart and said, ‘You know what, I think you WILL be able to drive. We can put a special lens in your right eye, and, yes, you’ll be able to drive.’ I walked out of that office on a cloud. I don’t know why he didn’t figure this out during the previous exam, but right now I don’t care. I’m just thrilled that I’ll be able to drive for a while longer. What would have happened if I hadn’t gone back to him to talk about things?”
Monday, 10 November 2008
ACP Podcast Still Relevant
I just found this link to a podcast I participated in a while back:
"Fraser Health is known nationally for its expertise
and award-winning programs in End of Life and
Palliative Care. So it is no surprise that a podcast would feature Sue Grant (former Project Coordinator for Fraser Health's Advance Care Planning initiative) as a recognized authority in Canada in understanding, navigating and
operationalizing Advance Care Planning. Originally
aired in 2006, the podcast is still available."
"Fraser Health is known nationally for its expertise
and award-winning programs in End of Life and
Palliative Care. So it is no surprise that a podcast would feature Sue Grant (former Project Coordinator for Fraser Health's Advance Care Planning initiative) as a recognized authority in Canada in understanding, navigating and
operationalizing Advance Care Planning. Originally
aired in 2006, the podcast is still available."
Tuesday, 4 November 2008
Chronic Illness and Advance Care Planning - What's Taking Us So Long to Get it Right?
It seems like such a simple thing--asking patients and families what they understand and what they hear when their healthcare is discussed. Despite the simplicity, and even ease, with which a practitioner can check out the perspective of a patient or family member, it just isn't done that often. Moreover, comprehensive advance care plans that document agreement among the patient, significant other(s), and the health care team about how to respond to the anticipated complications of a chronic illness, are rare.
Respecting Choices, the best practice Advance Care Planning initiative of Gundersen Lutheran Medical Foundation, has developed an interview tool that promises to dramatically increase patient, family, and healthcare provider satisfaction as it pertains to the management of chronic illness. This interview is delivered by clinicians certified in the Disease Specific/Patient Centered Advance Care Planning (DSPCACP)intervention. Research at Gundersen Lutheran has demonstrated the efficacy of this intervention on a number of levels.
Key features of the interview include:
1. 1.5 hour interview with patient and healthcare agent in outpatient setting
2. Assessment of dyad’s understanding of illness
3. Structured interview that integrates replicable communication techniques
A randomized control study(312 dyads--patients and their family members with end stage renal disease and congestive heart failure)has demonstrated that the DSPCACP significantly increases family members' congruence with patient wishes. One dyadic group received usual advance care planning support and the other received the interview intervention. The DSPCACP group had decreased difficulty in making decisions for future healthcare. There was no difference in anxiety between the two groups. Data are currently being tabulated on the increased likelihood of the patients' wishes being followed at time of death.
I'm excited about what the DSPCACP intervention offers in the field of Advance Care Planning. It's a giant step forward and I believe that its use will change how healthcare providers deliver care to patients (and significant others)with chronic illness.
Way back in 2003, an article by Joanne Lynn and Nathan Goldstein: Advance Care Planning for Fatal Chronic Illness: Avoiding Commonplace Errors and Unwarranted Suffering, chronicles the need for a tool such as the DSPCACP interview. Why, after 5 years, aren't we moving forward faster?
Respecting Choices, the best practice Advance Care Planning initiative of Gundersen Lutheran Medical Foundation, has developed an interview tool that promises to dramatically increase patient, family, and healthcare provider satisfaction as it pertains to the management of chronic illness. This interview is delivered by clinicians certified in the Disease Specific/Patient Centered Advance Care Planning (DSPCACP)intervention. Research at Gundersen Lutheran has demonstrated the efficacy of this intervention on a number of levels.
Key features of the interview include:
1. 1.5 hour interview with patient and healthcare agent in outpatient setting
2. Assessment of dyad’s understanding of illness
3. Structured interview that integrates replicable communication techniques
A randomized control study(312 dyads--patients and their family members with end stage renal disease and congestive heart failure)has demonstrated that the DSPCACP significantly increases family members' congruence with patient wishes. One dyadic group received usual advance care planning support and the other received the interview intervention. The DSPCACP group had decreased difficulty in making decisions for future healthcare. There was no difference in anxiety between the two groups. Data are currently being tabulated on the increased likelihood of the patients' wishes being followed at time of death.
I'm excited about what the DSPCACP intervention offers in the field of Advance Care Planning. It's a giant step forward and I believe that its use will change how healthcare providers deliver care to patients (and significant others)with chronic illness.
Way back in 2003, an article by Joanne Lynn and Nathan Goldstein: Advance Care Planning for Fatal Chronic Illness: Avoiding Commonplace Errors and Unwarranted Suffering, chronicles the need for a tool such as the DSPCACP interview. Why, after 5 years, aren't we moving forward faster?
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