Gawande: Good palliative care blocked by quality measures, lack of communication

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The quality measures currently in place in skilled nursing facilities and hospice settings are too focused on safety and health to promote effective palliative care, physician Atul Gawande, M.D., MPH, told lawmakers on Thursday.

Gawande, whose work include authoring the seminal end-of-life book Being Mortal, testified before the Senate Special Committee on Aging as part of a hearing on person-centered care for people with serious illnesses. He pinpointed barriers that exist to providing person-centered end-of-life care.

Among those barriers are the “narrowly focused” quality measures implemented by SNFs, hospitals, hospices and other elder care organizations that place an emphasis on safety and health while neglecting other domains of well-being, Gawande said. While measures on fall prevention and pressure ulcers are important, they're missing the bigger picture, he claimed.

“We publicly report survival rates for particular conditions and measures for preservation of health and safety, but we do not have measures that ask how effectively care supports well-being,” Gawande said. “People have reasons they wish to be alive, but in our incentives and expectations for healthcare and elder care, we don't seem to acknowledge that at all.”

Gawande, who has twice spoken at national LeadingAge meetings, recommended developing and prioritizing quality measures for serious illness care planning and well-being that take patients' preferences on privacy, decision making and even room decorating into account. He also endorsed six measureable goals for end-of-life care launched by the Massachusetts Coalition for Serious Illness Care, including that all adults have a designated healthcare decision maker and all clinicians have training on advanced care planning conversations.

That training could help close a critical gap between patients and physicians when it comes to end-of-life conversations — while 85% of people believe that doctors should have those conversations with patients, only 15% have ever conducted such a discussion, Gawande noted. Only a quarter of patients with serious illnesses have had a conversation about their goals with their physician.

Thursday's hearing also included testimony from Kate Lally, M.D., FACP, chief of palliative care for Care New England Health System. Lally shared her experiences implementing a palliative care program for skilled nursing facilities.