by Dr. Howard Epstein MD, FHM
I have practiced medicine for more than 20 years now, and it still amazes me how poorly the health care system meets the needs of those nearing end of life. The chance to do better and help others do so led me to become a hospice and palliative medicine physician, start a hospital-based palliative care program at Regions Hospital in St. Paul, chair the former Society of Hospital Medicine (SHM) Palliative Care Task Force, serve on the SHM Board, and as President of the Minnesota Network of Hospice & Palliative Care.
Last April, I was honored to be invited to speak on Choosing Wisely® at a triple aim health improvement conference in Columbia, South Carolina. As often happens at these events, they hosted a faculty and sponsor dinner with cocktails, handshakes, and schmoozing followed by dinner. How fortunate I was to score a seat right next to Dr. Atul Gawande, surgeon and accomplished writer on health and healthcare. He shared with me that he had a new book forthcoming and, much to my delight, it would focus on late-life and end-of-life care. We had a wonderful conversation that evening, but unfortunately his book was already at the editor and nothing I said would be included. Still, I am so pleased to see that Dr. Gawande has used his gifts of healing and communication to help us rediscover one of the central tenets of medicine captured in this Fifteenth Century French folk saying:
To cure sometimes, to relieve often, to comfort always.
A couple weeks ago, the Sunday Times published an Opinion piece from Dr. Gawande that captures the essence of his book through one person’s late-life story, his daughter Hunter’s piano teacher. It is my hope that by sharing Dr. Gawande’s story, we will all recognize the difference we can make by encouraging frank and honest conversations during those difficult times – especially the patients we care for who have chronic progressive illnesses such as congestive heart failure, COPD, dementia and kidney failure. Here is a brief excerpt with a few key questions to consider:
I also discovered that the discussions most successful clinicians had with patients involved just a few important questions that often unlocked transformative possibilities: (1) What is their understanding of their health or condition? (2) What are their goals if their health worsens? (3) What are their fears? and (4) What are the trade-offs they are willing to make and not willing to make? These discussions must be repeated over time, because people’s answers change. But people can and should insist that others know and respect their priorities.
The Conversation Project, Honoring Choices Minnesota® and other advance care planning initiatives help patients and families address these difficult questions. It is crucial for everyone to have a good understanding of their hopes, dreams, fears and goals of care along with their prognosis and possible treatment options before they near end-of-life so that they might have many more “best possible days” than they otherwise might have.
Dr. Howard Epstein MD, FHM is Executive Vice President & Chief Medical Officer at PreferredOne®, a Minnesota-based health plan. Dr. Epstein’s previous positions have included Chief Health Systems Officer at the Institute for Clinical Systems Improvement (ICSI), Medical Director for Quality and Health Management at Blue Cross and Blue Shield of Minnesota. He was also the founding medical director of the Palliative Care program at Regions Hospital in St. Paul, MN. Among his many activities, Dr. Epstein currently serves on the SHM’s Board of Directors and the Alumni Board of Governors at Washington University in St. Louis where he received his AB and MD degrees. He is a past President on the Minnesota Network of Hospice & Palliative Care, and is a contributing author for an upcoming hospital medicine reference on hospital-based palliative care. He is board certified in both internal medicine and hospice and palliative medicine and is a recipient of the SHM National Award for Clinical Excellence.
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