Skip to main content

Give patients end-of-life options

By Joan M. Teno, Special to CNN
March 15, 2013 -- Updated 1520 GMT (2320 HKT)
A massage therapist embraces a terminally ill patient at a Colorado hospice.
A massage therapist embraces a terminally ill patient at a Colorado hospice.
STORY HIGHLIGHTS
  • Joan Teno asks: Why do doctors continue to test and treat patients who are clearly dying?
  • She says instead they should be helping very sick patients weigh quality of life against quantity
  • Teno: Hospice care doubles, but patients still in ICU until last 3 days of life. Do they want this?
  • Teno: Intervention lucrative for medical industry; this wars with patient-centered end-of-life care

Editor's note: Joan M. Teno is a physician and professor of health systems, policy and practice at the Warren Alpert School of Medicine of Brown University.

(CNN) -- The urban dictionary defines "cheech" as a verb used among physicians in training that refers to the act of ordering every conceivable radiological and laboratory test for a patient, often to diagnose a condition that once diagnosed is untreatable. Thirty years ago, the macabre joke during my three-month stint as an intern in the medical ICU was first cheech, then death.

I remember sitting at the bedside of a frail, older woman with dementia dying of septic shock. A litany of subspecialists had rounded earlier in the day, but no one said what was so obvious. She was dying. Instead, I sat at her bedside at 4:30 a.m. watching the sun rise over Narragansett Bay, increasing vasopressors to try to maintain her blood pressure.

Joan Teno
Joan Teno

Instead of being surrounded by her family and loved ones, the only person at her bedside was an exhausted intern who had never met the woman in bed No. 2 until the night before. This was simply wrong. Why were we rearranging the deck chairs on the Titanic instead of ensuring that her death was peaceful and that she was surrounded by her family?

Intensive Care Units save some patients and play an important role in our health care system. But the overarching concern is, "Are we talking to frail, older patients and their families at the right time about when to stop (or avoid) ICU care and recurrent hospitalizations?" Decisions about hospitalizations and ICU admission must weigh the quality vs. the quantity of life.

Opinion: End-of-life planning eases suffering

These decisions must reflect a patient's informed wishes and goals for care, be based on what the patient and/or family understand about the medical condition -- their hopes and goals -- and educate them about the prognosis and treatment options to arrive at a care plan that honors realistic patient goals of care.

Our research published in the February 8 edition of JAMA finds that hospice is now part of mainstream medical care, with nearly half of older Medicare beneficiaries receiving hospice services. However, that's only half the story. More than a quarter (28.4%) of these people had the benefit of hospice for three days or less, and nearly half (40.3%) were in an ICU immediately before.

Become a fan of CNNOpinion
Stay up to date on the latest opinion, analysis and conversations through social media. Join us at Facebook/CNNOpinion and follow us @CNNOpinion on Twitter. We welcome your ideas and comments.



Indeed, contrasting end of life care in 2000 vs. 2009, in spite of a doubling of hospice use, we found more ICU care, more repeat hospitalizations and more patient transfers from hospital to another health care setting in the last three days of life. Does this pattern of care reflect the informed wishes of dying patients and their families? Our research does not provide the answer to this important question. But it is something we really need to know.

On the face of it, our research findings should not be surprising. You get what you pay for. All the financial incentives in fee-for-service Medicare are aligned to induce more hospitalizations, more ICU care and late hospice referrals. As we try to reform our health care system to provide care that is patient centered and care that improves the health of our population, we need to do a better job of paying for quality rather than simply paying for another day in the ICU, particularly if it does not change the inevitable.

Where dying kids' lives are celebrated
Dedicated to caring for the dying

Yet during the debate over health-care reform, a proposal to pay health-care providers for advance care planning was eliminated from the legislation based on the mistaken argument that promoting shared decision making with the goals of honoring patient wishes was equivalent to creating a "death panel."

The key is that decisions be based upon discussions that weigh the quantity vs. the quality of life reflect informed patient preferences. The evidence to date suggests we are falling short of that goal. We've previously shown that 11.6% of family members felt pressured by a physician to put a feeding tube in a dying patient with advanced dementia, and about 10% reported that no one discussed that decision with them.

A recent study of two ICUs that differed on the aggressiveness of care provided found contrasting decision-making styles: a futility based decision-making process where one talks to the patient only when death is certain in the aggressive ICU vs. a shared decision making model where physicians work with patients and families early in the ICU stay to arrive at a decision that is consistent with the patient's prognosis and goals of care in the ICU.

We must have publicly reported data on the degree in which our health care system delivers on the promise of patient centered care -- that health care providers are informing patients and their families of the expected prognosis and treatment options, helping them in making these difficult decisions, and that patients are provided the right care at the right time, in the right place, and consistent with their informed wishes. We must hold our health care system accountable to the goal that medical decisions should reflect patient informed goals and values.

Follow us on Twitter @CNNOpinion.

Join us on Facebook/CNNOpinion.

The opinions expressed in this commentary are solely those of Joan M. Teno

ADVERTISEMENT
Part of complete coverage on
October 21, 2014 -- Updated 2006 GMT (0406 HKT)
Timothy Stanley says Lewinsky is shamelessly playing the victim in her affair with Bill Clinton, humiliating Hillary Clinton again and aiding her critics
October 23, 2014 -- Updated 1414 GMT (2214 HKT)
Imagine being rescued from modern slavery, only to be charged with a crime, writes John Sutter
October 21, 2014 -- Updated 1600 GMT (0000 HKT)
Tidal flooding used to be a relatively rare occurrence along the East Coast. Not anymore, write Melanie Fitzpatrick and Erika Spanger-Siegfried.
October 21, 2014 -- Updated 1135 GMT (1935 HKT)
Carol Costello says activists, writers, politicians have begun discussing their abortions. But will that new approach make a difference on an old battleground?
October 21, 2014 -- Updated 1312 GMT (2112 HKT)
Sigrid Fry-Revere says the National Organ Transplant Act has caused more Americans to die waiting for an organ than died in both World Wars, Korea, Vietnam, Afghanistan and Iraq
October 21, 2014 -- Updated 1851 GMT (0251 HKT)
Crystal Wright says racist remarks like those made by black Republican actress Stacey Dash do nothing to get blacks to join the GOP
October 21, 2014 -- Updated 2207 GMT (0607 HKT)
Mel Robbins says by telling her story, Monica Lewinsky offers a lesson in confronting humiliating mistakes while keeping her head held high
October 20, 2014 -- Updated 1329 GMT (2129 HKT)
Cornell Belcher says the story of the "tea party wave" in 2010 was bogus; it was an election determined by ebbing Democratic turnout
October 20, 2014 -- Updated 2012 GMT (0412 HKT)
Les Abend says pilots want protocols, preparation and checklists for all contingencies; at the moment, controlling a deadly disease is out of their comfort zone
October 20, 2014 -- Updated 0336 GMT (1136 HKT)
David Weinberger says an online controversy that snowballed from a misogynist attack by gamers into a culture war is a preview of the way news is handled in a world of hashtag-fueled scandal
October 20, 2014 -- Updated 1223 GMT (2023 HKT)
Julian Zelizer says Paul Krugman makes some good points in his defense of President Obama but is premature in calling him one of the most successful presidents.
October 20, 2014 -- Updated 0221 GMT (1021 HKT)
Conservatives can't bash and slash government and then suddenly act surprised if government isn't there when we need it, writes Sally Kohn
October 22, 2014 -- Updated 1205 GMT (2005 HKT)
ISIS is looking to take over a good chunk of the Middle East -- if not the entire Muslim world, write Peter Bergen and Emily Schneider.
October 20, 2014 -- Updated 1300 GMT (2100 HKT)
The world's response to Ebola is its own sort of tragedy, writes John Sutter
October 17, 2014 -- Updated 2033 GMT (0433 HKT)
Hidden away in Russian orphanages are thousands of children with disabilities who aren't orphans, whose harmful treatment has long been hidden from public view, writes Andrea Mazzarino
October 18, 2014 -- Updated 1722 GMT (0122 HKT)
When you hear "trick or treat" this year, think "nudge," writes John Bare
October 18, 2014 -- Updated 0442 GMT (1242 HKT)
The more than 200 kidnapped Nigerian schoolgirls have become pawns in a larger drama, writes Richard Joseph.
October 17, 2014 -- Updated 1345 GMT (2145 HKT)
Peggy Drexler said Amal Alamuddin was accused of buying into the patriarchy when she changed her name to Clooney. But that was her choice.
October 16, 2014 -- Updated 2043 GMT (0443 HKT)
Ford Vox says the CDC's Thomas Frieden is a good man with a stellar resume who has shown he lacks the unique talents and vision needed to confront the Ebola crisis
October 18, 2014 -- Updated 0858 GMT (1658 HKT)
How can such a numerically small force as ISIS take control of vast swathes of Syria and Iraq?
October 17, 2014 -- Updated 1342 GMT (2142 HKT)
How big a threat do foreign fighters in Syria and Iraq pose to the West? It's a question that has been much on the mind of policymakers and commentators.
October 17, 2014 -- Updated 1221 GMT (2021 HKT)
More than a quarter-million American women served honorably in the Iraq and Afghanistan wars. Now they are home, we have an obligation to help them transition back to civilian life.
October 16, 2014 -- Updated 2027 GMT (0427 HKT)
Paul Begala says Rick Scott's deeply weird refusal to begin a debate because rival Charlie Crist had a fan under his podium spells disaster for the Florida governor--delighting Crist
October 16, 2014 -- Updated 0407 GMT (1207 HKT)
The longer we wait to engage on Ebola, the more limited our options will become, says Marco Rubio.
October 15, 2014 -- Updated 1153 GMT (1953 HKT)
Democratic candidates who run from President Obama in red states where he is unpopular are making a big mistake, says Donna Brazile
October 16, 2014 -- Updated 0429 GMT (1229 HKT)
At some 7 billion people, the world can sometimes seem like a crowded place. But if the latest estimates are to be believed, then in less than a century it is going to feel even more so -- about 50% more crowded, says Evan Fraser
October 20, 2014 -- Updated 1653 GMT (0053 HKT)
Paul Callan says the Ebola situation is pointing up the need for better leadership
October 15, 2014 -- Updated 2245 GMT (0645 HKT)
Nurses are the unsung heroes of the Ebola outbreak. Yet, there are troubling signs we're failing them, says John Sutter
October 15, 2014 -- Updated 1700 GMT (0100 HKT)
Dean Obeidallah says it's a mistake to give up a business name you've invested energy in, just because of a new terrorist group
October 15, 2014 -- Updated 2301 GMT (0701 HKT)
Fear of Ebola is contagious, writes Mel Robbins; but it's time to put the disease in perspective
October 14, 2014 -- Updated 1744 GMT (0144 HKT)
Oliver Kershaw says that if Big Tobacco is given monopoly of e-cigarette products, public health will suffer.
October 18, 2014 -- Updated 1335 GMT (2135 HKT)
Stop thinking your job will make you happy.
October 15, 2014 -- Updated 0208 GMT (1008 HKT)
Ruben Navarrette says it's time to deal with another scandal involving the Secret Service — one that leads directly into the White House.
October 14, 2014 -- Updated 1125 GMT (1925 HKT)
Americans who choose to fight for militant groups or support them are young and likely to be active in jihadist social media, says Peter Bergen
October 13, 2014 -- Updated 1303 GMT (2103 HKT)
Stephanie Coontz says 11 years ago only one state allowed same sex marriage. Soon, some 60% of Americans will live where gays can marry. How did attitudes change so quickly?
October 14, 2014 -- Updated 2004 GMT (0404 HKT)
Legalizing assisted suicide seems acceptable when focusing on individuals. But such laws would put many at risk of immense harm, writes Marilyn Golden.
October 13, 2014 -- Updated 1307 GMT (2107 HKT)
Julian Zelizer says the issues are huge, but both parties are wrestling with problems that alienate voters
October 13, 2014 -- Updated 2250 GMT (0650 HKT)
Mel Robbins says the town's school chief was right to cancel the season, but that's just the beginning of what needs to be done
October 11, 2014 -- Updated 1543 GMT (2343 HKT)
He didn't discover that the world was round, David Perry writes. So what did he do?
ADVERTISEMENT