Showing papers by "Diane E. Meier published in 2009"

Palliative Care in the Treatment of Advanced Heart Failure

Abstract: Heart failure is epidemic in developed countries and is expanding rapidly worldwide. Roughly 5% of patients with heart failure have end-stage disease that is refractory to medical therapy (stage D heart failure).1 Palliative care consultation relieves symptoms, improves patient satisfaction, and decreases the costs of care for these patients. Despite this, only a small fraction of end-stage heart failure patients receive palliative care consultation. In recognition of this, palliative/hospice care referral was recommended for end-stage heart failure (Level of Evidence 1A) in the most recent American College of Cardiology/American Heart Association heart failure guidelines.2 To identify evidence-based studies of palliative care in heart failure, we searched the Medline database for literature with the medical subject headings “heart failure” and “palliative care,” “supportive care,” or “symptom management” and found 394 results. We identified 92 systematic reviews, 44 of which were English-language systematic reviews published within the past 5 years. More than 5 million Americans have heart failure, with a yearly incidence estimated to be >500 000.3 The number of deaths due to heart failure in 2004 was 284 365, which exceeds the deaths due to lung cancer, breast cancer, prostate cancer, and HIV/AIDS combined (Table 1).3–5 Even as the national death rate decreased by 2% from 1994 to 2004, deaths due to heart failure increased by 28%. View this table: Table 1. Incidence of and Number of Deaths Due to Heart Failure Compared With Other Common Causes of Death in the United States The yearly cost of heart failure was roughly $30 billion in 2006.6 The mean hospital length of stay is almost 6 days, and more than one third of patients are admitted for more than 5 days. Nearly half of the hospitalizations for heart failure exceed Medicare diagnosis-related groups reimbursement.7 Compared with all other patients, …

POLST offers next stage in honoring patient preferences.

Abstract: National advocacy groups have spent considerable effort promoting advance care planning and encouraging completion of advance directives in order to enhance congruence between the kind of medical care people say they would want to receive during serious or terminal illness and the care they typically receive. These efforts continue despite a growing body of evidence suggesting that conventional advance directives have not been as helpful as proponents hoped. A new and rapidly diffusing approach to ensuring care concordant with patient preferences, executed closer to the time of need, is called the Physician Orders for Life-Sustaining Treatment or POLST. POLST translates patient preferences into specific medical orders to be honored by physicians and other health care workers during a medical crisis. POLST advocates emphasize that this approach, first developed in Oregon in 1991 and recently adopted statewide in California and New York, is not an advance directive but rather is a set of medical orders. An advance directive is a legal document, such as living will or durable power of attorney for health care decisions, which is completed far in advance to inform a potential future medical circumstance in which the individual may be incapable of making decisions or expressing preferences for care. POLST, by contrast, is a medical order signed by a physician, after consultation with the patient or—if the patient lacks capacity—with the patient’s legal surrogate. POLST is appropriate for people who already have an advanced chronic illness, for whom the prognosis is measured in 1 to 2 years. It specifically addresses medical decisions and options that are likely to arise in the near future, including cardiopulmonary resuscitation, antibiotics for infections, artificial food and fluids, and whether or not the patient would want to be rehospitalized. More relevant and specific than conventional advance directives, POLST provides explicit guidance to health professionals under predictable future circumstances (such as development of pneumonia in a patient with advanced dementia). (See Fig. 1 for an illustration of a POLST form.) The Center for Ethics in Health Care at Oregon Health & Sciences University (OHSU) describes POLST as a new paradigm for the health care system. The center established the National POLST Paradigm Initiative Task Force (see www .polst.org) to facilitate the development, implementation, and evaluation of POLST initiatives nationwide. Subsequent to the Oregon initiative, a number of states have implemented POLST programs, either statewide (Idaho, New York, North Carolina, Washington, and West Virginia) or as regional or community projects. Others are exploring POLST coalition building, dissemination and implementation, with consultation, facilitator training and technical assistance from OHSU. (See Fig. 2 for a map showing participating states.) The basic POLST approach provides actionable information on how to honor the wishes of a patient with a lifethreatening condition regarding a range of available medical treatments; documents those wishes in a physician-signed medical order on a brightly colored (typically pink) form that accompanies the patient across and between settings of care, including ambulance rides; and formalizes agreement by health professionals across all settings in the community to honor medical orders contained in the POLST form. Experts emphasize that POLST is not just a glorified donot-resuscitate (DNR) order. Patients with POLST may indicate their desire either for or against specific life-sustaining treatments, and may endorse different combinations of relevant treatments. According to one study in Oregon, a majority of patients requesting DNR via POLST actually wanted potentially life-prolonging interventions in at least one other treatment category. (For example, a nursing home patient’s POLST might specify no rehospitalization and no cardiopulmonary resuscitation [CPR], but request antibiotics in case of infection, and tube feeding for nutrition and hydration.) Through its specificity and provision of yes-or-no answers for each of the common decision points (hospitalization, CPR, intensive care, ventilatory support, artificial nutrition and hydration) POLST provides quick and clear guidance to any health professional who simply reads the single-page form. Patients may also revoke an old POLST form and write a new one as their disease and other circumstances change. When combined with state policies and=or legislation recognizing the document as a valid medical order and broadbased education for health care professionals on how it works, POLST can convert patient preferences into immediately actionable medical orders that are readily accessible to medical

Center to Advance Palliative Care Inpatient Unit Operational Metrics: Consensus Recommendations

Abstract: The need to standardize the prospective collection and analysis of data has been a cornerstone of education and technical assistance provided by the Center to Advance Palliative Care (CAPC

Finding my place.

Abstract: On the first day of my internship, at about 8:00 in the morning, I was paged to the CCU. There a patient who was assigned to my service was undergoing resuscitation after cardiac arrest. Running after my resident, we arrived at the bedside of an 89-year-old man with end-stage congestive heart failure. The bed was surrounded by cardiology fellows, nurses, residents, a ventilator, crash cart, and ECG machinery, and the floor and bed were strewn with paper, ECG strips, discarded tubing. I watched as we shocked the patient repeatedly; tried four times to get a central line in; injected pressors directly into his heart; stuck the femoral artery for blood gases; and carried on chest compressions for over an hour. Finally the cardiology fellow called the code. Leaving the patient naked and covered with tubes, paper, and bloodstained sheets, we left his bedside. The patient’s wife was seated outside the unit. We all walked past her, to get back to the work of the first day. I do not know if anyone spoke with her to explain what happened. Certainly no one explained it to me. This patient’s death was the first I witnessed. My colleagues were committed to trying to save his life and we applied every technology at our disposal to achieve this end. There was no sense of uncertainty or ambivalence about what we were doing. Our motives were simple and clear: prolong life. The primary emotion after the code was one of both discouragement and determination—we had failed to save this life, but next time we would know more, do better, and have more knowledge to help us—next time we will get it right. My own emotions were a confused tangle of feelings of complete inadequacy and guilt—I should have learned to put in central lines as a medical student, I should have known how to conduct CPR, I should have arrived earlier in the morning, I should have come in the day before to get to know my patients. The principle of respect for life, that all life—no matter how diminished by disease or illness—is precious, and that the medical profession’s only raison d’etre was to use all tools available to prolong it—was such a fundamentally held assumption that it was not (at least consciously) questioned throughout all my 9 years of training. This patient died 31 years ago in July 1977. I have been carrying him with me ever since. Three months later, my grandfather, Frank Meier, died suddenly. I adored my grandpa and learned to love ice cream and gardening and to understand that all people were one, from him. He was a socialist in his youth and instilled firmly held values about service to others in his two sons and three granddaughters. He came to visit me in September of my internship, and during his visit, asked me what it meant that

Billing for palliative consultations a prerequisite for the field's maturation.

Abstract: Billing for palliative care consultations is an essential function of efficiently run palliative care programs. Despite the obvious advantages of being paid for our work, many practitioners have found the process difficult to master. The most successful programs have built effective working relationships and are in regular communication with their colleagues in billing and coding, leading to mutual education, enhanced efficiencies, and better income with fewer denials. Some Medicare intermediaries have denied payment because until now, Medicare had not recognized palliative medicine as an official specialty. This problem is resolved, thanks to the work of Judi Buckalew and the public policy committee of the American Academy of Hospice and Palliative Medicine. A new code designating hospice and palliative care as a recognized medical specialty (Table 1), is set for implementation on October 1, 2009, by the federal Centers for Medicare and Medicaid Services (CMS). Billing for palliative care is the same as for consultations by any other medical specialty. It requires a procedure=service code from the American Medical Association’s Current Procedural Terminology (CPT), usually for evaluation and management (E&M), and an International Classification of Diseases, 9 Revision (ICD-9) diagnosis code. Medical charges are based on location (inpatient=outpatient=home), and either complexity or time, with documentation needed to support the billing level. Palliative care providers must be careful to avoid using the same diagnosis (ICD-9) code as colleagues in the same specialty who may be seeing the patient and billing for their services on the same day. For example, an oncologist providing chemotherapy for lung cancer will use the diagnosis code for cancer, while a different oncologist providing a palliative medicine consultation may bill for a symptom, such as dyspnea. These concurrent visits can be paid, but only if the coding distinguishes the palliative care consultant’s service from the attending physician’s, typically by using a different ICD-9 code. (See Table 2 for additional modifiers that may be used on bills.) Since palliative care consultations typically require a significant time commitment, services also quantify their time spent in counseling, coordinating care, and informationgiving and bill accordingly, but with mixed success. Medicare intermediaries or carriers (now called Medicare Administrative Contractors or MACS) have varied in their acceptance of prolonged time codes. To ensure appropriate payment for prolonged services, it is critical for palliative care providers to understand the circumstances under which prolonged service codes (inpatient 99356 and 99357 and outpatient 99354 and 99355) may be used. Specifically, Medicare currently bases payment for prolonged services on CPT 2008, which requires that prolonged services must occur face-to-face with the patient. Hence, a family meeting held in a conference room in an intensive care unit (ICU), while the patient is intubated and sedated down the hall, does not qualify for prolonged service codes. When CMS adopts the new CPT 2009 guidelines, the rules will change to allow use of prolonged service codes for non– face-to-face services, including charting, speaking with other providers, meeting with families, and reviewing imaging and laboratory studies. Furthermore, use of prolonged service codes requires documentation of encounter onset and completion (e.g., 1:30 pm to 3:00 pm, 50% spent face-to-face with the patient in coordination and counseling). Other billing problems reported by palliative care practitioners include: