Monthly Archives: August 2012

Divulging Information to Patients With Poor Prognoses

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Divulging Information to Patients With Poor Prognoses

We have seen several instances where our colleagues’ families have been given very little prognostic information by their physicians in situations where important decisions involving benefits versus harms, quality of life and other end of life decisions must be made. In both cases when a clinician in the family presented the evidence and prognostic information, decisions were altered.

We were happy to see a review of this topic by Mack and Smith in a recent issue of the BMJ.[1] In a nutshell the authors point out that—

  • Evidence consistently shows that healthcare professionals are hesitant to divulge prognostic information due to several underlying misconceptions. Examples of misconceptions—
    • Prognostic information will make patients depressed
    • It will take away hope
    • We can’t be sure of the patient’s prognosis anyway
    • Discussions about prognosis are uncomfortable
  • Many patients are denied discussion about code status, advance medical directives, or even hospice until there are no more treatments to give  and little time left for the patient
  • Many patients lose important  time with their families and and spend more time in the hospital and in intensive care units than would be if prognostic information had been provided and different decisions had been made.

Patients and families want prognostic information which is required to make decisions that are right for them. This together with the lack of evidence that discussing prognosis causes depression, shortens life, or takes away hope and the huge problem of unnecessary interventions at the end of life creates a strong argument for honest communication about poor prognoses.

Reference

1. Mack JW, Smith TJ. Reasons why physicians do not have discussions about poor prognosis, why it matters, and what can be improved. J Clin Oncol. 2012 Aug 1;30(22):2715-7. Epub 2012 Jul 2. PubMed PMID: 22753911.

 

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Institute of Medicine CEO Checklist for High-Value Healthcare

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Institute of Medicine CEO Checklist for High-Value Healthcare

In June, 2012 the Institute of Medicine (IOM) published a checklist for healthcare CEOs as a way of encouraging further efforts towards achieving a simultaneous reduction in costs and elimination of waste.[1] EBMers will find the case studies of great interest. Many of the success stories contain two key ingredients—reliable information to improve decision-making and successful implementation.  The full report is available at—
http://www.iom.edu/Global/Perspectives/2012/CEOChecklist.aspx.

Foundational Elements

1. Governance priority—visible and determined leadership by CEO and board

  • Culture of continuous improvement—commitment to ongoing, real-time learning
  • Infrastructure Fundamentals

2. Information technology (IT) best practices—automated, reliable information to and from the point of care

  • Evidence protocols—effective, efficient, and consistent care
  • Resource utilization—optimized use of personnel, physical space, and other resources

3. Care Delivery Priorities

  • Integrated care—right care, right setting, right providers, right teamwork
  • Shared decision making—patient-clinician collaboration on care plans
  • Targeted services—tailored community and clinic interventions for resource-intensive patients

4. Reliability and Feedback

  • Embedded safeguards—supports and prompts to reduce injury and infection
  • Internal transparency—visible progress in performance, outcomes, and costs

References

1. Cosgrove D, Fisher M, Gabow P, et al. A CEO Checklist for High-Value Health Care. Discussion paper. Washington, DC: Institute of Medicine; 2012. http://www.iom.edu/Global/Perspectives/2012/CEOChecklist.aspx (accessed 08/13/2012).

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