Dr. Diane Meier, Director of the Centre of Advanced Palliative Care at Mount Sinai Hospital in New York, in a paper published in the HBR-NEJM blog (Harvard Business Review - The New England Journal of Medicine) poses the question of what should be the value of clinical practice in patients with complex health and social needs.
Lost in the country of the pink bibs
To illustrate what kind of patients Dr. Meier is talking about, I found an article in The New York Times, where the writer Marcy Cottrell House explains the case of her father, who at age seventy, developed dementia and also broke his femur. Cottrell says that during the long postoperative period, the father got much worse and often found him in a room with other insane patients, all of them with a pink bib around their necks. The quiet of the place was impressive and the old man's gaze no longer recognized anyone. The nurse told them not to worry, it was normal to be more disconnected because of the tranquilizers they gave him to avoid the aggressiveness that he displayed during his stay. The writer ended up going in the office of a good geriatrician, who told him that the postoperative pain or that of poly-arthritis was likely to be torturing his father. He clarified that cognitive problems don’t stop him feeling the pain of bones and joints. The fact - explains the author - is that with a gram of Tylenol three times a day (a painkiller), his father revived and returned to smile when he heard his music and, better still, managed to escape the country the pink bibs.
4 tactics to bring more value to patients with complex needs
Dr. Diane Meier says (in the video) that most people, if they have a serious illness, would give priority to preserving their personal independence, while only a minority (10% according to her) say they would accept any measure in order to stay alive. On the other hand, if we pay attention, we notice that the money from the health systems circulates in the opposite direction: there is usually no limitation to the extreme clinical performances, many of them clearly disproportionate, while money is always lacking for dependency aids.
In order to increase the value of the services offered to complex patients, Dr. Meier suggests four tactics:
a) Ask the patients and their families, explicitly, what are their wills, and ensure that they are recorded in the medical record in a position well visible for all specialists and healthcare centres that at one time or another will end up intervening in the often long clinical processes.
b) Encourage that all physicians, nurses, social workers and other professionals involved are trained in the detection and treatment of uncomfortable symptoms for patients, especially pain. Encourage training in alignment of care objectives, coordination and integration of services.
c) Denounce the perverse economic incentives that foment the inappropriate assistance activity above the services that contribute value.
d) Provide palliative care to all people suffering from complex pathologies, without having to wait to do so only in the last days.
Many think that to adequately address patients with complex chronic pathologies, we must rethink the model, and this is true, but now the writer Marcy Cottrell House and Dr. Diane Meier remind us of the importance of introducing geriatric thinking and palliative care on how to treat people when their problems begin to be difficult to manage.