Clinicians and patients typically agree there are advantages to having medical wishes clearly documented in advance of a health crisis. Despite this understanding, and an abundance of cautionary anecdotes to serve as examples, why do conversations about end-of-life decisions remain so difficult?
According to research published in July 2017 in Health Affairs, nearly two-thirds of adults have not completed an advance directive of any kind. The article underscored one of the most significant sources of cognitive dissonance in U.S. health care: there is a disconnect between the care that Americans wish to receive near the end of life and the care they actually receive.
Last fall, at our annual campuswide flu vaccination event, members of the Vanderbilt community were surveyed about advance directives. Of 2,185 respondents, 27 percent had completed some form of an advance directive, although 77 percent thought they should have one. Eighty-two percent of those who felt they didn’t need one were younger than 35 years old.
As a leader in health care, we have a responsibility to take a hard look at all aspects of the care we deliver. Too often, while focusing on prevention and treatment of disease, we pay less attention to an equally important responsibility — supporting our patients through the journey we all eventually encounter at the end of life. A key to helping patients understand their options is to encourage conversations between clinicians and patients about a subject that for many of us, including those of us in the healing professions, can be uncomfortable.
In the process of growing the proportion of VUMC patients documenting advance directives, we are working to build greater alignment between clinicians and their patients via conversations that support our patients to clearly identify what is most important to them in the context of their current health circumstances. This approach allows patients and their care team to adjust along the way, revising plans designed to help achieve goals that maximize quality of life.
A special committee led by Bonnie Miller, MD, MMHC, Executive Vice President for Educational Affairs and Senior Associate Dean for Health Sciences Education, has been established to spearhead efforts to educate Medical Center staff about the importance of completing their own advance directives and to guide clinicians as they initiate conversations with patients and their families. These efforts also include training students, residents and fellows on end-of-life care options.
The committee, along with the Medical Center’s Palliative Care Service and the Center for Biomedical Ethics and Society, recently led a three-day event to build skills around opening a dialogue with patients and families. Individuals from eight specialties participated in role-playing exercises that highlight effective and empathetic practices for difficult discussions.
At VUMC, we believe leadership in defining personalized care includes growing our capacity for compassion and understanding as well as breakthroughs in technology and science. As we continue to build both the cultural and operational foundations for addressing one of health care’s most delicate health challenges, we have made it a priority this year to document the goals of care in the electronic health records of all VUMC patients, including preferences for end-of-life care.
To read more about the Medical Center’s efforts around this important topic, please see the article in this issue titled “A Delicate Dialogue” on page 24.
Jeff Balser, MD, PhD
President and CEO, Vanderbilt University Medical Center
Dean, Vanderbilt University School of Medicine