Most physicians consider end-of-life and advance care planning conversations important, yet there are barriers to these discussions, and electronic health records are one obstacle, according to a recent survey.
The John A. Hartford Foundation, the California Health Care Foundation and Cambia Health Foundation surveyed 736 primary care and specialist physicians in 50 states for a poll entitled “Conversation Stopper: What’s Preventing Physicians from Talking with Patients about End-of-Life and Advance Care Planning?” The specialist physicians who participated in the survey were oncologists, pulmonologists and cardiologists.
In January 2016, the Centers for Medicare & Medicaid Services (CMS) began reimbursing doctors and other professionals for end-of-life discussions with patients. According to a press release about the survey, the benefit covers multiple conversations and is not limited to patients close to death. Advance care planning enables patients to learn about their health care treatment options, decide on the type of care they want and share those wishes with family, friends and providers, ideally as part of a patient’s EHR.
A 2015 poll from the Kaiser Family Foundation found strong support for this benefit among the public (80 percent). The recent California Health Care Foundation survey found that 95 percent physicians also support the new benefit, and 75 percent of physicians said the new Medicare benefit will make them more likely to talk with older patients about advance care planning.
All the physicians surveyed see Medicare patients, and three out of four (74 percent) report seeing many patients who could die within a year. And, most physicians (75 percent) believe that they, not the patient, another doctor or other healthcare professional, are responsible for initiating these conversations, according to the survey report. However, only 14 percent reported that they have billed Medicare for an advance care planning conversation since reimbursement.
According to the survey, physicians identified a number of barriers to these discussions. One in four (24 percent) reported that there is no place in their electronic health record indicating if a patient has an advance care plan, and for those whose EHR systems have that functionality, a little more than half (54 percent) said they can access the plan’s contents.
Only three in 10 respondents (29 percent) report that their practice or healthcare system has a formal system for assessing patients’ end-of-life wishes and goals of care, according to the report. And less than one-third report having had any formal training specifically on talking with patients and their families and end-of-life care.
“Too many people at the end of life receive care that is completely at odds with their personal wishes,” Terry Fulmer, PhD, president of the John A. Hartford Foundation and a nurse, said in a statement. “The new benefit, with its strong support from clinicians, is a promising first step in ensuring that more people remain in control of their health care experience to the very last day of their lives."
The survey results indicate that training makes a significant difference in physician responses. Physicians who report having explicit training in end-of-life conversations say they feel unsure about what to say in these conversations "rarely or not too often" (60 percent), compared to those who have not had explicit training (52 percent).
“As health care delivery becomes more patient-centric, this improvement in communication can relieve significant pain and suffering for patients and their families. These conversations, though not easy, benefit from taking into account the patient and physician's knowledge, attitudes, and beliefs about end-of-life care options,” said Sandra R. Hernandez, M.D., president and CEO of the California Health Care Foundation.
The survey responses also indicate that doctors value advance care planning as a way to honor the patient's values and wishes (92 percent), reduce unwanted hospitalizations at the end of life (87 percent), and have patients and families feel more satisfied with their care (81 percent).