The importance of communicating your end-of-life wishes

April 27, 2015

The ConversationBy Terri Hobbs, Executive Director

“The failure of doctors to have discussions with patients about how to live life’s final chapter…is one of the most important problems facing American medicine today,” writes Harvard Medical School physician and researcher Dr. Angelo Volandes in his important new book “The Conversation: A Revolutionary Plan for End-of-Life Care.” Dr. Volandes, who is coming to Portland’s Powell’s Bookstore to discuss his book on June 1, 2015, urges that all clinicians “should be highly trained communicators who insist on discussions with patients about medical care at the end-of-life.”

We couldn’t agree more. The importance of well-informed discussion with patients and families about treatment options during end-of-life, as well as having choices like receiving primary medical care or hospice care in the home, are part of a revolution in thinking how best to meet the needs of our most elderly and frail citizens.

It wasn’t so long ago that most Americans spent the last few months of life at home surrounded by family and friends. Today, less than a quarter of older Americans die at home. The vast majority die in hospitals and nursing homes, sometimes connected to machines and often with unnecessary suffering and pain. Living wills and “do not resuscitate” directions often do not provide the clarity and precision necessary for difficult end-of-life decisions, nor guidance in how best to meet the patient’s immediate goals. Often complicating the situation are mental disabilities like dementia or Alzheimer’s disease. This places the burden of decision squarely on the shoulders of family members who are typically ill-prepared to handle the care and stress. What’s needed is a well-informed, direct conversation about patient life goals and medical needs during life’s last mile.

According to Dr. Volandes, “the transformation of death from a natural process occurring at home to a medicalized event taking outside of the home has been disastrous.”

Fortunately, we are learning more about the important conversations we need to have at life’s end—and rediscovering the benefits of providing primary medical care in the home for elderly and homebound patients. Since our creation in 1995, Housecall Providers has specialized exclusively in providing primary medical care in the home, including providing transitional care and hospice services outside the institutional setting. We have made over 133,000 house calls to homebound, medically complex and disabled adults – the patients who traditionally have been the highest utilizers of Medicare dollars. This year we will make over 11,500 house calls and treat over 1,800 patients in the Portland metropolitan area.

Many of us have spent our professional lives addressing the challenges outlined by Dr. Volandes and we applaud his insight and guidance on this important healthcare responsibility. We’ve had many conversations and we welcome Dr. Volandes’ ideas on how to make them more humane, more informed and more responsive to patient needs.

At Housecall Providers, we employ social workers, care coordinators, and other dedicated professionals to ensure that the entire care team, including family, friends and caregivers, understands patient goals and likely health care scenarios.

 The ideas of Dr. Volandes on end-of-life care, and the benefits of providing primary medical care and hospice in the home are becoming more understood by healthcare professionals, insurance companies and policymakers. Several studies confirm that costs can be reduced and quality of care improved by providing primary medical care in the home, but more research is needed.

Currently, Medicare is nearing the completion of a three-year Independence at Home (IAH) demonstration project on the efficacy and cost efficiency of providing primary medical care in the home. Housecall Providers is one of 17 individual practices and consortia participating in the study and the only one in the Western United States. We are confident the study will confirm that providing primary medical care and hospice care in the home can improve patient comfort, increase positive health care outcomes and reduce health care costs.

The ideas of Dr. Volandes about essential end-of-life conversations, as well as the new opportunities to deliver quality health care at home, is part of a much-needed upgrade to our thinking about the best way to provide quality health care to the elderly. We welcome his book and look forward to the IAH study and other studies that help us provide the most informed, effective and humane care to patients nearing the end of their lives.


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