Today we talk with Kim Vass-Eudy, Senior Director of Clinical Operations at CHESS and practicing Doctor of Osteopathic Medicine about the importance of Advanced Care Planning and strategies for starting those conversations.

Dr. Kim Vass-Eudy, welcome to the move to value podcast!

Thank you, Thomas, it's good to be here.

So today I want to discuss some things that I know are of great importance to you, which is advanced care planning. Can you tell me or tell us what that is and what it consists of?

Sure. It's basically a discussion with patients about their plans for their future. It's about what they want to do if something were to happen to them and they couldn't speak for themselves. It's about end of life care, in a lot of ways, making their wishes known. It's a discussion that can occur between a provider and their patient and their patient’s family members or someone that they want to make decisions about their care and it really outlines what their wishes are so that there's no guesswork, there's no stress at the end of life. That the patient’s wishes are known

That's fascinating. So, you are a practicing physician, and a darn good one from what I understand!

Thank you.

So how important do you deem advanced care planning in the care plan for your patients?

So I think it's essential. I think as providers, we're just not doing it enough. It's one of those things that they don't teach us about in medical school or in our training or at least I didn't have that education. I've been out about 16 years or so. So no one ever told me how to do this. The goal of being a doctor is to save people and to keep them alive for as long as possible, so having those discussions about end of life care feels very different and probably goes against what my teaching has been as a provider. So when they looked at, they actually asked patients and people if they're having these discussions with their primary care physicians or physicians in general, and 84% of Medicare age patients said that they've never had this discussion with their doctor and these are patients that are in the older generation so no one's talking to them about this. And they also polled Americans in general, so this is not just Medicare age patients but Americans in general said 92% of them said they'd like to have these kind of conversations, that they're interested in that, that they're willing to have those conversations with their patient or with their providers and and to discuss their wishes. 53% of that group said it would be a relief you know if someone would bring this up to them and have this discussion so that they don't have to think about it or talk about it, that they can start making decisions now about their future.

So in my practice you know I tend to do these discussions at well visits because that's when patients aren't thinking about anything but just being healthy. So I start saying to them, well what if something were to happen? What are your wishes have you talked about this with your family? And I think it's just as important as talking to them about diet, exercise, vaccines, cancer screening, and the you know one of the drawbacks though is this takes time. That's why I typically do this at the well visit because it takes a lot of time to have these discussions and I give myself about 30 minutes for those visits so I'm able to really discuss it with patients and answer their questions about it. You know for providers, there's a lot of issues because we're not trained and we don't have guidelines. No one tells us how to do this. Providers, one of the things that they say they're most fearful of even having these conversations because they don't want to destroy hope for people. They don't wanna tell them Oh yeah guess what you know the end is near and you better start thinking about it they don't want to take that hope away from them that there's a chance that they could survive something. So you know there's issues there that providers find difficulty in talking about it. But I think it's important. I think and patients have made it clear that they think it's important as well.

I remember in a presidential election, maybe 2012, and there was a lot of talk of death panels.

Yes, I remember that too.

Was, and when I started learning more about value-based care, it seemed like that was just part of the Medicare benefits, right? Is that what that was all about?

I think so. I think, you know, there's this well and we'll talk about this too as we continue on with our you know discussion that there is a lot of money being spent at the end of life. That's when we spend the most money on someone with their healthcare. So knowing that, we look at how do we save money in healthcare that takes up this giant chunk of the total spending in this country and I think that's where the death panel discussion came from, it's like oh, when you're getting old and you're costing a lot of money let's just put an end to it. That's not what this is. In fact, this is more about what are your choices. What does it look like for you at the end of life? Nobody's pulling any you know any tubes out of anyone or turning off any machines that's not what this is about, but if the patient is having the discussion and the choice what does this look like?

What are - what I want to take back control of that time of my life because there is an inevitable end like that we're not getting out of here alive. What does that mean how do I want that to end for myself or my family members and it's a good idea to have the discussions with your family. I think that's where the that's where the death penal conversation came from. Unfortunately, it gets a little skewed. I mean it is a little morbid to talk about money and death and what do we cost and what does that look like, but unfortunately there's only so much to go around and we have to think about that, but we also have to take back control of what this looks like for us.

So, you recently wrote an article describing an encounter with a patient where you had to deliver bad news. That article is available on the on our website if anyone's interested, but can you tell our listeners about that scenario you described and how, although you were delivering bad news, the patient was able to have the conversation on their own terms and your realization that patients actually want to talk about end of life?

Sure. This was, and this is a pretty quick story, I was needing to tell a patient a CAT scan result and she had had a history of cancer, lung cancer, and it had gone away but there was some symptoms, so we repeated the CAT scan and it showed that the cancer had returned. Well, typically, I like to give that news in the office in a visit face to face. I called her myself and I said you know I'd like to talk to you can you come in and she said you just need to tell me now, tell me whatever it is. And I said where are you because I could hear sort of traffic noises and just the noise of being outside somewhere and she's in the Walmart parking lot. And I said well are you sure? She's like yes, I want to know. So unfortunately, at least for me, I told her the news right there, but that's what she wanted. She wanted to know right now. So patients, you give them you give them the choice. Where is it comfortable for you? Sometimes they just can't stand the idea of waiting to get in the car drive over to the clinic to hear the bad news.

I will tell you though an issue or a time when I did not do this well, like I did not do an advanced care well, and it was actually pretty recent, so I should have known better but sometimes you just think that somebody else is going to do it. I had a patient who was diagnosed with cancer, had not seen the patient because they were now following up with the oncologist. But they ended up in the hospital and came in to see me for a follow up. And when I saw him and understood what was going on I knew that there wasn't a lot of time left, you know the medications were not working, the chemotherapy was not working, and no one had had the conversation with him yet. I know. So that was tough because that's not ideal. I want this conversation had when no one is at you know in the moment. Like when you don't have to make these decisions facing the end of life. You want to have it early so you can really contemplate, ask questions, make decisions, because he had one way of thinking and his wife had another way of thinking. They were not on the same page. Yeah, and so that that can be hard, you know that was a time when I don't want that kind of episode to happen again because I feel like I didn't do the right thing for the patient. It turns out OK, I mean he was able to get his decisions made, but it was in a time that was a little bit more stressful than I would have liked for him.

So that is hard because as a primary care physician we are the ones who should be having the conversations even though you assume, OK, he's been going to another doctor for this, they're not. They want to have it with us, as primary care physicians, they want to talk to us because I know them the best. I know their life situations, I know their family members sometimes I know the name of their dog. These are the things that they entrust me with and so who better to talk to them about their full life cycle than me? So that was a time when I probably was not my best but I definitely learned from that and I try to get ahead of things now.

Yes, life lesson learned. You know it amazes me because I'm as guilty as the patient in the story you described and I feel like, you know, as a parent we talk to our kids about promiscuity, the dangers of alcohol, you know all of these things, preemptive measures that will make hopefully better decisions down the road. And we learn this at our place of employment, you know, with whatever policies we have the rules that we have to follow. Why is it we, as a patient, why do we struggle with this, in in your opinion? Do you do you feel that there is a causation because it's the end of life, because it's just something you want to think, about although every human has to think about this in some capacity?

I think there's a lot of factors. For instance, family members and their desires. So family members can have their idea of what your life should be like. There are also religious factors. What does it mean to me in a religious way? Do I survive or do I make other decisions to sort of support my life until I pass, do I do everything possible? So patients have all of these ideas in their mind, what it looks like to pass or to have an end of life discussion and that doesn't always come from within. Like it's not obvious to them that this is happening, that they need to make that decision now. I think all of us put it off. There's always that glimmer of hope that something will change and that factors will intercede that will create a miracle that that this will not happen. So, it's difficult. I think most people though, want to start the conversation. That's what the statistics show even though it seems like maybe we're not preparing, people want to start talking about it.

How does a provider who may not be having these conversations, start the conversation off in the best way to get the patient to talk, and some best practices that you've discovered that facilitate a successful advanced care planning process, and maybe some of the questions that provider may ask the patient?

the first thing to do is acknowledge if it's uncomfortable and I think most providers probably have a little discomfort. We have to face this ourselves. I think telling the patient, I really want to have this conversation with you, it's a little bit awkward for me but I really want to know what your wishes are if something were to happen. That's fair and patients appreciate that vulnerability. They understand it and they feel they're feeling the same way, so they want their providers to acknowledge that. You can start to assess though what are their desires and it's really just a few simple questions. What is your understanding of your health and your current illness? What are your most important health related goals? What does a good day look like for you? What brings value to your life? What are your fears or worries regarding your health and what are the trade-offs you would be willing to make or not make if your condition worsened? It's really just getting it started. Of course there are details that can be worked out, but in the beginning you just want to know where are they in the process what are their thoughts about their life and their condition.

And once a patient's wishes are known how are they formalized?

Well in North Carolina we have something called the MOST form which is the medical orders for scope of treatment. This form is great because it can be done in the office between the provider and the patient. It does not have to be formalized in any way as far as notary and it really lays out some of the most important questions that a patient may be asked at the end of life or their family member may be asked, such as do they want CPR? What kind of medical interventions would they like? What do they want for antibiotics fluids or nutrition. The MOST form is reviewed yearly. It's reviewed when a patient is admitted or discharged from a hospital. It's reviewed if the patient changes their mind, which can happen and patients can change their mind over time if they don't want certain interventions or if they do want certain interventions and the MOST form can be changed accordingly.

Another thing that can be done, and this is pretty much anywhere in any state, is an advanced care directive with a living will. That is more formal it can be done with or without a lawyer. It does need to be notarized and it does outline the what the decisions are that the surrogate would make in the case that the patient couldn't make the decisions for themselves. So it's a little bit more legally you know legalese but it's important because that is a standing document. It's a declaration of their desire for a natural death and it allows for withholding of any sustaining life treatments or with parameters so it can also say things like I want antibiotics or I don't it's just a little bit more formal.

So, Dr. Vass-Eudy, do you feel like this is a scenario where it's like a diagnosis where you have the conversation which is the treatment and then the patient is cured, or is this an ongoing conversation similar to how you would have a conversation about diet or wellness or exercise? what are your what are your thoughts there?

I definitely think this is not a one and done conversation. You get the conversation started and even things like the MOST form and advanced care directives do not have to be done that same day. This is something you want to continue over time. I often, usually about three times, I've had this conversation before forms or even really introduced to be honest with you. I want the patient to start thinking in the direction, start having the talk at home with their family member, answer questions the next time and maybe potentially give them some websites to look at where they can read more about the forms and then potentially give them the form. I could also do that you know, sooner, but it's usually a longer conversation than one time and I definitely feel that that's important. You don't want to rush this. You want everyone to weigh in and everyone's feelings to be heard and meet all the expectations. Because the person that we often don't talk about, we’re talking about the patient and the provider, but we are not talking about the family member who has to now know my mom or dad or family member has these wishes and I'm the one who has to carry that out. So, it's important to bring them in at some point too and that may take another visit. So, and we can talk about coding eventually but that can all be coded for visits that you have these discussions with people. It is a way to get paid to do the conversations, I don't like how that sounds though, but it is a way to get acknowledgement for the work that you do and it doesn't have to be done once you can do it multiple times.

I hope that we can continue this conversation but for now Dr. Kim Vass-Eudy thank you for joining us today on the move to value podcast.

Thank you, Thomas