Breaking the barriers

Identifying “teachable moments” for patients is an important part of quality care.

As a hospitalist working in a community hospital in the upper Midwestern U.S., where adult smoking rates are higher than national average (11. Current cigarette smoking among adults in the United States. CDC Fact Sheet. ), it is no surprise that a fair share of my census consists of patients with acute exacerbation of chronic obstructive pulmonary disease (COPD).

While rounding on a busy Monday morning a few weeks ago, I came across a frail elderly woman, extremely short of breath and anxious, who had been admitted the previous night with an acute COPD exacerbation. It was just another trip to the hospital for her, but her cautiously tempered optimism had gradually faded away over the years as she invariably found herself struggling to take a deep breath. As I evaluated her, I realized that hers was a losing battle.

Photo by Ajit Singh
Photo by Ajit Singh

Seeing her multiple recent hospitalizations and persistent respiratory distress, with frequent trips to the emergency department, I planned on discussing hospice and palliative care to alleviate her suffering. When I reviewed her chart, I saw that she had refused hospice in the past, although the reasons for her refusal remained unclear.

As I talked to her, I tried to ascertain her degree of understanding her condition. She had a deep insight into her malady and knew very well that it was incurable at that point. The most important goal of her life now was, in her own words, “to breathe.” I realized how mundane physiologic functions of our body, which we take for granted when healthy, become so precious and valuable when we are sick. Knowing that she had a realistic understanding of her condition reassured me, and I reintroduced the concept of hospice to her, explaining the importance of alleviation of her symptoms in maintaining a good quality of life.

She told me the main reason behind her previous refusal of hospice, which was that the last thing she wanted to be was homebound. She enjoyed driving and buying her own groceries, even if it meant carrying an oxygen tank in her car, and she worried that hospice would take that independence away from her. I sat with her and explained the philosophy of hospice care and told her that she would be able to live the remaining days of her life fully without necessarily being homebound. The following day, nursing staff from hospice met with her and she went home.

After she left, I kept wondering if she would have opted for hospice earlier had her misconception and fear of being homebound been allayed by conversation with a clinician. Studies have shown underutilization of palliative care in hospitalized patients with advanced COPD compared to those with lung cancer (22. Chou WC, Lai YT, Huang YC, Chang CL, Wu WS, Hung YS. Comparing end-of-life care for hospitalized patients with chronic obstructive pulmonary disease and lung cancer in Taiwan. J Palliat Care. 2013;29:29-35. [PMID: 23614168]). COPD patients also receive less mental health support and have worse social, physical, and emotional well-being than those with non-small-cell lung cancer (33. Gore JM, Brophy CJ, Greenstone MA. How well do we care for patients with end stage chronic obstructive pulmonary disease (COPD)? A comparison of palliative care and quality of life in COPD and lung cancer. Thorax. 2000;55:1000-6. [PMID: 11083884]).

Although most care for advanced COPD patients is assumed by primary care physicians and pulmonologists in outpatient settings, hospitalists and intensivists also play a crucial role, taking care of these patients at their most vulnerable, when they are critically ill and in maximal distress. A study has shown that discussion with a hospitalist regarding prognosis, goals of care, and values was associated with improved quality of life and alleviation of emotional distress at the end of life (44. Anderson WG, Kools S, Lyndon A. Dancing around death: hospitalist-patient communication about serious illness. Qual Health Res. 2013;23:3-13. [PMID: 23034778]).

Hospitalists might be able to play a key role in referring patients with chronic debilitating illnesses, like COPD, to palliative care and promoting high-value care practices in this population (55. Lin RJ, Adelman RD, Diamond RR, Evans AT. The sentinel hospitalization and the role of palliative care. J Hosp Med. 2014;9:320-3. [PMID: 24474682]). They might be able to identify those who would benefit from palliative care strategies early in the trajectory of their terminal decline. Some hospitalists will have to navigate end-of-life discussions, counseling, and comfort care without collaboration with palliative care specialists, especially in rural and critical access hospitals without subspecialty support.

CMS monitors our performance based on various parameters, including length of hospitalization, readmission rates, and documentation, and these issues have become a focus for compliance and quality. However, as physicians committed to the Hippocratic Oath, I feel it is our moral and ethical responsibility to also identify the so-called “teachable moments” for our patients and tirelessly strive not only to cure their illnesses but also to provide a good quality of life.