There will be a crush of middle players finding ways to ring money out of this. Will this save us money? Short answer: no. While I am not totally against this as IMHO there is some reasonable aspects to this, I won't like how it will be "sold" to the public. It will be sold as "all in the interests of patient care". The real driver is costs.
****IMPROVING PATIENT CARE
Engaging Public Health in End-of-Life Issues: It Is Time to Step Up to the Plate
Jaya K. Rao, MD, MHS, Deputy Editor
The Doctor: For Life and at the End of Life
Ann Intern Med. 2015;162(3):230-231. doi:10.7326/M14-2479
This article was published online first at www.annals.org
on 9 December 2014.
In September 2014, the Institute of Medicine (IOM) released its fifth full report on end-of-life issues, “Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life” (1). Acknowledging the substantial progress made since its first report on these issues was published in 1997 (2), this report identifies recommendations within 5 domains. It is particularly encouraging to see the following recommendation for public education and engagement in the report: “Civic leaders, public health and other governmental agencies ... should engage their constituents and provide fact based information about care of people with advanced serious illness to encourage advance care planning and informed choice based on the needs and values of individuals.” Because I was one of the first authors to articulate a role for public health with respect to end-of-life issues (3) while I was working at the Centers for Disease Control and Prevention (CDC), it is noteworthy that this is the first IOM report to explicitly mention that public health has a role in this arena. By describing the work on end-of-life issues done by the public health community during the past decade, I hope that policymakers, members of the IOM Committee, and health professionals can use and build on these efforts.
Although end-of-life issues have long been considered a societal problem that needs to be improved, the field of public health has only begun to embrace end-of-life as a health concern. Because public health's primary focus is to prevent illness and premature death due to chronic disease and other health threats, public health professionals' reluctance to acknowledge death or its circumstances may be understandable. However—whether we wish to admit it or not—prevention has its limits, and everyone will die eventually. Some public health professionals may also believe that end-of-life issues are a health system problem rather than a priority to be addressed through population health efforts. Public health priorities tend to have at least one of the following characteristics: a large population burden, a major effect in terms of health and other consequences, and the potential for prevention.
In 2002, a literature review that I coauthored (3) clearly showed that end-of-life issues met the criteria of a public health priority. This review was designed as a primer to document the relevance and importance of these issues to the public health community. Given that public health is a key partner of the health care system for many health issues, we proposed that public health could disseminate culturally appropriate materials about advance care planning to the public, thus reaching persons before they were faced with making end-of-life decisions. In addition, we made a case for considering advance care planning as a critical part of chronic disease management programs.
Working closely with the CDC, chronic disease partners in state health departments identified priority end-of-life actions for public health (4). More than 200 public health stakeholders were engaged in this effort and made 103 recommendations for end-of-life activities across a range of topics (for example, public education, professional education, and research and evaluation). Of note, 3 of the 5 initial priorities identified as public health end-of-life actions are consistent with the spirit of the IOM's recommendation to educate and engage the public: to educate the public about hospice and palliative care and the importance of having an advance directive or health care proxy and to collect, analyze, and share data about the end of life through state surveys.
One of these actions has resulted in the development of online information on advance care planning for the public and public health and aging services professionals. For example, the CDC's Healthy Aging Web site (www.cdc.gov/aging/advancecareplanning/index.htm
) presents materials for the public on advance care planning, including links to decision aids, state-specific advance directive forms, legal guides, and other end-of-life resources (such as hospice and palliative care organizations and information for caregivers). An online modular training course on advance care planning also was developed for public health and aging services professionals. Since then, more than 1000 health professionals have completed the course (Anderson L. Personal communication.), which is available for free and offers continuing education credits (www.cdc.gov/aging/advancecareplanning/care-planning-course.htm
In addition to providing educational materials to the public, the 2014 IOM report suggests that government agencies undertake and share behavioral research aimed at assessing public perceptions and actions with respect to end-of-life care. Although national polls in the United States have provided periodic insights into public perspectives on end-of-life issues, ongoing population-based national surveys currently do not include questions about the end of life (5). Recently, end-of-life surveillance items were administered to a nationally representative sample of U.S. consumers to assess factors associated with completion of advance directives. This survey found that 26.3% of respondents had an advance directive and nearly 70.0% had concerns about end-of-life care, such as the costs of care, the pain that they might have, or their comfort and dignity during this period (6). Black or Hispanic persons or those who lack the knowledge to have concerns about the end of life were less likely to have advance directives; these groups may represent potential targets for intervention.
Although a PubMed search for “public health” and “end of life” still yields few articles addressing a population approach to end-of-life issues (most of which are presented here), the broader public health community has recently begun to acknowledge this issue. Several states (5, 7) and communities included palliative care questions as state-added items to the Behavioral Risk Factor Surveillance System. Other authors have declared end of life as a public health crisis (
and the dying as a vulnerable population that should be a concern of public health (9). More recently, the American Public Health Association adopted a policy statement in 2013 on the role of public health in addressing unmet needs in serious illness and at the end of life (10). Such steps represent incremental progress.
In making its recommendations, the IOM appropriately considered the end of life as an issue that requires the involvement of sectors beyond the health care system. Hopefully, public health will heed the IOM's call for action and continue to build on the recommendations of the IOM and key public health stakeholders with respect to end-of-life issues. And, when the IOM writes its next end-of-life report, perhaps public health can influence the next set of recommendations.