Hospitalists and End-of-Life Decisions

Idée reçue number one:  when hospitalists are the doctors in charge of inpatients, hospitalizations are more efficient, and care is better.

Idée reçue number two:  thoughtful end-of-life planning is a laudable and comforting goal.

What happens when these values—efficient care, thoughtful planning—clash?

This question arose because of a friend’s 100-year-old mother. She was vigorous and alert at her 100th birthday party in August; in November she suffered a stroke. She became less coherent—on transient occasions—incoherent and confused, then she developed some new medical problems. She is now confused and incoherent more often than not, but sometimes she recognizes her family and friends. She is not moribund, but she is not going to improve. During a hospitalization in late January end-of-life care discussions took place.

In-hospital care has changed, so that now hospitalists, not the referring physicians, care for inpatients on the general medical services. I was there as an available friend; her regular physician, according to the new rule, ceded first responsibility to the hospitalist, a perfectly competent physician, but a stranger. The end-of-life conversation was first introduced by the hospitalist. Her private doctor and I answered the family’s questions after the fact. A few days later January became February. Since hospitalists rotate duty call schedules monthly, a new hospitalist came on the scene. Hospitalist number two had different approach to end-of-life care. The rules do not—cannot—specify that the recommendations of the January physician be carried out by the February physician. So the family (and her private physician and I) faced confusing, partially contradictory recommendations from strangers. Is this the best we can do?

The medical details are unimportant. What is important is that it was not clear which set of physicians—the old or the new—should guide, or even introduce, such emotion-laden discussions. What is important is that there is not now, but should be, a process through which hospitalists and personal physicians can interdigitate their different roles.

It’s a hard choice. If hospitalist teams are asked to manage a floor of 40 or so patients, they must be able to act without obtaining other doctors’ consents, and they must be protected against constant interruptions by the 40 patients’ other doctors. Yet if end-of-life decisions are to be kind, graceful, and caring, those who know the patient best should take the lead. The conversations about my friend’s mother were all ad hoc, arranged when the parties (the hospitalist, the family, the social worker, but not me or her private physician) could meet. Maybe hospitalists could have office hours, like college professors, scheduled times to converse with interested parties. Maybe one should stay responsible for a patient throughout his or her entire inpatient stay.

This is a transition time. Definitions regarding which doctor does what and when are changing. Personal and efficient (or cheaper) medical care values are in conflict. In a more ideal world the families, the personal doctors, and the hospitalists would sit down each night and discuss the end-of-life plans, but that is not going to happen, at least in a way that would be affordable to all.

So, do we structure time for more personal conversations? Revert back to each attending physician writing all the orders and making all the decisions for his or her patient? Accept that the personal aspect of medicine is not affordable? Upgrade the hospice care concept in the acute care setting?

No easy solution, here. But at least we can acknowledge the problem and work to get something better than having these discussions among strangers, some of whom disappear at the end of the month.

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