In May, the Howell Foundation hosted Dr. Daniel Hoefer. His palliative care presentation “Why Palliative Medicine Must Become Mainstream” provided a sobering look at the current status of healthcare. For him, it’s not a matter of the latest in healthcare technology, but a matter of setting the additional protocols and metrics to define new standards of successful healthcare, especially in the growing, aging population.
Dr. Hoefer was presented with the first annual Doris A. Howell MD Award for Advancing Palliative Care from the California State University San Marcos. His vision to develop an evidence-based care model for palliative care and late stage illness is recognized nationally.
His presentation focused on aspects that can improve the outcome of elder patients’ healthcare management:
- Understanding the culture of healthcare and the concepts under which care is practiced.
- Analyzing the differences between traditional an current management metrics to evaluate good care.
- Prognosticating the risks associated with care, including surgeries, medication prescriptions, and hospitalization that allow healthcare providers to guide their patients towards the best outcome possible.
“It’s about moving forward from a traditional, paternalistic healthcare industry – or hospital-centered industry, to a patient-centered one that takes into consideration the outcomes and needs of the patients.”
When discussing palliative care, his perspective is based on a common sense approach to a series of quality patient-centered measures. Physicians need to ensure clear and concise communications with their patients:
- Rate and quality of survival.
- Risks of having kidney damage, a stroke or a heart attack.
- Is the patient going to live autonomously?
- Ability to recognize their loved ones
- Level of exhaustion
- Will they be in pain?
- Monitoring secondaty effects, such as nausea
- Will their chemotherapy cause permanent neuropathic pain that they wish they’d known about ahead of time?
- The fear of moving to an institution
- Importantly, what is the emotional and financial burden to the patient and their family?
Dr. Hoefer cited the Terry Schiavo case as an example. She suffered a cardiac arrest from hyperkalemia – a dangerously high level of potassium in the blood that can lead to devastating consequences. Dictated by traditional metrics, the medical community reported her treatment as medical success. Terry Sciavo however, lived for 30 days after being discharged from the hospital.
Today, physicians around the country realize that a disease does not exist in isolation, and that criteria to measure a determined “success” may not be so; especially when considering the possibility of causing harm to other organ and body functions. “We need to be able to get the short-term and long-term consequences of the care we provide.”
Looking beyond the “unintended consequences of well-intended care” in palliative care
Dr. Hoefer specializes in the care of the advanced elderly, a group has not been evaluated in studies regarding healthcare. He referenced a study from 2016, in which the American College of Cardiologists, American Heart Association and the American Geriatric Society concluded that “the care of people over the age of 75, when it comes to cardiac care, is not evidenced based.” The fact that care practices of a younger generation is extrapolated to the elder without medical evidence should be alarming. “We need to care about them just as much as we do the younger and healthier population and we must make sure that the medical care we give them is consistent with actual medical research.”
There are two aspects that Hoefer highlighted when discussing elderly care:
- Although care has come a long way, working in silos can be detrimental to the patient. Just like a primary care physician may not know the consequences of referring their patients for a surgery, the surgeons may not know, for example, the consequences of the number one side effect of hospitalization: hospital-induced delirium.
The condition affects patients who already suffer dementia and are particularly frail. It can be caused by a combination of numerous factors, including surgery, infection, isolation, dehydration, poor nutrition and medications such as painkillers and sedatives. Cross-information and communication can be beneficial in erasing obstacles of working in silos.
- The misconceptions that surge from the term “curative care”, when the actual service provided is “chronic disease management.” A study in the Annals of Internal Medicine states that 27% of Americans believe the healthcare industry has failed patients. The lack of clarity of the term “curative care” created different expectations; expectations that often are not met.
When discussing a patient-centered care strategy, accurate information will help the patient build an adequate frame of reference to make sound decisions on his/her care. The parameters that Dr. Hoefer evaluates before making a prognosis center around the patients’ unique risks, and focuses on mobility, cognitive function and overall well-being:
- The length of a hospital stay almost doubles in elderly population, from 4.7 to 8.1.
- Possible infections derived from surgery or illness.
- Number of medications required to ease discomfort/pain – or polypharmacy, defined as six or more medications.
- Loss of mobility. For an elderly patient, the daily loss of muscle strength due to hospitalization is estimated to be 5% per day, compared to 1%-1 ½% in younger individuals; severely affecting the patient’s mobility after surgery.
- The patient’s frailty. It is impossible to determine a person’s frailty based on how he/she looks. There are specific, science-based. examinations that can determine the patient’s frailty based on weight loss, muscle strength, decreased walking speed, level of exhaustion and inactivity.
- The family’s emotional and financial well-being.
In other words, will their quality of life be better or worse should a patient decide to go through the surgery recommendations or other interventions suggested by their physicians?
The need to change the paradigm in accurate palliative care in the elderly population is additionally motivated by a personal case: his father’s illness. Concerned by the swelling in his legs he urged his father to visit his doctor. After an echocardiogram, they found severe aortic stenosis – one of the most serious valve disease problems that restricts the blood flow from the left ventricle to the aorta. He had an incredibly high risk of cognitive and functional decline.
Despite Dr. Hoefer’s efforts to create consciousness of the difficulties he would face given the geriatric frailty he suffered, his father decided to go through with the surgery. And as the evidence showed, his father started declining. He passed away nine months after his surgery.
As we age, we are increasingly more susceptible to the issues brought up by Dr. Hoefer. If considering life-changing surgery, the major takeaways from this presentation are related to whether as patients our quality of life will be the same, better or worse:
- Age plays a significant factor in determining overall health. Be informed about the differences between a younger and older patient as they influence the outcome of the surgery.
- Seek existing research that provides a full picture of the risks of any planned surgery or intervention according to your age and overall state of health.
- Determine the quality factors that are important to YOU to make a duly informed decision.
It almost seems like the human lifespan is extending faster than the research community can find answers for complications related to aging. Information for you and the ones you love is key!
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The Doris A. Howell Foundation for Women’s Health Research has been dedicated to keeping the women we love healthy by making a long-term, positive impact on women’s health. It is the premier organization advancing women’s health.
The organization does so by:
- Awarding undergraduate research scholarships and graduate nursing research grants to scientists researching issues affecting women’s health;
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