April 2015 by San Francisco Marin Medical Society

SAN FRANCISCO MEDICINE J O U R NA L O F T H E S A N F R A N C I S C O M E D I CA L S O C I E T Y

END-OF-LIFE CARE ADVANCES AND CONTROVERSIES Palliative Care: Myths, Progress, and Pitfalls Physician-Assisted Dying Religious Perspectives on Death Advance Care Planning Reflections on Being Mortal

Plus: Medicare Payment Reform at Last?

VOL.88 NO.3 April 2015

MIEC Belongs to Our Policyholders! “ As your MIEC Claims Representative, I will serve your professional liability needs with both steadfast advocacy and compassionate support.” Senior Claims Representative Michael Anderson

Toni Brayer, MD

Board of Governors, Internal Medicine

Service and Value MIEC takes pride in both. For over 35 years, MIEC has been Keeping true to our mission steadfast in our protection of California physicians. With conscientious MIEC has neverexcellent lost sightClaims of its original mission, and always putting Loss Underwriting, management hands-on policyholders (doctors like you) first. For 40 years, MIEC has been steadfast Prevention services, we’ve partnered with policyholders to keep in our protection of California physicians with conscientious Underwriting, premiums low. excellent Claims management and hands-on Loss Prevention services; we’ve partnered with policyholders to keep premiums low.

Added value: Added value: carrier with low overhead n Zero-profit n No profit motive and low overhead n Dividends with an average savings on 2011 premiums of 40.4%* Dividends for an average savings of 25% on 2015 premiums for California Forphysicians* more information or to apply:

For more information or to apply: n www.miec.com n n www.miec.com Call 800.227.4527 n Call 800.227.4527 n Email questions to underwriting@miec.com n Email questions to underwriting@miec.com * (On premiums at $1/3 million limits. Future dividends cannot be guaranteed.)

* On premiums at $1/3 million limits. Future dividends cannot be guaranteed.

MIEC 6250 Claremont Avenue, Oakland, California 94618 800-227-4527 • www.miec.com

SFmedSoc_ad_02.13.15

MIEC Owned by the policyholders we protect.

IN THIS ISSUE

SAN FRANCISCO MEDICINE April 2015 Volume 88, Number 3

End-of-Life Care FEATURE ARTICLES

MONTHLY COLUMNS

12 Palliative Care Myths: Debunking Myths for Truths Steven Pantilat, MD

Membership Matters

Classified Ad

Ask the SFMS: ICD-10

President’s Message Roger S. Eng, MD, MPH, FACR

Advance Care Planning: A Community-Based Initiative in San Francisco Jeff Newman, MD, MPH; Rebecca Sudore, MD; Caroline Stephens, RN, PhD, GNP; BJ Miller, MD; Christine Ritchie, MD, MSPH

16 Palliative Care: An Essential Tool in Care Management Edward A. Chow, MD, and Mark Morewitz, MSW 17 When Death Comes Early: Pediatric End-of-Life Care Nancy Iverson, MD 20 What Matters Now? Thoughts on Being Mortal Michael Lerner, PhD

22 On Death and Dying: Reflections on End of Life from Local Religious Leaders 25 True Healing: Learning in the Face of Illness Frank Ostaseski

26 Physician-Assisted Dying: Why We Support Legalization Robert Liner, MD; Donald Abrams, MD; Marcus Conant, MD

27 Physician-Assisted Dying: A Deadly Choice for the Medical Profession Michel Accad, MD 28 Advisory Guidelines for Physician-Hastened Death: A Model Policy Developed for the San Francisco Bay Area

31 The Lone Ranger is Dead: On the Need for Teamwork in End-of-Life Care William Andereck, MD

Editorial and Advertising Offices: 1003 A O’Reilly Ave. San Francisco, CA 94129 Phone: (415) 561-0850 Web: www.sfms.org

11 Editorial Gordon Fung, MD, PhD, and Steve Heilig, MPH 32 Medical Community News 34 Upcoming Events

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members

SFMS Applauds Legislators for HR 2—Bipartisan SGR Repeal Package; CMS to Hold Claims to Avoid 21% Cut House Speaker John Boehner and House Minority Leader Nancy Pelosi have unveiled a bipartisan bill to eliminate the Medicare sustainable growth rate (SGR) formula. HR 2, The Medicare SGR and CHIP Reauthorization Act, is an updated version of the policies set forth in last year’s bipartisan, bicameral Medicare payment reform bill. SFMS and the California Medical Association fully support the SGR bill, the funding framework, and the Children’s Health Insurance Program (CHIP) extension. SFMS leaders have contacted Leader Pelosi’s office to thank her for her work on this bill and for her tireless efforts to improve access to care in San Francisco and California.

HR 2 calls for: • Immediate repeal of SGR • Positive annual payment updates of 0.5 percent would be provided for four and a half years, beginning July 1. • Current Medicare quality reporting programs would be replaced with a simplified and consolidated merit-based incentive payment system (MIPS). • Five percent incentive payment for physicians is provided for those who participate in alternative payment models and meet certain thresholds. • Provisions similar to the Standards of Care Protection Act are included. • Two-year extension of Children’s Health Insurance Program (CHIP) funding is included. The Senate failed to take a vote to permanently fix the Medicare SGR formula before leaving for spring recess, but will take the measure up on April 13. SFMS would like to thank Senators Boxer and Feinstein for supporting the legislation. And with the landslide vote of 392-37 in the House, the momentum should propel the Senate to act quickly when they return from recess. In the meantime, the Centers for Medicare and Medicaid Services (CMS) has announced they can hold physician claims on the payment floor for fourteen days to avoid the devastating 21% payment cut that occurs on April 1, 2015. However, the Senate will need to act the first day they return to avoid the actual 21% payment cut.

Physicians join California Legislators and We Care for California Coalition to Reignite MediCal Legislation, Reduce Health Care Inequality Coordinated by the CMA, physicians, health care workers, and patients joined legislators at the State Capitol to call attention to California’s very low Medi-Cal reimbursement rates and the negative impact on access to care. Senate Health Committee Chair Ed Hernandez and Assembly Health Committee Chair Rob Bonta introduced legislation to repeal the 10 percent cut to Medi-Cal reimbursement and propose Medi-Cal payments to be on par with Medicare rates. SB 243 and AB 366 would not only repeal prior year rate cuts to Medi-Cal, but they would increase payments rates for inpatient hospital services and most outpatient services. The legislative proposals would also require the Department of Health Care Services to pay MediCal managed care plans at the upper end of their rate range so as to ensure a more robust Medi-Cal provider network. Please join the San Francisco Medical Society in this effort. Get status updates by following #WeCare4CA and @SFMedSociety on Twitter.

CMA Foundation Releases Adult Vaccine Schedule

The California Medical Association Foundation has released an adult vaccine schedule that physicians can hand out during patient visits. The one-page guide can be found at http://bit. ly/1Hv2Wft.

Physician Groups Urge CMS to Create Contingency Plans for ICD-10 Transition

The California Medical Association (CMA), American Medical Association (AMA), and 98 other state and specialty societies urged the Centers for Medicare and Medicaid Services (CMS) to put contingency plans in place for the October transition from ICD-9 to ICD-10 to avoid possible failures that could result in sig-

SAN FRANCISCO MEDICINE APRIL 2015 WWW.SFMS.ORG

nificant disruptions for physicians and Medicare patients. According to recent end-to-end testing by CMS, if ICD-10 were implemented today, claims acceptance rates would fall from 97 percent to 81 percent, and cause a catastrophic backlog of millions of unpaid Medicare claims. CMA, AMA, and the other groups are asking CMS to conduct endto-end testing in all modes of practice for a larger sample of physicians and to publicly release the results. The groups are also asking CMS to provide advance payments to physicians in the event that claims are delayed.

Update Your Practice Information for the SFMS Online & Print Pictorial Directory Spotlight your practice and expand your referral base with an updated member profile! With the SFMS online Physician Finder and print directory, physician members have the opportunity to promote their practices on customizable individual Web profiles and connect with a larger patient and referral base. SFMS has sent out email and mail notifications to all physician members currently engaged in the practice of medicine to update contact information for the directory. If you did not have your picture in the 2014 directory, or if your information is outdated, we encourage you to update your directory entry by contacting SFMS at ayoung@sfms.org or (415) 5610850 extension 200.

Promote Your Practice with the SFMS Directory

If you would like to reach 1,000 health care professionals in San Francisco, please consider placing an ad in the 2015 SFMS Member Directory. Members are eligible for an exclusive discount on quarter-page vertical ad placements. Advertising rates start at $395. To obtain the ad rate and contract agreement, contact Ariel Young at ayoung@sfms.org or (415) 5610850 extension 200.

Anthem System Error Results in Missing Remittances

A system issue caused electronic remittance advices (ERA) to go missing at Anthem Blue Cross. Anthem reports that the problem began in midDecember and affected ERAs for exchange/mirror and Federal Employee Program (FEP) claims. A system fix was put into place on February 16 to fix the issue going forward. Practices can obtain missing ERAs through the ProviderAccess portal on the Anthem website or can contact Anthem customer service: • For missing FEP remittances: (800) 322-7319 • For missing Covered California remittances: (855) 854-1438

Classified Ad

Family Medical Practice for sale. East San Francisco Bay, CA – Multidiscipline practice serving the Asian community. Revenue over $1 million. Multi-language staff; buyer doctor must be fluent in one Chinese dialect. EMR; high profit margin; seller will train buyer in proprietary systems. $682,000. Real estate also available. info@PracticeConsultants.com. 800576-6935. www.PracticeConslutants.com WWW.SFMS.ORG

April 2015 Volume 88, Number 3 Editor Gordon Fung, MD, PhD Managing Editor Amanda Denz, MA Copy Editor Mary VanClay EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Erica Goode, MD, MPH Michel Accad, MD Erica Goode, MD, MPH Stephen Askin, MD Shieva Khayam-Bashi, MD Payal Bhandari, MD Arthur Lyons, MD Toni Brayer, MD John Maa, MD Chunbo Cai, MD David Pating, MD Linda Hawes Clever, MD SFMS OFFICERS President Roger S. Eng, MD President-Elect Richard A. Podolin, MD Secretary Kimberly L. Newell, MD Treasurer Man-Kit Leung, MD Immediate Past President Lawrence Cheung, MD SFMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA Associate Executive Director, Public Health and Education Steve Heilig, MPH Associate Executive Director, Membership and Marketing Jessica Kuo, MBA Director of Administration Posi Lyon Membership Coordinator Ariel Young

BOARD OF DIRECTORS Term: Jan 2015-Dec 2017 Steven H. Fugaro, MD Brian Grady, MD John Maa, MD Todd A. May, MD Stephanie Oltmann, MD William T. Prey, MD Michael C. Schrader, MD

Term: Jan 2013-Dec 2015 Charles E. Binkley, MD Gary L. Chan, MD Katherine E. Herz, MD David R. Pating, MD Cynthia A. Point, MD Lisa W. Tang, MD Joseph Woo, MD

Term: Jan 2014-Dec 2016 William J. Black, MD Benjamin C.K. Lau, MD Ingrid T. Lim, MD Keith E. Loring, MD Ryan Padrez, MD Rachel H.C. Shu, MD Paul J. Turek, MD CMA Trustee Shannon Udovic-Constant, MD AMA Delegate Robert J. Margolin, MD AMA Alternate Gordon L. Fung, MD, PhD

APRIL 2015 SAN FRANCISCO MEDICINE

PAYOR REIMBURSEMENTS HEALTH CARE

PROFESSIONAL DEVELOPMENT

DISPUTES

PHYSICIAN

SFMS

Get answers to your important practice-related questions with the help of SFMS experts. The “Ask the SFMS” feature connects members with SFMS partners who can answer questions on a wide variety of topics dealing with the practice of medicine, including practice management, patient education, EHR assistance, health policy, legal/malpractice, financial management, and many more! If you would like to submit a question for our experts, please email info@sfms.org.

ICD-10 Moving to a new coding system for medical classifications after thirty-five years will certainly be an adjustment. But it won’t be nearly as extreme as some are trying to make it out to be. In fact, physician offices should be able to manage the transition quite well, both in terms of codes and cost. Following are some commonly asked questions we hear from physicians.

When will ICD-10 be implemented, and is there a grace period for the use of ICD-9 codes submitted after implementation?

The U. S. Department of Health and Human Services (HHS) issued a rule on July 31, 2014, that ICD-10, both CM (Clinical Modifications) and PCS (Procedural Coding System), will be implemented into the HIPAA-mandated code set on October 1, 2015. However, coding is based on date of service. For example, if a patient was in the hospital from September 27 to September 30, 2015, and you bill the service on October 3, 2015, you will still bill those services with ICD-9 because the date of service was prior to October 1, 2015. However, if a patient presents to your office on or after October 1, 2015, you must bill that out with ICD-10. Remember to refer to the dates of service (not the actual date of the claim submission) to determine whether you will be billing ICD-9 or ICD-10. You will be required to run a billing system for a time after 6

KEEPING

CME

REFORM

CODING

MEDICAL RECORDS

FINANCIAL MANAGEMENT

BILLING

& IMPLEMENTATION

ASK THE

CONTRACT NEGOTIATIONS

EHR SELECTION

PRACTICE MANAGEMENT

the implementation of ICD-10 that can handle both ICD-9 and ICD-10. The ICD-9 system will need to be maintained until all claims prior to October 2015 have been submitted and resolved. This could take time, considering you may need time to resubmit claims electronically.

How is ICD-10 different from our current system?

In many ways, ICD-10 is quite similar to ICD-9. The guidelines, conventions, and rules are very similar. The organization of the codes is very similar as well. Anyone who is qualified to code ICD-9 should be able to make the transition to coding ICD-10. Many improvements have been made to coding in ICD-10. For example, a single code can report a disease and its current manifestation (i.e., type II diabetes with diabetic retinopathy). In fracture care, the code differentiates an encounter for an initial fracture, follow-up of fracture healing normally, follow-up with fracture in malunion or nonunion, or follow-up for late effects of a fracture. Likewise, the trimester is designated in obstetrical codes. ICD-10 has about 70,000 diagnosis codes, versus about 14,500 for ICD-9. No physician will ever use all 70,000 diagnosis codes, or anything close to that number. Just as today, physicians will use a limited number of codes within their specialty. While much has been said about the huge increase in the number of codes under ICD-10, some of this growth is due to laterality. While an ICD-9 code may identify a condition of, for example, the ovary, the parallel ICD-10 code identifies four codes: unspecified ovary, right ovary, left ovary, or bilateral condition of the ovaries. The big differences between the two systems are those that will affect information technology and software at your practice.

What will transitioning to ICD-10 cost me?

Estimates of costs for converting a physician practice to ICD-10 have varied wildly, depending on the source. Let’s put

SAN FRANCISCO MEDICINE APRIL 2015 WWW.SFMS.ORG

this in context: • Physicians need only the ICD-10 diagnosis codes. They can purchase a code book or they can download the code book for free from the Centers for Disease Control and Prevention website: ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ ICD10CM/2015/. • Training in ICD-10 diagnosis coding, estimated to take about three hours, is available for physicians and for practice staff both online and in person at reasonable cost from medical societies, coding organizations, and vendors. • EHRs, for which many practices have received conversion funding, are the ideal platform for documentation templates needed to assign ICD-10 codes. Many EHR providers incorporate ICD-10 software upgrades automatically. • Physician offices that rely on vendors (e.g., billing services, clearinghouses) can often receive free or low-cost ICD-10 software upgrades as part of their packages. • For offices that use super bills, conversion to ICD-10 codes is a one-time process that can use common codes supplied for free by CMS, professional societies, and payer policies. • CMS and many payers are making end-to-end testing available for free. For offices relying on vendors, most testing responsibilities are on the vendor, not the practice. • With EHRs and support from vendors, physician office costs for lost productivity are modest. • A new study released in February 2015 by the Professional Association of Health Care Office Management (PAHCOM) shows the financial barriers to ICD-10 implementation for the small physician practice are dramatically less than originally projected. The survey of 276 physician practices of fewer than six providers revealed that total ICD-10-related costs for an entire practice averaged $8,167; per provider expenditures averaged $3,430.

How do I determine what training is needed? While there will need to be significant education and training for coders, billers, practice managers, physicians, and other health care personnel to fully implement this major code change, not everyone requires the same type of training. You need to create an ICD-10 training plan that prepares all staff members, not just the medical coders. You need to make five decisions when developing your ICD-10 training plan: • Assess what there is to learn. • Identify which staff members will need what training. • Pick the best training options for each—formal classroom sessions, in-house sessions, or remote, online sessions. • Schedule the training. • Budget resources. Once your staff’s ICD-10 training is complete, you need to consider what resources are available (manuals, online help or prompts, personal consultation, etc.) for resolving problems and questions as they arise in the course of the transition.

Information provided courtesy of the Cooperative of American Physicians, Inc., and Mary Jean Sage, president and founder of The Sage Associates. The Cooperative of American Physicians, Inc. (CAP) offers a range of products and services, including medical professional liability protection, in the health care field. For more information about CAP, contact Dorine Leong, senior account executive, at (650) 543-2183, dleong@CAPphysicians.com, or visit www.CAPphysicians.com. The Sage Associates is a leading multispecialty provider of health care management consulting services. Questions related to the information in this article may be directed to Mary Jean Sage at (805) 904-6311.

SFMS Spring Physician Networking Social a Success Local physicians participated in SFMS Physician Networking Mixer at Pa’ina in late March. Attendees took advantage of the opportunity to meet SFMS leaders and connect with colleagues from various specialties and practice settings. SFMS President Roger Eng, MD welcomed member physicians and provided a brief update on the issues SFMS is championing on behalf of our members, including co-sponsorship of the tobacco tax legislation, vaccination advocacy, and collaboration with city supervisors and state legislators on ensuring access to quality health care for all San Franciscans. With great attendance and positive feedback from all, SFMS plans to organize another networking mixer in the coming months. Additional information can be found at https://www.sfms.org/events.aspx or follow SFMS on Twitter (@SFMedSociety). SFMS would like to thank Cooperative of American Physicians (CAP) for their support of this event and the medical society.

WWW.SFMS.ORG

APRIL 2015 SAN FRANCISCO MEDICINE

Enhancing Our Network for PatientCentered Care

At Kindred and Gentiva we put patients at the center of everything we do. By combining our companies we are building the largest network of post-acute services in the United States with expertise focused on reducing rehospitalizations, smoothing care transitions and helping patients recover. By expanding our Kindred at Home nationwide reach of home health and hospice services, we can provide the care that patients deserve in the place they want it most - home. Making healthcare easier is just one more way Kindred continues the care. For more information about how Kindred and Gentiva look forward to shaping the future of American healthcare visit us at www.kindredandgentiva.com.

CONTINUE THE CARE kindredandgentiva.com

In the San Francisco area, Kindred offers services including aggressive, medically complex care, intensive care and short-term rehabilitation in: Transitional Care Hospitals • Nursing and Rehabilitation Centers • Home Health • Hospice Care • Personal Home Care Assistance

PRESIDENT’S MESSAGE Roger S. Eng, MD, MPH, FACR

Physician Aid in Dying: First Do No Harm? Primum non nocere. This axiom was drilled into all physicians from the first days of medical school. For most of a patient’s lifespan, our sacred pledge is a pretty straightforward motto to follow. Yet physician-assisted suicide/aid in dying (PAD) is one area where we continue to struggle with its meaning and significance. A bill has been introduced in California to legalize PAD, a lawsuit has been filed by a patient and five physicians with the same intent, and we may see a state ballot initiative as well. This all comes at a time when up to 70 percent of Californians may support legalization of this option in some form. For the SFMS, this topic is not new. SFMS has a longstanding policy of neutrality in this area, understanding there are many components to consider. Moreover, SFMS has previously surveyed SF physicians on PAD. You would be interested to hear that, at least as of a couple of decades back, a majority of your local colleagues (70 percent, to be exact) supported legalized PAD in some fashion. Many other surveys of physicians have indicated similar divisions on this topic. With the new possibility of legalization looming, SFMS members will soon be asked this same question in an upcoming survey to see if opinions have trended upward, as they have in the general population. Given current events, the SFMS Board revisited our policy earlier this year. I was deeply impressed with the thoughtful and sensitive discussion that ensued about the ethical questions, physician opinion surveys, and experience in other states where PAD has been legalized and studied. There were differing opinions on some issues, of course, and you will see some of that reflected in this issue of our journal. In the end, your SFMS Board reaffirmed its neutral stance and has recommended CMA further evaluate this timely topic. CMA also is listening and revisiting its long-standing policy of opposing legalization of PAD, which is also the policy of the AMA. One of the strengths of organized medicine is that as a democratic body it is receptive to changes in health care, scientific evidence, and professional opinion. The CMA Council on Ethical Affairs and Council on Legislation is examining the legislative and other proposals regarding PAD, with further vetting by its Board of Trustees and 500-member House of Delegates, acting virtually. The outcome of the CMA’s policy decision will guide our state association’s position on many pieces of legislation in Sacramento. Naturally, our primary role is to heal and extend lives when we can. There have been many improvements in endof-life care and education, as is reflected in the following pages. The SFMS has long been involved in some of these efforts, fostering better policy and practice regarding advance WWW.SFMS.ORG

directives (including POLST), advocating for rational use of controlled medications at end of life, supporting reimbursement for counseling end-of-life decisions, and much more. Yes, this does include developing sound clinical guidelines and safeguards for situations when PAD does occur—see more inside this issue. Living and practicing in the epicenter of the HIV epidemic pushed such issues to the forefront here, and many of our members became leaders in the struggle to provide the best possible care to patients when there were no curative options. That scenario has thankfully changed dramatically, yet the fact remains we all eventually succumb to the circle of life. The physician’s role in this last chapter of our patients’ lives is still being defined. Stay tuned. The SFMS will keep you informed, and we welcome your input. Connect with Dr. Eng via Twitter @RogerEngMD or send him an email at reng@sfms.org.

Welcome New Members PHYSICIANS Nobl Barazangi, MD,PhD | Neurology Lavanya Krishnan, MD | Dermatology Lynn Ellen Schroeder, MD | Psychiatry Jennifer Grando Ting, MD | Internal Medicine STUDENTS Robert Orynich

APRIL 2015 SAN FRANCISCO MEDICINE

A Successful Medical Practice It’s what California’s finest physicians strive for... and what CAP can help you achieve. Since 1977, the Cooperative of American Physicians (CAP) has provided superior medical professional liability coverage and valuable risk and practice management programs to California’s finest physicians through its Mutual Protection Trust (MPT).

As a physician-directed organization, we understand the realities of running a medical practice these days, and are committed to supporting you with a range of programs and services that no other professional liability company offers. These include a 24-hour early intervention program, HR support, EHR consultation, a HIPAA hotline, and a robust group purchasing program, to name a few.

Are You ICD-10 Ready? Get Your “ICD-10 Action Guide” FREE! On October 15, 2015, all medical practices must comply with new, expanded ICD-10 codes. CAP’s ICD-10 Action Guide for Medical Practices has the answers you need to successfully make the transition.

Request your free electronic or hard copy today!

800-356-5672 CAPphysicians.com/icd10now

EDITORIAL Gordon Fung, MD, PhD, and Steve Heilig, MPH

All Things Must Pass: Helping, Healing, and Letting Go He still loves life but O O O O how he wishes the good Lord would take him. —W.H. Auden’s final poem

As the old jokes go, we have both good news and bad news. The bad news first: We are all going to die. Someday. Despite wishful thinking on the part of some who are hoping various attempts at high-tech “life extension” might edge us toward immortality, it seems clear that for now and the foreseeable future, “biology bats last.” The good news: We’re getting better at dealing with the whole “end-of-life” arena— albeit slowly. For some time now, demographers have been warning of a looming “age wave,” wherein the baby boomer bulge reaches older age and begins to put great stress on resources needed— and also begins to transform policy, law, attitudes, and much else, as a generation that has tended to mold such things to their liking for decades. This is looking to be true for health care as well. At least in some ways, we seem to be improving the way we take care of each other as that time approaches— at least in some settings. Last fall, the Institute of Medicine released a report titled Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. It found that end-of-life care is “woefully deficient and in need of sweeping changes.” This is not really a new complaint, but it is good to have the IOM issuing it now. The attention is warranted, and hopefully real action, from the policy realm to the bedside, will continue and accelerate. Many of us by now know the kind of recommendations the IOM makes: better communication of options and preferences including advance care planning, less default to aggressive care, more support for family caregiving, improved and expanded clinical training and payment policies, and more. Again, there is gradual improvement on most of those fronts, but we’ll also need many more clinicians trained in EOL care, and hopefully a bit more reassurance regarding the future health of Medicare, the ACA, Social Security, and their like. Palliative care is the focus of much of the improvement in clinical care, and its mainstreaming in hospitals and beyond is heartening. Hospice care is evolving and becoming more accepted, although many patients are not referred there as soon as they should be. But the relatively rapid development and acceptance of these multidisciplinary clinical services is surely a needed advance for both patients and clinicians. The goals of care change as old age comes on, and these services can help meet those goals for many if not most patients. One relatively new tool many have found useful is the POLST form, or Physician Orders for Life-Sustaining Treatment. The SFMS has been the locus of a coalition to improve POLST WWW.SFMS.ORG

use (and the form itself), and we’ve included the actual form in this journal annually for years now. And as noted herein, we have just convinced CMA (and soon, we hope, the state of California) to allow nurse practitioners to “POLST” patients themselves, as is done in other states. The need here to have this medical order used for all appropriate patients prevailed over “scope of practice” concerns, and we are proud of our role in this. Now, as to what might be an ethical elephant in the room, the SFMS has long taken a “neutral” position on the question of “physician-assisted dying.” Our pioneering survey of members a quarter century ago shocked the SFMS board when 70 percent of almost 800 respondents favored a legal option for PAD. Those results also landed on the front pages of newspapers nationwide. Since then there have been many more such surveys, and states have legalized the practice. Now PAD is big news again, with proposed legislation, a lawsuit, and maybe a ballot initiative aimed at legalization here. But of course it remains controversial, and likely always will. What should laws allow? We have included here pieces on both sides of the debate over legalization, plus a revised reprint of clinical guidelines for PAD first published years back when legalization again seemed imminent—those also wound up as front-page news. In any event, there is no doubt physicians are divided on this topic, and organized medicine—the CMA in particular, which has much influence on such laws—is undertaking a concerted look at long-standing policy on this topic as we write. In any event, we hope and expect that this focus will result in a more general increase in attention to end-of-life care, as seems to have been the case in states where PAD has been legalized. So even for opponents, there might be a silver lining there. Finally, this observation: Research has demonstrated a striking dynamic: When asked what choices they might make for themselves toward the end of life, physicians are much less “aggressive” than they tend to be with patients. There are multiple reasons for this, of course. It is harder to maintain the common human denial of mortality when one sees and hears of it daily. Such a crumbling of denial may be spreading; some of the renowned authors who have gifted us with their perspectives in this issue of our journal are part of that much-needed movement. So while immortality may be too much to ask, healthier, more functional “golden years” with more control of our own fates seems not too much to wish—and work—for. As we all should know, someday we too will be on the other side of that bedside. APRIL 2015 SAN FRANCISCO MEDICINE

End-of-Life Care

PALLIATIVE CARE MYTHS Debunking Myths for Truths Steven Pantilat, MD Palliative care is growing, with more services being developed and more people asking for them. A recent report by the California HealthCare Foundation shows that San Francisco County is near the top in the state in providing access to palliative care services (http://www.chcf.org/publications/2015/02/palliative-care-data). The increasing availability of palliative care services is great news for the many seriously ill people in our county, and yet people across the country harbor myths about palliative care that keep them from accessing this valuable service. This article debunks the most common myths and offers the truth about palliative care. The goal is to provide information and language that can be used to talk with patients about palliative care, to reduce barriers to palliative care, and ensure that patients with serious illness and those approaching the end of life get the care they need to have the best possible quality of life for as long as possible.

Myth: Palliative care is the same as hospice.

Truth: Palliative care is not the same as hospice. Palliative care is specialized medical care for people with serious illness. This type of care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness—whatever the diagnosis. The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient’s other doctors to provide an extra layer of support. Palliative care is appropriate at any age and at any stage in a serious illness, and it can be provided together with curative treatment. Hospice is a particular type of palliative care service typically provided at home to people with serious illness who have a prognosis of six months or less. Unfortunately, the average stay in hospice is very short, about thirty days, and 15 percent of people have a stay in hospice of seven days or less. All hospice is palliative care, but not all palliative care is hospice.

Myth: Palliative care is just end-of-life care.

Truth: Palliative care is not just end-of-life care. People approaching the end of life certainly need and benefit from palliative care and should receive it. However, palliative care is appropriate for people with serious illness at all stages. All end-of-life care is palliative care, but not all palliative care is end-of-life care. 12

Myth: People have to choose between living well with palliative care and living longer. Truth: Palliative care helps you live longer. Although many people think that there has to be a tradeoff between length of life and quality of life and that a path that includes or focuses on palliative care will result in shorter lifespan, rigorous studies show that palliative care can help people with serious illness live longer. In fact, there is no study that associates palliative care with shorter lifespan. In addition, studies demonstrate that palliative care helps people achieve a better quality of life, eases pain and depression, and reduces the chance that loved ones will experience depression or complicated grief after the person dies.

Myth: Palliative care is for when people are near the end of life and no longer want diseasefocused treatments.

Truth: It’s always the right time for palliative care. Many people ask when the right time is for palliative care. The answer is that it’s always the right time for palliative care for people with serious illness. One challenge is that if we wait for the right time, then adding palliative care is seen as a marker of things going poorly for the patient. If palliative care is integrated as a routine part of care for people with serious illness, then there is no transition, no marker, no signpost that something is now different. Such an approach also allows people to benefit longer from palliative care.

Myth: Palliative care is just good medical care that all doctors and nurses should provide.

Truth: Palliative care is a medical specialty with specific expertise. Some people will say that palliative care, with its focus on improving quality of life, relieving symptoms, providing clear communication, and offering support, is really just good medical care that all doctors and nurses should provide. It is true that we should expect all health care professionals to know the basics of pain management, to be able to communicate clearly and compassionately, and to provide people with support. However, there are situations when more expertise is needed, and addressing the needs of seriously ill patients requires specialized training and experience. Palliative care specialists and interdisciplinary teams

SAN FRANCISCO MEDICINE APRIL 2015 WWW.SFMS.ORG

have those skills. Training all health care professionals in the basics of palliative care is critical, in much the same way that all physicians should know the basics of how to treat diabetes. Yet, just as there are experts in treating diabetes who have specialized training and are often needed to manage complex cases, many people need and benefit from the expertise of palliative care specialists.

Myth: People don’t want to talk about illness and end of life and don’t really want palliative care. Truth: People want palliative care.

It is true that in our society we tend to avoid discussions of illness and end of life. However, it is also true that people with serious illness overwhelmingly want to talk with their doctors and nurses about their preferences for care and expect them to raise the issues. While the general public is generally not familiar with the term palliative care, when they learn about what palliative care is, they overwhelmingly want that type of care for themselves and their loved ones and think that it should be a standard part of health care. And while the term “death panels” was grossly misused to describe paying doctors to talk with patients about their preferences for care, and that misuse scared many people, surveys show that Americans overwhelmingly agree that physicians should talk with their patients about their preferences for care should they become seriously ill.

Myth: It’s important to know the right way to approach serious illness and end of life. Truth: There is no best or right way to approach serious illness and end of life.

Decisions about care for people with serious illness are very personal and based on many factors, including culture, religion, and socioeconomic status. Although people will talk and write about a “good death,” the truth is that serious illness and the end of life is filled with loss and grief, and we can’t quite make it “good.” Nonetheless, we must make the end of life as peaceful and dignified as possible. The goal in health care is to help people have the best possible quality of life, as they define it, for as long as possible. The palliative care approach is to ensure that people understand all of their options for care so that they can make the best decisions for themselves.

Steven Pantilat, MD, is a professor of medicine and director of the Palliative Care Program in the UCSF Department of Medicine.

Tracy Zweig Associates INC.

REGISTRY

PLACEMENT

FIRM

~ Physicians ~ Nurse Practitioners Physician Assistants

Voice: 800-919-9141 or 805-641-9141 FAX: 805-641-9143 tzweig@tracyzweig.com www.tracyzweig.com

Attorneys representing doctors, their patients, families, and friends to obtain their disability insurance and other insurance coverage beneﬁts.

LAW OFFICES OF MANN LAWRENCE S.F. Medicine 02-20-14 (855) 592-7664

LarryMann@TheDisabilityInsuranceSite.com

WWW.SFMS.ORG

APRIL 2015 SAN FRANCISCO MEDICINE

Confidence The feeling you have when you are affiliated with Hill Physicians. Lyra Ng, M.D.

Hill Physicians provider since 2011. Uses Ascender preventive care reminders and Hill inSite to review eClaims and eligibility.

At Hill Physicians, we continue to improve upon coordinated care, with remarkable results. We provide the tools and support that practices need to be financially successful and improve the coordinated care experience for their patients. Our advantages include: • Fast, accurate claims payments • Free eReferrals, ePrescribing and online doctor-patient communications • Experienced RN case management for complex, time-intensive cases • Deep discounts on EPM and EHR solutions to help you meet the federal mandate • Easy preventive care and disease management reminders for patients • Extensive health resources that boost patient engagement • High consumer awareness that builds practice volume That’s why 3,800 independent primary care physicians, specialists and healthcare professionals have joined Hill. Feel confident in the future of your practice and your patients by affiliating with Hill Physicians Medical Group.

For more about the advantages of affiliating, visit HillPhysicians.com/JoinUs.

Hill Physicians’ 3,800 healthcare providers accept HMOs and many PPOs from Aetna, Anthem Blue Cross, Blue Shield, CIGNA, Easy Choice, Health Net, Humana, SCAN, San Francisco Health Plan, United Healthcare WEST and Western Health Advantage. Medicare Advantage plans in all regions. Medi-Cal in some regions for physicians who opt-in. SAN FRANCISCO MEDICINE APRIL 2015 WWW.SFMS.ORG

End-of-Life Care

ADVANCE CARE PLANNING A Community-Based Initiative in San Francisco Jeff Newman, MD, MPH; Rebecca Sudore, MD; Caroline Stephens, RN, PhD, GNP; BJ Miller, MD; Christine Ritchie, MD, MSPH

Given the complexity and importance of advance care planning (ACP) for serious illness and end-oflife care, we propose a campaign for the San Francisco Pallia-

tive Care Task Force with the following goals: • Interprofessional training to initiate and support ACP conversations • Community health education in collaboration with the diverse health and social service organizations that serve San Francisco with respect and cultural humility ACP goes beyond a one-time conversation and the completion of an advance directive (AD) or POLST document. It is an ongoing process in which patients and their loved ones work collaboratively with clinicians to identify their values and effectively cope with ongoing and evolving illnesses and care decisions.1 Communication and trust built over time facilitate complex and difficult decisions that arise in advanced illness. These conversations take time and empathetic dialogue and should be initiated before declining cognitive function of patients interferes with their participation. Many patients, family members, and physicians are hesitant to initiate and revisit discussions about life goals and values during busy clinic appointments. However, the benefits of ACP documents depend on the quality of the ongoing dialogue upon which they are based. There are already a variety of excellent ACP programs in San Francisco (and the Bay Area) that deserve greater recognition and use by clinicians and patients. In addition, interprofessional training and collaboration is needed to elevate ACP at the population level. Though physicians need to be involved in diagnosis, prognosis, and explanation of treatment options, nurses and other clinicians, social workers, and chaplains may also assist patients and their families in clarifying goals, considering trade-offs, and supporting informed decisions. We applaud the recent CMA adoption of an SFMS-initiated resolution supporting nurse practitioner, advance practice nurses, and physician assistant signature of POLST documents in California (as in several other states). The potential benefits of well-considered AD and POLST documents can only be achieved when they are available as needed by EMS and in other acute and long-term care settings. We also propose to explore ways to help health care organizations incorporate ACP decisions into electronic medical records and data exchanges. For widespread ACP adoption, community health education is imperative. Innovative programs have been designed to facilitate ACP for patients, families, and clinicians. For example, the PREPARE website, https://www.prepareforyourcare.org, is an easy-to-use, interactive online ACP program. PREPARE walks people through a five-step process to help identify a surrogate WWW.SFMS.ORG

decision maker and what is most important in life, to be able to communicate this information to clinicians, and to use their values to make informed medical decisions. This tailored program creates a personalized values summary that can be shared with family, friends, and clinicians, making ACP discussions more effective and efficient. If and when patients are ready to put their wishes in writing, easy-to-read advance directives are also available in more than ten languages (https://www.iha4health.org/ our-services/advance-directive/). We invite active SFMS participation in our evolving initiative, as well as modeling of best practices. How many of our members and staff have engaged in meaningful conversations with family, friends, and their clinicians on general goals of care, and who they would like to participate in shared decision making if and when that becomes necessary? Addressing these issues ourselves will assist us in our efforts with patients and community.

Jeff Newman, MD, MPH, is adjunct professor at the UCSF Institute for Health & Aging and a member of the SFMS. Rebecca Sudore, MD, is associate professor in the UCSF Division of Geriatrics. Caroline Stephens, RN, PhD, GNP, is assistant professor of the UCSF Community Health Systems. BJ Miller, MD, is executive director of Zen Hospice. Christine Ritchie, MD, MSPH, is a professor in the UCSF Department of Medicine.

Reference 1. Sudore RL, Fried TR. Redefining the “planning” in advance care planning: Preparing for end-of-life decision making. Ann Intern Med. 2010; 153(4):256–261.

APRIL 2015 SAN FRANCISCO MEDICINE

End-of-Life Care

PALLIATIVE CARE An Essential Tool in Care Management Edward A. Chow, MD, and Mark Morewitz, MSW Palliative care is a dynamic person- and familycentered modality that focuses on improving quality of life during serious or life-threatening illness. Unlike hospice, palliative care can be provided at any age and any stage of an illness, even alongside curative treatment. Best provided by interdisciplinary teams (doctors, nurses, social workers, chaplains, and others), palliative care can be delivered in multiple settings: acute care hospitals, skilled nursing and other long-term care facilities, clinics, assisted living facilities, and private residencies.1 Palliative care services are sponsored by a range of organizations including health systems, home health agencies, social service agencies, hospices, and medical groups.

Key elements of palliative care include the following:1

• Relieves symptoms, pain, and stress of a serious illness— whatever the diagnosis • Facilitates communication with patients about patient-care goals and provides support for complex medical decision making; improves quality of life for both the patient and the family • Is provided by a team of doctors, nurses, social workers, chaplains, and other specialists (e.g., psychologists, pharmacists, etc.) who provide an extra layer of support, in conjunction with all other appropriate medical treatments, including curative and life-prolonging therapies • Is appropriate at any age and at any stage in a serious illness

In 2013, a series of community meetings were held with key San Francisco health and social service leaders to discuss opportunities to improve palliative care service coordination in San Francisco. The meetings revealed that a significant number of San Francisco organizations were providing palliative care services and support across San Francisco but few were collaborating. Many of the health and social service leaders participating in the meetings reported being unaware of the range of palliative care services offered in San Francisco. In response to these findings, the San Francisco Department of Public Health (SFDPH) agreed to lead the development of a San Francisco Palliative Care Task Force. In May 2014, the SFDPH and the Department on Aging and Adult Services brought together a diverse group of representatives from San Francisco’s leading health care and community organizations, advocacy and professional associations, and consumers to discuss San Francisco’s palliative care needs because 16

of the importance of palliative care as a component of the spectrum of care. The San Francisco Palliative Care Task Force met five times over three months “to develop recommendations to move San Francisco closer to meeting current and future palliative care needs.”2 The Task Force members, with the assistance of a group of engaged members of the public, identified three deliverables: 1) definitions for palliative care and a palliative care target population, 2) an inventory of dedicated palliative care services currently available in San Francisco, and 3) short- and long-term palliative care recommendations aimed at improving access to quality palliative care in San Francisco. Four Task Force Workgroups were formed: Quality, Finance, Systems, and Community Education. The Quality Workgroup recommendations adhere to the National Consensus Project (NCP) framework for quality palliative care and NCP guidelines for developing and measuring the structures, processes, and outcomes of palliative care. Key recommendations include promoting measurement of palliative care service quality by acute care hospitals and third-party payers in addition to advocating for palliative care training for direct care workers in social service and home health care organizations. The Finance Workgroup recommendations provide a stepwise approach to building the business case necessary to fund and support the delivery of palliative care. Key recommendations include promoting broader understanding of palliative care among stakeholders who are in a position to fund palliative care services, collecting data to help understand the current service use patterns in the final twelve to twenty-four months of life, and developing an advisory board to be affiliated with the Long Term Care Coordinating Council that can continue the work of the Palliative Care Task Force. The Systems Workgroup recommendations actively support collaboration across systems to minimize barriers and disparities in access to hospice and palliative care services. Key recommendations include creating a database of palliative care resources, developing standards for advance care planning (ACP) and information sharing across locations and systems of care, and integrating palliative care services into complex care management programs for patients with high use of emergency services. The Community Engagement Workgroup issued key recommendations that include creating public campaigns to increase awareness of ACP and striving to make San Francisco a community competent in ACP while honoring the impact of cultural diversity in decisions relevant to this service area. The Workgroup hopes to eventually provide community training to medical providers to increase skill and comfort levels of all physicians. In December 2014, the San Francisco Health Commission

Continued on page 19 . . .

SAN FRANCISCO MEDICINE APRIL 2015 WWW.SFMS.ORG

End-of-Life Care

WHEN DEATH COMES EARLY Pediatric End-of-Life Care Nancy Iverson, MD “That must be so horrible” is the reaction I encounter most often when relating that I worked with Comfort for Kids, an in-home pediatric hospice and palliative care service. Substitute the word “hard” for “horrible” to get another common response. Occasionally confusion and disbelief are almost palpable: “Hospice—for children? As in children dying?” Yes, children do die. Approximately 55,000 in the United States each year. From causes as diverse as congenital malformations and degenerative diseases to cancer and trauma. But, no, I don’t label the realm of pediatric palliative care as “horrible.” Challenging—yes. Heartrending—often. Complicated—absolutely. But not horrible. What is horrible to consider is how much more unbearable this catastrophic experience is for children and families when they must flounder through the myriad of blows that accompany a child’s life-limiting diagnosis without the aid of support and services that a palliative care philosophy and team can provide. And how especially devastating this trajectory is when, along with grappling with adjustments to a “new normal” such as navigating through tertiary care institutions, painful and/or toxic interventions, relapses, physical limitations, and enormous stresses on family dynamics, an abrupt jump off the “curative therapy” track is demanded with the threat or reality of imminent death, and the fear of abandonment adds to the anguish. A father may perceive the doctor who recommends discontinuing invasive interventions as “writing off” his child, a mother may see herself as relinquishing all hope by participating in a discussion about DNR, parents may feel like they are disloyal to the hospital team by accepting a hospice referral. And a powerful sense of failure and shame may emerge for us as doctors—that in failing to save the life of our young patient we have betrayed not only the child and family but also our profession.

The death of a child is devastating. As parents, siblings, grandparents, aunts, uncles, and friends all grapple with the both the immediate loss and the shattering of plans, hopes, and dreams for the future, the medical team also struggles. Denise Taylor, whose son Joe died at nineteen months of age, writes, “They say a child’s death is the worst thing that can happen to a parent, but I sometimes think it’s the worst thing that can happen to a professional. They are trained to sort things out, to make things better, to get you through—and there’s no sortWWW.SFMS.ORG

ing this out or making it better, or getting through it.” (http:// www.theguardian.com/lifeandstyle/2014/jul/05/can-parentget-over-death-of-a-child) Deeply embedded in the medical model is the injunction to fix and to cure, to fight death and disease. How disheartening when these exemplary goals fall short for many diagnoses and real-life situations, especially in the practice of pediatrics, which, of all the medical specialties, most wholeheartedly celebrates the start of a new life and champions every milestone of growth and development. The context of palliative care philosophy invites us to expand our concept of care, to reframe the question, “How can we cure this?” to “How can we best help to ease suffering?” When we accompany a child and family throughout all chapters of illness and end of life, we deepen our capacity to be of service even when a life won’t be saved. We become a resource to help a family more skillfully give voice to otherwise unspeakable fears, hopes, and despair and to partner with them in making choices for a child’s care. Discussions about end-of-life decisions generally run the spectrum from extremely hard, at best, to excruciating—for all involved. When postponed, usually with the intention of sparing anxiety for families, these conversations are often relegated to crisis points, in which choices feel limited to an “either-or” option, and the distress and turmoil are enormous as the medical team and parents wrestle for control in a situation that is beyond control. When, instead, we adhere to the WHO guideline for palliative care for children, which states that “it begins when illness is diagnosed, and continues regardless of whether or not a child receives treatment directed at the disease,” we may integrate compassionate explorations about the “what if’s” early on in the course of an illness. We can invite what Atul Gawande, in Being Mortal, describes as “a series of conversations to sort out when they need to switch from fighting for time to fighting for the other things that people value—being with family or traveling or enjoying chocolate ice cream.” Even when we are not able to prevent a death, we may help alleviate suffering as we learn what is most important to children and parents during illness and at the end of a life, and we can continue relentlessly to access every resource possible to provide care and support. Gawande says, “Endings matter, not just for the person but, perhaps even more, for the ones left behind.” In medicine, no matter what skills, technology, or financial resources are available, we will encounter unfixable situations and endings, even in pediatrics. When we, as pediatricians, can grapple with the implications of accepting the limitations of a curative medical model and allow for the possibility that even—especially—in end-of-life care of a child we can and must continue to encour-

Continued on page 19 . . .

APRIL 2015 SAN FRANCISCO MEDICINE

Working together, the San Francisco Medical

TOP

REASONS

To Join SFMS and CMA

PRACTICE MARKETING ASSISTANCE

Society and the California Medical Association are strong advocates for all physicians and for the profession of medicine. Of the many reasons for joining SFMS and CMA, 10 stand out.

MEMBER-ONLY ACCESS Gain full access to the SFMS website for guidelines, reports, and a variety of tools and resources to help you navigate the ever-changing health care environment. Members also receive exclusive admission to our private networking socials and the Annual Gala.

Promote your practice through our customizable physician member page on SFMS’ website, printed Member Directory, and networking mixers.

LEGISLATIVE ADVOCACY: Ensure physicians have a voice and remain in control of medicine this year and in years to come. By speaking as a united voice, SFMS/CMA exert a powerful influence on health policy and public health issues at the local, state, and national levels.

IMPROVING COMMUNITY HEALTH Spearhead community health issues in San Francisco including Hep B Free, anti-tobacco legislation and education, formation and continuation of the Healthy San Francisco program, advocacy on reproductive and end-of-life issues, and much more.

EXPAND YOUR NETWORK Grow your professional network and referral list by networking with peers, established physicians, and health care leaders across the state at SFMS events and online communities.

PROTECTING MICRA SFMS and CMA work diligently to protect the Medical Injury Compensation Reform Act (MICRA), spearheading a successful campaign to defeat Prop 46 in the 2014 Election. Prop 46 would have dramatically altered MICRA by making it easier to file lawsuits against health care providers, increasing health care costs, reducing access to care and ultimately generating more legal fees for lawyers.

CAREER CENTER Discover new employment opportunities through the annual SFMS Career Fair. This member-only event connect SFMS physicians with recruiters from San Francisco Bay Area hospitals, medical groups, and community clinics.

STAY CONNECTED Stay up to date on vital health care issues that affect San Francisco physicians with online and print media – San Francisco Medicine journal, SFMS News e-Newsletter, and SFMS blog.

COMMITMENT TO THE PROFESSION

PRACTICE MANAGEMENT ASSISTANCE Resolve contracting, billing, and payment problems with one-on-one assistance from CMA’s team of practice management experts.

Your support of the SFMS and CMA through membership affirms your commitment to the medical profession and ensures physicians remain in control of medicine this year and in years to come.

PLEASE JOIN OR RENEW YOUR MEMBERSHIP TODAY JOIN ONLINE AT www.sfms.org/Membership/JoinNow/MembershipJoin

RENEW YOUR MEMBERSHIP ONLINE AT www.sfms.org/membership/pay-dues-online

CONTACT SFMS AT (415) 561-0850 or membership@sfms.org

When Death Comes Early Continued from page 17 . . . age and promote health—physical, emotional, mental, and spiritual—for each child and his or her family, we expand the dimensions of our care beyond the constricting confines of cures and failures. Rather than subscribing to the idea that there is nothing we can do, we can explore every possible avenue to help families sojourn this horrific terrain. Even as we bear witness to unfathomable pain and loss, we also have the opportunity to be in the company of heroes as children, parents, and their families live their stories and the endings with indescribable courage, grace, and love.

Bay Area resources for pediatric palliative care and hospice include:

• Children’s Hospice and Palliative Care Coalition www.chpcc.org/about-us/ • George Mark Children’s House www.georgemark.org • Hospice by the Bay and By the Bay Kids www.hospicebythebay.org/index.php/patients-families/ped • UCSF Benioff Children’s Hospital Compass www.ucsfbenioffchildrens.org/services/compass_care • Lucille Packard Children’s Hospital, Stanford www.stanfordchildrens.org/en/service/palliative-care

Nancy Iverson, MD, followed her pediatric internship and residency at San Francisco Kaiser with a year as a pediatric nephrology fellow at UCSF. She has practiced pediatrics for more than twenty years in the San Francisco Bay Area and has been on staff at CPMC, Kaiser, and UCSF. She worked early on with the development of the pediatric palliative care programs, especially the educational components, at UCSF and served as a pediatric consultant for Comfort for Kids, an in-home pediatric palliative hospice and palliative care service. Through Support for Families of Children with Disabilities, she runs a support group for parents living with loss. She is the founder and director of PATHSTAR, a nonprofit dedicated to revitalizing health and well-being within Native American communities.

Looking for Palliative Care Everywhere

Palliative Care Continued from page 16 . . . approved resolution 14-17, supporting the recommendations of the Palliative Care Task Force, and directed the SFDPH to consider these recommendations when planning relevant health services. The Health Commission is the governing body of the SFDPH and is mandated by the City and County Charter to manage and control the City and County hospitals; to monitor and regulate emergency medical services; and to oversee all matters pertaining to the preservation, promotion, and protection of the lives, health, and mental health of San Francisco residents. The San Francisco Long Term Care Coordinating Council has established a Palliative Care Workgroup to continue the work of the Palliative Care Task Force. The Health Commission will receive annual updates from this workgroup and has directed the SFDPH to cooperate with the workgroup as it considers the Palliative Care Task Force recommendations. Physicians in private practice can do their part to integrate palliative care by discussing advance care planning options as appropriate. Many patients and their families want to address these issues but may need prompting by a caring medical provider. A current inventory of local resources is available at https://www.sfdph.org/dph/files/palliative/PalliativeSupportiveCareResourcesDirectory-Final.pdf. Edward A. Chow, MD, is a practicing internist and president of the San Francisco Health Commission. He is board advisor to the Chinese Community Health Care Association and is the senior advisor for the Chinese Community Health Plan. He is also treasurer of the Board of Directors of the Institute of Medical Quality, a subsidiary of the California Medical Association. He is a member and Past President of the SFMS. Mark Morewitz, MSW, is the executive secretary to the San Francisco Health Commission.

References 1. What Is Palliative Care? Center to Advance Palliative Care, 2014. Accessed May 6, 2014, at http://getpalliativecare.org/ whatis/. 2. The San Francisco Palliative Care Task Force Final Report, https://www.sfdph.org/dph/files/hc/HCAgen/HCAgen2014/ December%2016/HC%20Memo_Palliative%20Care%20 Task%20Force_12.11.14-1.pdf.

Sandra R. Hernández, MD When I started practicing medicine decades ago, there was no formal field of palliative care. Today, it’s an established medical specialty that has gained recognition and respect in the US. Thanks to the dedicated pursuit of appropriate care for patients with serious illness, the number of interdisciplinary teams offering palliative care has risen steadily over the past decade. However, research released this month by CHCF shows that palliative care is unavailable to many Californians due to a general shortage in supply and uneven distribution of services across the state. Against this backdrop, there are some rays of hope. Our recent publication, “Up Close: A Field Guide to Community-Based Palliative Care in California,” is a collection of promising practices from 21 organizations that have pioneered palliative care delivery. Dr. Hernandez is President and CEO of the California Healthcare Foundation, former San Francisco Director of Public Health, and practices at San Francisco General Hospital. She is an SFMS member. Excerpt; full piece at chcf.org.

WWW.SFMS.ORG

APRIL 2015 SAN FRANCISCO MEDICINE

End-of-Life Care

WHAT MATTERS NOW? Thoughts on Being Mortal Michael Lerner, PhD Being Mortal: Medicine and What Matters in the End By Atul Gawande, MD “This is a book about the modern experience of mortality— about what it’s like to be creatures who age and die, how medicine has changed the experience and how it hasn’t. . . . Lacking a coherent view of how people might live successfully all the way to their very end, we have allowed our fates to be controlled by the imperatives of medicine, technology, and strangers.” —Atul Gawande, MD Atul Gawande’s Being Mortal is essential reading. It is essential for all who are entering older age. For all who are facing serious illness. And for all who are nearing the end of life. Gawande is a surgeon, Harvard professor, public health researcher, New Yorker staff writer, activist for improved health care, and author of four books. He was a Rhodes Scholar at Oxford and a MacArthur Fellow. An article he wrote contrasting revenue—maximizing health care versus low-cost, high-quality health care systems like the Mayo Clinic influenced President Obama’s thinking on health care. Who Gawande is shapes how he thinks, how he writes, and how this remarkable book is being received. While our elderly population is rising rapidly, Gawande tells us that the number of geriatricians has actually fallen 25 percent in the last few decades. Geriatrics is poorly reimbursed. Geriatric departments are closing even as the need for geriatrics is rising. What this means in practical reality is there will be fewer physicians with the skills or interest to address the difficult concerns of the elderly. These facts mean that, one way or another, our collective amnesia about our aging society is coming to a rather abrupt end. But Gawande goes far beyond who will provide elder care to make a much more fundamental point about medicine: We’ve been wrong about what our job is in medicine. We think our job is to ensure health and survival. But really it is larger than that. It is to enable well-being. And well-being is about the reasons one wishes to be alive. . . . Whenever serious sickness or injury strikes and your body or mind breaks down, the vital questions are the same: What is your understanding of the situation and its potential outcomes? What are your fears and what are your hopes? What are the trade-offs you are willing to make and not willing to make? And what is the course of action that best serves this understanding? These four questions—how do you understand your situation, what are your hopes and fears, what trade-offs are you willing to make, and what course of action serves you best— are at the heart of Gawande’s approach to serious illness and 20

end-of-life care. Of these four questions, the question about your hopes and fears—the question of what matters to you now—Is the most critical of all. Gawande does not take for granted that what we say matters at one time will be what matters in later years or at the end. He describes the groundbreaking research by Stanford psychologist Lauren Carstensen that our priorities shift dramatically depending on how much time we perceive ourselves as having. Our driving motivations in life . . . change hugely over time and in ways that don’t quite fit Maslow’s classic hierarchy. In young adulthood, people seek a life of growth and selffulfillment, just as Maslow suggested . . . when people reach the latter half of adulthood . . . they narrow in. . . . They focus on being rather than doing and the present rather than the future. . . . Tolstoy recognized this. As Ivan Ilyich’s health fades and he realizes his time is limited, his ambition and vanity disappear. He simply wants comfort and companionship. But no one understands . . . [except] his servant Gerasim. But where, pray tell, will the frail elderly live? Gawande traces the rise of the modern hospital as warehouses for the frail elderly. That failed experiment led to the rise of nursing homes. The failure of nursing homes in turn led to the rise of assisted living facilities. Assisted living facilities in turn have been cheapened into a shadow of their original intent by market forces. Who makes the decisions about where elders live? Today, Gawande point out, families are scattered across the country and around the world. More and more people live alone. When people are married or partnered, most often both partners work. So the problem of what to do when older parents or relatives need extended care or assisted living is one of the most fundamental problems we face.

The hope Gawande offers is that there is a better way. But the better ways are not easy.

When it comes to medical decisions that respect what matters, the conversations take more time at the start—but frequently lead to dramatic savings and greatly improved outcomes for the patient. Simple conversations about what patients want in end-of-life care can reduce ER visits and enhance skillful decisions that fit a patient’s hopes and values. At other times, the challenges are quite heroic. It takes more time for a physician to understand what matters for a patient than to write a prescription—and physician scheduling often doesn’t provide that time. It takes more time for nursing home staff to help a patient dress than to dress him. Then there is the end, and “[t]he conversation that we all

SAN FRANCISCO MEDICINE APRIL 2015 WWW.SFMS.ORG

need to have when the chemotherapy stops working, when we start needing oxygen at home, when we face high-risk surgery, when the liver failure keeps progressing, when we become unable to dress ourselves. I’ve heard Swedish doctors call it a “breakpoint discussion,” a series of conversations to sort out when they need to switch from fighting for time to fighting for the other things that people value—being with family or traveling or enjoying chocolate ice cream. Few people have these conversations, and there is good reason for anyone to dread them. They can unleash difficult emotions. People can become angry or overwhelmed. Handled poorly, the conversations can cost a person’s trust. Handled well, they can take real time. . . .” We [physicians] are increasingly generals who march the soldiers onward, saying all the while, “You let me know when you want to stop.” All-out treatment, we tell the incurably ill, is a train you can get off at any time—just say when. But for most patients and their families, we are asking too much. They remain riven by doubt and fear and desperation; some are deluded by a fantasy of what medical science can achieve. Our responsibility in medicine is to deal with people as they are. People die only once. They have no experience to draw on. They need doctors and nurses who are willing to have the hard discussions and say what they have seen, who will help people prepare for what is to come—and escape a warehoused oblivion that few really want. I do not fault Gawande for the book he didn’t write. He doesn’t talk about how integrative therapies can improve physical and mental health and thereby improve the chances that people may live better—sometimes extending as well as enhancing life. He doesn’t explore how intentional healing work can help people find the meaning in their lives that he clearly understands as essential to the human journey. He doesn’t say a word about environment and how fundamentally it contributes to the modern epidemics. He does, to his credit, address inequity, but he does not address the dramatic increase in inequity, nor does he say that income disparities are the single greatest predictor of health outcomes. More to the point, while Gawande does an excellent job of describing the decline in quality of assisted living facilities, he does not do a similar appraisal of hospice. He doesn’t talk about how hospice services have been stripped to bare essentials, about the difficult trade-offs that capitated costs involve, about the greatly varying quality of hospice services, about how patients can assess competing hospice services, about the choices patients face between palliative care and hospice, or about how patients may need to navigate between hospice and palliative care to achieve the best outcomes. Again, I understand the reasons. So let us focus on what he achieved. Gawande’s contribution is as much his art as his science. He has seen the pathology of our health care system with perfect clarity. He has understood the suffering this pathology creates with deep empathy. He has experienced this suffering himself, with his father’s cancer and with his wife’s family. Gawande calls for a fundamental refashioning of our institutions, culture, and conversations about our last chapter. He omits mention of one formidable ally in effecting this transformation. It is no secret that the baby boomers have entered the last WWW.SFMS.ORG

long (or short) chapter of their lives. Few have saved enough to ensure a safe haven. Even with expanded health coverage, healthrelated draining of savings will remain common. Even if one avoids medical bankruptcies, the cost of high-quality assisted living for the elderly and at end of life remains disastrously high. Baby boomers have transformed every stage of life they have moved through. Their final contribution may be to transform how we care for the elderly, how we redefine medical care and self-care, and how we negotiate the end of life. That is not a sure thing—but it is a possibility. And it will take a tremendous effort.

What we will see—what Gawande vividly describes—is a grand national and international experiment to solve these problems, because there is no real alternative to solving them.

Gwande awakens us from our profound cultural amnesia about elder care, end of life, and the real choices in serious illness. If you embark on this reflection, you cannot help but ask what we will need to do—because it is by definition impossible to face this passage alone. You can’t read this book without thinking about your own family, and your own community of friends and potential caregivers. And then you can’t help but ask what other communities like yours have discovered that works. Reading Being Mortal affected me deeply. It moved me to tears. It subtly changed how I think about my own mortality. And it deepened my understanding of the work I have been doing with people with cancer for thirty years in the Commonweal Cancer Help Program. I will make Being Mortal recommended reading for all who participate in our work in intentional healing. Don’t leave home without Being Mortal. In fact, if possible, don’t leave home. Stay in the community that gives your life meaning. And join with others to make it work. Consider the alternative. Michael Lerner is founder and president of Commonweal, author of Choices in Healing, a MacArthur Fellow, and cofounder of the Collaborative on Health and the Environment.

APRIL 2015 SAN FRANCISCO MEDICINE

End-of-Life Care

ON DEATH AND DYING Refections on End of Life from Local Religious Leaders

Michael Pappas, SFIC Executive Director “Celebrating our diverse faith and spiritual traditions, the San Francisco Interfaith Council (SFIC) brings people together to build understanding and serve our community.” In the spirit of this mission, we are grateful for the invitation to contribute spiritual reflections from a variety of faith perspectives on death and dying for this issue, which shines a light on end-of-life care. Each of our contributors brings a long history of firsthand experience in spiritual care giving to the terminally ill and their families. Rev. Dr. Paul Fitzgerald, SJ, is the president of the University of San Francisco, a Jesuit university with a rich tradition of compassion, social justice, and outreach in our community; Dr. Robert Crane, a longtime supporter of the United Muslims of America, offers Islamic wisdom on the topic; Reagan Humber, currently a candidate for the traditional diaconate in the Episcopal Diocese of California, is a hospice chaplain and the bereavement coordinator at Gentiva Hospice; Rev. Ron Kobata is the resident minister of the Buddhist Church of San Francisco and a clergyman who brings the deep spirituality of his tradition to all to whom he ministers; Kaushik Roy, rooted in the Hindu faith, is the executive director of the Shanti Project, a community of volunteers and staff who provide emotional and practical support to San Francisco’s most vulnerable individuals living with life-threatening illness; and Rabbi Eric Weiss is the president and CEO of the Bay Area Jewish Healing Center, whose mission is dedicated to providing Jewish spiritual care to those living with illness, to those caring for the ill, and to the bereaved through direct service, education and training, capacity building, and information and referral.

Rev Dr. Paul Fitzgerald, President, University of San Francisco

The Catholic tradition provides two principles to keep in mind when dealing with end-of-life care: We are to find meaning in suffering, and we are to alleviate suffering when it is appropriate to do so. Applying these to the context of palliative care should be made against the larger horizon of faith in a God who invites us into collaboration with grace, loving care for others in an imitation of Christ, and hope built on the promise that this life opens up into eternity through the reality of death. Suffering and death are inevitable in every human life. We are not called to seek out or worship suffering per se, yet in the book of Job in the Hebrew scriptures and in the Passion narratives of the four Gospels, we find patterns, pathways, and frameworks for us to enter into the depths of human suffering as a unique place of encounter with the divine. Easy explanations of the meaning of suffering are typically inadequate or wrong; God does not seem to want us to suffer, yet God is especially present 22

to those in extremis in ways that either heal and give a temporary reprieve or lead the dying person through the doorway of death. A good death is one in which the dying person accepts all that has been, forgives all who have offended, and embraces forgiveness for all that went awry. Care for the dying is provided in light of these beliefs. There is thus no necessity to artificially forestall death through extraordinary means, nor is there warrant to speed the end through active euthanasia. Palliative care is a balance of relieving pain and preserving as much quality of life as possible, chiefly so that the dying person can fully experience this last chapter of a lifelong spiritual journey.

Eric Weiss, Executive Director, Jewish Healing Center

We spend a lot of time in our beloved community talking about how to care for our young and for our aged, and we should. But we all know that not everyone lives to see old age, and certainly not everyone bears or raises children. No matter our life circumstance, everyone becomes ill, comes to their last breath, and comes to fold grief into their lives. Illness, death, and grief are the universal human experiences. These universal human experiences naturally stimulate spiritual reflection, and they reasonably yearn for a communal response. Judaism emphasizes the blessing of life itself, to be fully living and engaged in the world, and at the same time to recognize that we come to die. At our last breath it is assumed we will ascend to Heaven. Our tradition encompasses many rabbinic perspectives on the nature of Heaven, the afterlife, reincarnation, and other natural human curiosities. This is because the emphasis is on life in this world. There is a famous rabbinic story that tells us that when the teacher Zusya was on his deathbed, his students said, “You will be welcomed into Heaven because you are as great as Moses.” To which Zusya replied, “When I die and arrive to Heaven, God will not ask me why I was not more like Moses, rather God will ask me why was I not more like Zusya?” Even at the moment of death our tradition asks us to simply be our authentic selves.

Dr. Robert D. Crane, supporter of the United Muslims of America

The traditionalist or classical wisdom of all the Abrahamic religions about the end of human life is essentially the same, because they agree on its purpose, though with different emphases. In Islamic teachings, the purpose of everyone’s life is to become the person that God created one to be by seeking to know one’s deepest identity, instead of trying to create an artificial self. This is the key to salvation, which has only three requirements. These are to love God in return for God’s love, to recognize the continuum of justice from this life to the next, and to do good works. One of the

SAN FRANCISCO MEDICINE APRIL 2015 WWW.SFMS.ORG

Prophet Muhammad’s favorite prayers was, “Oh God! I ask You for Your love, and for the love of those who love You, and for the love of everything that will bring me closer to Your love.” To know oneself in Islam is to recognize one’s own human nature, and especially the basic teaching of Islam that one’s own essence includes what is known as infaq, which is the inclination to give rather than to take in life. One’s own nature is also to value one’s own life and the life of others as a gift, which produces a reverence for the human transition from this life to the next, to the extent that one has no fear of death, so that those who have lived a life in awareness of God and repented their failures can regard their own death as the greatest moment in their life. For untold millennia, traditionalist communities have provided support for those who can no longer be cured so they and their loved ones no longer fear the disappearing quantity of life and instead can enjoy the growing quality of life available to those who recognize their own purpose and its final fulfillment.

Rev. Ron Kobata, Resident Minister, Buddhist Church of San Francisco

In our Jodo Shinshu Buddhist tradition, we have a custom of reading an epistle during funerals/memorials. “On White Ashes” was composed in the fifteenth century by the eighth-generation head of our denomination. It clearly and simply sets out that facing the fact of our own death and shared inevitability of death can lead to deeper and fuller living. The reflective statement, “whether it be today or tomorrow, who is to know?” offers an awareness that end-of-life care might well occur throughout the course of this finite experience we call human life. After all, our dying began the moment we were born, and the paradox is that in dying to our finite self a new sense of living comes ALIVE: Aware, Loving, Inspired, Valued, Engaged. Rennyo Shonin’s “On White Ashes” In silently contemplating the transient nature of human existence, nothing in our world is more fragile and fleeting than our life. Thus, we hear of no one sustaining human form for a thousand years. Life swiftly passes and who among us can maintain our human form for even a hundred years? Whether I go before others, or others go before me; whether it be today, or it be tomorrow; who is to know? Those who leave before us are as countless as the drops of dew. Though in the morning we may have radiant health, in the evening we may return to ashes. When the winds of impermanence blow, our eyes are closed forever; and when the last breath leaves us, our face loses its color. Though loved ones gather and lament, everything is to no avail. The body is then sent into an open field and vanishes from this world with the smoke of creation, leaving only white ashes. There is nothing more real than this truth of life. The fragile nature of human existence underlies both the young and old, and therefore we must one and all, turn to the teachings of the Buddha and awaken to the ultimate source of life. By so understanding the meaning of death, we shall come to fully appreciate the meaning of this life which is unrepeatable and thus to be treasured above all else . . . —NamoAmidaButsu (I take refuge in the Buddha Amida: Immeasurable Life/Light)

WWW.SFMS.ORG

Reagan Humber, Hospice Chaplain and Bereavement Coordinator, Gentiva Hospice “Rest in peace and rise in glory.” These words have become something of a mantra among Anglicans as a public acclamation following death. This prayer reflects the Christian hope for the person who has just died but also expresses two of our chief concerns when caring for those at the end of life. Our first concern is that we attend to the embodied experience of the person. Is there suffering, physical or spiritual? Through Jesus Christ, we believe that God has fully entered into the human condition, and with this faith, we are called to constantly live out the good news that God is with us, even in the midst of immense suffering. God, who does not cause our suffering, shares in our suffering and therefore we share in the suffering of our fellow humans. Yet our suffering is not what ultimately shapes the meaning of our lives. The labor of our bodies—our pain and pleasure—does not determine the value of our lives. Through Jesus the Christ, God has shared with us that the apparent shape of our life does not determine our fate for all eternity. Through one who appeared to suffer the ultimate shame, God cried out that we are all meant to be at God’s right hand. And so, at death, we proclaim that, though our body may be destroyed, yet shall we see God. Therefore, we embrace the fullness of death’s mystery as a human experience fraught with pain and suffering, and a divine passage into the life of God. “All we go down to the dust; yet even at the grave we make our song: Alleluia, alleluia, alleluia!”

Kaushik Roy, Executive Director, Shanti Project

In the ancient epic The Mahabharata, King Yudishtra is administered a test on morality by the God of Righteousness, which ends with the question, “What is the greatest wonder of human existence?” To which the King responds, “Every day, people look around and observe others entering the abode of death—yet in their heart of hearts, they think that perhaps they somehow will avoid having to enter as well—what could be a greater wonder than this?” The blissful ignorance highlighted above is something to which every person can relate. Yet Hinduism encourages us to cultivate an attitude of fearlessness toward death, because beyond our physical bodies lie our true selves—the Atman, our individual soul, which is eternal and changeless. Human existence is the vehicle through which our soul strives to realize its true nature, “Brahman,” or the cosmic soul. The amazing conclusion Hinduism posits, then, is that each living being, at our eternal core, is divine, and the purpose of our lives is to realize this divinity (or God-nature)! Many Westerners might have some familiarity with the concepts of karma and reincarnation. Our karma is both the cause and result of our actions—the karma from one of our lives dictates our next, and our individual soul continues this evolution from life to life. When the soul identifies more with its gross or physical body, it will suffer through this attachment. Hinduism offers four ways to liberate ourselves from this suffering and realize our true divine nature: selfless acts, rigorous analysis of the nature of reality, devotional love of God, and meditation. When we dedicate our life to the combination of these four methods that is most suitable to our individual temperament, then, and only then, do we hold the key to solving what my Guru would refer to as “the mystery of life and the riddle of death.” APRIL 2015 SAN FRANCISCO MEDICINE

MEDICAL PROFESSIONAL LIABILITY INSURANCE FOR PHYSICIANS BY PHYSICIANS

Our

beats in

Our heart beats in California â&#x20AC;Ś and has for almost 4 decades. Since 1975 NORCAL Mutual has served healthcare professionals throughout the Golden State. Strength, stability and innovative products are just a few reasons why physicians continue to look to us for their medical professional liability insurance. We provide you: Industry-leading claims and risk solutions support 24/7 Full access to our interactive risk management library Flexible coverage options tailored to your needs California is important to us. So is your peace of mind. See how homegrown strength can help protect your practice.

Visit heart.norcalmutual.com or call your agent/broker today. 844.4NORCAL (844.466.7225) ÂŠ 2015 NORCAL Mutual Insurance Company

End-of-Life Care

TRUE HEALING Learning in the Face of Illness Frank Ostaseski A few years ago, while teaching a training on compassionate care to a group of health care clinicians, I began to have heart pain. Like most people, I denied the

symptoms at first. But later others kindly drove me to the hospital, where I had a heart attack in the emergency room. I am alive thanks to the brilliance of health care technology. Miniature endoscopic cameras, catheters passed through arteries, CT scans and sonograms. ACE inhibitors, beta-blockers, enzyme markers, CBC blood draws . . . yes, you too can have “better living through the magic of chemistry.” Long vessels harvested from my leg and mammary arteries now wrap around my heart, redirecting blood flow past a blocked portion of the coronary artery. Surgeons with remarkable expertise skillfully grafted vessels in what could be seen as an elaborate attempt to raise plumbing to a high art form. My sternum was split open, my heart stopped, lungs deflated, I was packed in ice, while machines breathed for me and performed other vital functions. Technology promises me a near complete recovery—in effect a full cure of the body. However. While I was in the hospital I had a conversation with one of my colleagues on the Metta Institute faculty. He asked, “How is the care in the hospital?” I responded, “Well, put it this way—we still have a fair amount of work to do in the world.” At one point in the hospital, after surgery, I lost my stability. I couldn’t concentrate. My mind was like a barking junkyard dog. I got swept up in the fear, pain, and dependency. The mind, heart, and body became confused. Perhaps, like lots of other patients, I started identifying with the anxiety, with my shrinking world. I felt myself getting smaller and smaller. Hospitals have a “fix-it” mentality. They are environments of expectation. There is a protocol for everything and a plan to move you through the anticipated process. Some of this is necessary and even helpful to recovery. However, the emphasis is completely future-oriented. Immersed in such conditions, I found it difficult to stay present. Gradually I lost contact with myself, got swept up in solution consciousness, and joined the predominant mind-set of evaluating my state of being by some external measures. It was a hell realm. I was touched all the time, but rarely was that touch felt as healing. Mostly I was “monitored.” I’m sad to say that they often had more of relationship with the device they were using then they did with me. The staff was so unmercifully driven by tasks and expectations, and those simply got passed on to me. No one asked me how I felt, only where my pain was on a scale of one to ten. Had I had a bowel movement yet? Was I doing my breathing exercises? WWW.SFMS.ORG

Too often, caregivers tend to amplify the patient’s fear or exacerbate the condition of confusion by only focusing on problem solving. In so doing, they may intensify the contraction. Soon the patient, like me, loses contact with their resourcefulness; gradually the person disappears and only the problems remain.

But I don’t heal just through technology. I heal through real relationships. Expressions of love, touch, heart-to-heart conversations, generous listening, the loving attention of friends— these all cultivate and foster relationships. I’ve written before about what I call “helper’s disease”—the ways that we try to set ourselves apart from other people’s suffering. Through our pity, roles, protocols, professional warmth, even our charitable acts. The attachment to the role of helper is pretty old in most of us. If we’re not really careful, if we don’t stay aware, this identity will imprison us—and those we serve. In the chaos of illness, one calm person in the room can make all the difference. In caring for someone who is sick, we use the strength of our arms and backs to move a patient from the bed to the commode. We lend the patient our bodies. If we are wedded to our role as a helper, just fixing the problems without attending to the whole person, we may inadvertently be encouraging the person to see themselves as permanently broken. An old Tibetan Rinpoche, a wonderful Dzogchen master, kindly called the other day. He has had heart problems himself, so I asked him how he dealt with it all—the drama, the confusion, the precariousness, the beauty. He said simply, “Well, it’s good to have a heart . . . and if we have one, we should expect it will have problems.” Then he giggled and reminded me to rest. I thought to myself, “He’s right, it’s true.” All hearts will have problems. We need to accept that truth. I wouldn’t want to trade my heart or its suffering. Without my heart, how would I know all the love that surrounds me now?

Frank Osteseski, the founder of San Francisco’s Zen Hospice Project, the first Buddhist hospice in America, is a Buddhist teacher, international lecturer, and a leading voice in contemplative endof-life care. In 2004, he created the Metta Institute (mettainstitute. org) in Marin County to provide innovative educational programs and professional trainings that foster compassionate, mindfulnessbased care. He has taught at many medical schools, from Harvard to UCSF. To learn how you can study with Frank or with Rachel Naomi Remen, MD, Ram Dass, and the other Metta Institute faculty, visit http://www.mettainstitute.org/EOLoverview.html.

APRIL 2015 SAN FRANCISCO MEDICINE

End-of-Life Care

PHYSICIAN-ASSISTED DYING Why We Support Legalization Robert Liner, MD; Donald Abrams, MD; Marcus Conant, MD “SF woman sues for right to die at home” —San Francisco Chronicle, February 2015

We are San Francisco physicians joining in a lawsuit to recognize “physician-assisted dying” (PAD) as a legal option in California. As briefly as possible, we will explain our

position. We are not attorneys and will not get too deeply into the legal arguments. Similar lawsuits have been filed in other states, legislation to legalize the practice has been proposed in California, and there might be a ballot initiative as well. Canada’s Supreme Court just legalized PAD. So there is much happening regarding this issue. Collectively, we represent almost a century of medical practice, teaching, and research, including as professors and chairs of departments. Probably most relevant is our extensive experience caring for dying patients, including many years during the HIV epidemic when no curative treatment was available. At least one of us has himself faced potentially fatal illness. These professional and personal experiences have certainly influenced our perspectives.

Assisted Dying versus Suicide

One of the bases for our lawsuit is that under the clinical conditions where PAD could be allowed, the term “suicide” does not really apply. The American Psychological Association and others agree that profound differences characterize these behaviors: suicide generally involves a person who could live but, often driven by clinical depression, chooses not to. The PAD patient would want to live if an incurable disease were not killing them; they remain rational and act only to modify the manner and timing in which they die. Most instances of PAD have occurred when patients face a short life expectancy. Despite best efforts at palliation, including hospice care, they find the prospect of death preferable to prolongation of their process of dying.

Medical Opinion

Although the AMA and CMA have long opposed legal PAD, that position appears to no longer be “evidence based.” Starting with a 1989 SFMS survey showing two-thirds support, through many other surveys up to a 2014 Medscape survey of more than 20,000 physicians with 54 percent supporting PAD, it is clear that our profession is divided on this topic. The American Medical Women’s Association, among others, supports legal PAD. Public opinion in favor has also increased, with latest polls showing up to 70 percent support in California. Objection has been voiced by some based on religion and by certain disability groups, but the California Council of Churches has endorsed the proposed legislation and our lawsuit is sponsored by the Disability Rights Legal Center.

Evidence from the States

The U.S. now has many years of “laboratory” evidence from states that have already legalized PAD. In Oregon and Washington, 26

PAD takes place only with strict protocols and “safeguards.” Fears of a slippery slope toward abuse and involuntary death have not materialized. The New England Journal of Medicine noted, “The legalization of assisted death has been associated with substantial improvements in palliative care in Oregon, in areas including the appropriate training of physicians, the communication of a patient’s wishes regarding life-sustaining treatment, pain management, rates of referral to hospice programs, and the percentage of deaths occurring at home.” The then-president of the Oregon Medical Association—which was neutral on the original legalization proposal—later said the law was “a successful experiment” that has “done more good than harm . . .” Ann Jackson, director of the Oregon Hospice Association for more than twenty years, voted against the Death With Dignity Act in 1994 but, having witnessed the benefits, says she would vote for it today.

Policy/Guidelines

As in Oregon, appropriate practice guidelines should include such requirements as a terminal diagnosis, mental competence and informed decision-making, second opinions, and evaluation by pain and psychiatric specialists when indicated. There should be severe penalties for coercion or other violations. Other forms of palliation that abbreviate dying, such as palliative sedation and withdrawal of life support, are considered ethical and legal, yet also involve potential for abuse. PAD has been more closely scrutinized for more than 18 years and offers less likelihood of abuse. Paradoxically but logically, it has commonly been observed that granting the assurance of PAD to a terminally ill patient can actually have the effect of prolonging life. Possessed of a “key to the exit,” these patients are better able to focus on maximizing the quality of life that remains. Yes, the numbers of patients where PAD might be appropriate is relatively small; hopefully it will grow smaller as end-of-life care improves. We are strong supporters of that continual improvement of care and would advocate nothing we felt would harm patients. We do believe in “doing no harm,” but even optimal palliative care has its limits. Ultimately, patients should be permitted to define “harm” and should be in charge of their own final scenes. These are privacy and liberty interests for the Court to consider—further reasons why we feel that patients should have this option, whether they actually use it or not. Robert Liner, MD, retired after forty years of obstetrician/gynecology practice and teaching at Mt. Zion Hospital and UCSF. Donald Abrams, MD, is chief of Hematology-Oncology at San Francisco General Hospital and a professor of clinical medicine at UCSF. Marcus Conant, MD, is UCSF Clinical Professor of Dermatology, Emeritus, provided primary care to more than 3,000 patients who died of HIV/AIDS, chaired the California State Committee on AIDS, and received UCSF’s Chancellor’s Award for Outstanding Public Service. The authors are all SFMS members; the SFMS is not a party in the litigation.

SAN FRANCISCO MEDICINE APRIL 2015 WWW.SFMS.ORG

End-of-Life Care

PHYSICIAN-ASSISTED DYING A Deadly Choice for the Medical Profession Michel Accad, MD When a terminally ill but mentally competent patient wishes to die, should a physician be allowed to bring about this wish? The California legislature is

considering that question, and physicians will soon be asked to weigh in on it. Until recently, so-called “physician-assisted dying” (PAD) garnered little support among doctors. Currently, however, enthusiasm in its favor is growing. What are the reasons given to justify this emerging practice? Do they truly warrant legal sanction? And do they justify an about-face from the medical profession’s long-held stance on this matter? Supporters of PAD claim to be motivated by compassion and respect for patient autonomy.1 Even under such pretexts, however, PAD contradicts the essential role of the physician and confuses the public about the goals and worthiness of the medical profession. To begin with, compassion is a willingness to suffer with patients, not to eliminate them. According to PAD’s proponents, this practice constitutes neither homicide nor suicide, since the patient is predictably dying from a terminal disease. But if that is the case, isn’t the disease, rather than the patient, benefiting from the doctor’s assistance? A physician may believe that PAD compassionately puts an end to the suffering of the terminally ill. Many people also believe in the possibility of an afterlife. Can the doctor involved in PAD assure the patient that well-being will ensue? Obviously not. Shouldn’t this uncertainty, then, be part of the informed consent? Or, if that sounds absurd, isn’t it wiser to leave the timing of death and its aftermath to nature and to one’s God? Doing otherwise necessarily invites an overstepping of established professional boundaries. At times, and with appeal to compassion, supporters of PAD call upon doctors to specifically effect a less agonizing death. There is precedent for this practice. For example, some physicians participate in capital punishment, allegedly to ensure that various lethal infusions are delivered in the least painful manner. But PAD amounts to merely prescribing an overdose of a sedative. Clinical training is unnecessary and physician engagement boils down to what is basically a legal, not a medical, role. To justify PAD under pretext of respect for autonomy is faulty as well. According to surveys, fear of losing control over one’s mind and body, and fear of becoming a burden to others, are the main perceived indignities that prompt some terminally ill patients to seek PAD. But should the doctor agree with these despairing perceptions without applying a measure of objectivity? Hospice care expert Ira Byock has shown that among the terminally ill, fear of burdening others is invariably shortsighted. Families and friends need to tend the dying person as a WWW.SFMS.ORG

material expression of love. Burdensome as it may be, the care provided serves a therapeutic function in the grieving process and provides an unexpected opportunity to heal troubled relationships. Fear of burdening others is therefore subject to change, and the physician can play an effective role in alleviating the patient’s apprehension.2 And whether terminally ill patients are supported by loved ones or not, the compassionate and socially constructive response to feelings of unworthiness is to do everything possible to dissipate those feelings. A physician who validates a patient’s fear of losing control over mind and body implicitly devalues anyone with a serious disability—including the terminally ill. Respect for patient autonomy is essential to a sound patient-doctor bond. It acknowledges that health and disease have a subjective dimension and tempers the prerogatives of physicians who, by necessity, are invested with social or legal authority. As an ethical principle, respect for autonomy has been explicitly promoted since the 1970s, in response to a then-common attitude of “paternalism” that disregarded the patient’s right to choose. But has the pendulum swung too far? PAD now fits an environment in which doctors tolerate the label of “provider” and patient care is increasingly conducted like a mere economic transaction. Under these conditions, “The customer is always right” naturally replaces “First do no harm” as the foremost expression of our professionalism. But when “Your body, your choice” finally rules the day, are there any principles left to be professed? Providing death for the patient invites death for the medical profession. The wave of PAD legalization sweeping the country might well enact poetic justice, allowing the demise of patients who no longer value their lives and of physicians who no longer understand their role.

Michel Accad, MD, FACC, is a San Francisco cardiologist and internist in solo private practice. He is founder and medical director of Athletic Heart of San Francisco, a sports cardiology clinic dedicated to serving the cardiovascular needs of athletes and physically active men and women. He is also assistant clinical professor of medicine at UCSF/SFGH, Division of Cardiology. Dr. Accad is a member of the SFMS and of the editorial board of San Francisco Medicine. The views expressed in this article are his own.

References

1. Compassion and Choices is the leading national organization aimed at making PAD legal in all states. 2. Byock I. Dying Well. New York: Riverhead Books, 1997. Chapter 8. APRIL 2015 SAN FRANCISCO MEDICINE

ADVISORY GUIDELINES FOR PHYSICIAN-HASTENED DEATH A MODEL POLICY DEVELOPED FOR THE SAN FRANCISCO BAY AREA Editor’s Note: In the 1990s, the SFMS hosted BANEC, the Bay Area Network of Ethics Committees, an educational forum for members of hospital ethics committees. When a significant number of members felt that clinical and administrative guidelines for “physician-assisted dying” could be helpful, a subgroup was appointed to draft such guidelines, which were the subject of review by the entire network and at a large conference, and then published in the Western Journal of Medicine in 1997—resulting in front-page stories in the New York Times and San Francisco Chronicle, among others. As this issue is again debated in California, the WJM is no longer in publication, and the contents of the guidelines have been widely cited in subsequent discussion and policy development, it seems a good time to reprint a condensed version here.

ABSTRACT The public’s fear of suffering at the end of life has led to extensive debate about physicians aiding terminally ill patients to hasten their deaths, a practice that has long occurred underground, without scrutiny or standards in place by the medical community. In attempting to provide a pragmatic response from the medical profession and adopting a “harm reduction” perspective on this contentious topic, the Bay Area Network of Ethics Committees undertook the task of developing practice guidelines for responding to requests for a hastened death, to be offered to the local medical community for use by individuals and health care institutions should this practice become legal. A multidisciplinary consensus process was utilized in developing the guidelines, which address clinical, ethical, and procedural concerns related to physician-hastened death. BANEC offers these guidelines in response to the potential for such patient requests.

BANEC-generated Guidelines for Comprehensive Care of the Terminally Ill

Note: These guidelines are intended for use regardless of the patients’ residence—home, hospital, hospice, clinic, or extended care facility—as they approach death.

Principles I. The ultimate responsibility for the care of the patient, per-

taining to end-of-life decisions and treatments, resides with the patient’s physician.

II. The primary care physician is qualified to provide appropri-

ate care, with or without consultation, for the great majority of patients who are dying.

III. The care of patients experiencing “difficult deaths,” those undergoing (in their judgment) intolerable or prolonged suffering as they die, or patients who are making complex and irre28

versible decisions about end-of-life care (including the decision to hasten death), may fall out of the range of skills of many primary care physicians. Hospice programs have extremely effective teams which provide medical care and help patients with their decisions about end-of-life treatments. Certain physicians in the medical community are also recognized to have special expertise in palliative, end-of-life care. For those patients who face difficult deaths, or those who are making complex and irreversible decisions about terminal care (including a request for physician aid in hastening their death), THE BANEC GUIDELINES URGE REFERRAL TO A HOSPICE PROGRAM AND/OR CONSULTATION WITH A PHYSICIAN EXPERIENCED IN PALLIATIVE CARE (including, but not limited to, pain control). Many patients, given appropriate and skilled palliative end-of-life care, will withdraw their requests for a hastened death.

IV. At times, in spite of skilled physical, psychological, spiritual, and social care, an adult, mentally competent and terminally ill patient will desire a physician’s aid in hastening death.

V. These guidelines urge that, before a physician aids a patient to hasten his or her death, the following occur (with specific documentation in the patient’s hospital chart and/or outpatient medical records):

Note: No physician, nurse, physician-assistant, pharmacist, or other health care worker is required to participate in the act of hastening a patient’s death, nor in the patient’s evaluation for such an act. However, these guidelines recommend that practitioners who exclude themselves from such participation respond to a patient’s request for a hastened death by advising that patient of his or her right to obtain consultation from other practitioners, and/or facilitating the transfer of care should the patient so request.

Chart documentation should include: A. The primary care physician’s ascertaining of:

1. The terminal diagnosis (a reasonable certainty of death within six months provided the disease runs its expected course, ascertained by review of the medical records and pertinent history and physical examination). 2. An assessment to confirm that, in the best judgment of the physician, the patient is mentally competent and not suffering from a depression that impairs decision-making capability. (IT IS HIGHLY RECOMMENDED THAT PHYSICIANS NOT EXPERIENCED WITH SUCH AN EVALUATION SEEK APPROPRIATE AID, WITH THEIR PATIENT’S CONSENT, FROM OTHER PRACTITIONERS IN THE MEDICAL, PSYCHOLOGICAL, AND/OR SOCIAL SERVICES COMMUNITY.) 3. That high-quality palliative care, by hospice and/or a physician recognized to have expertise in palliative care, has been made accessible to the patient. 4. That, to the best of the physician’s knowledge, the pa-

SAN FRANCISCO MEDICINE APRIL 2015 WWW.SFMS.ORG

tient’s choice to hasten death has been freely made, independent of financial, family, health insurance, or other coercion.

B. A second opinion to confirm the four points noted above by the primary care physician. These guidelines strongly recommend that the second opinion be obtained from a physician recognized to have expertise in palliative end-of-life care.

C. Documentation of the patient’s evaluation by a hospice program and/or physician with palliative care expertise (this can coincide with the second opinion noted above). Documentation should also be made of the palliative-care recommendations resulting from this evaluation, and the ways in which they have or have not been followed. Alternately, documentation should be made that the patient declines an evaluation for improved palliative care. These guidelines recommend that these patients sign a form to indicate an understanding that they have waived a medical evaluation that could offer care with significant potential for improving their quality of life as they die.

D. The patient has been counseled that a decision to hasten death should, if at all possible, be discussed in detail with family members, loved ones, and others who are likely to be significantly affected by this decision. The patient has also been counseled that the hospital and hospice medical ethics committees are available and willing to discuss his/her care, and the decision to hasten death, with the patient and/or family.

E. A witnessed consent form should be signed by the patient, to include full disclosure of the illness, the procedure to aid the patient in hastening death and the associated risks, and a statement that other medical options exist (including hospice care) that might provide further comfort without hastening death. The witnessing procedure should be in accordance with that now established for the signing of a Durable Power of Attorney for Health Care Decisions, i.e.: “(1) Two qualified adult witnesses who are personally known to the patient (or to whom the patient provides evidence of his/her identity), and who are present when the patient signs and acknowledges the signature, or (2) acknowledged before a notary public in California. If the witness is other than a notary public, the law provides that none of the following be used: (1) a health care provider or an employee of a health care provider, (2) an operator or an employee of a community care facility or residential care facility for the elderly. Additionally, at least one of the witnesses cannot be related to the patient by blood, marriage, or adoption, or be named in the patient’s will. For patients in a skilled nursing facility, one of the witnesses must be a patient advocate or ombudsman.” For patients and/or witnesses who are not able to understand the consent form in English, the forms will be provided in a language they can understand, or the signatures should be accompanied by that of a competent translator. F. A second witnessed signature by the patient must be ob-

tained, no sooner than 48 hours after the first signature.

the right, at any time, to change his or her mind and to return to care that includes the involvement of a hospice team or another physician experienced in palliative care.

H. Chart documentation that the physical process of hastening death was initiated and completed by the patient: These guidelines emphasize that the physician may aid the patient in the process of hastening death (i.e., by provision of oral or injectable medication, or the starting and maintaining of intravenous access), but it should be the patient’s own physical effort that initiates and completes the process. Note: In the BANEC discussions of this document, a significant minority felt that section H draws an artificial mechanical boundary between a “patient-initiated” hastened death and a physician’s act of administration of drugs once other guideline recommendations have been met. However, the final BANEC guidelines reflect this limitation and refer only to a “patient-initiated and -completed” process.

I. These guidelines emphasize that, although it is the patient

who undertakes the proximate action that leads to the hastened death, a physician or the physician’s designee responsible for the care of the patient should remain immediately and continuously available to the patient and family until death has occurred.

J. The cause of death on the death certificate should be listed as the underlying disease.

K. Reporting: These guidelines urge that a system similar to that of the California Tumor Registry (including the confidentiality of information) be established to which all cases of physician aid in the hastening of a patient’s death be reported. This registry would be able to request, for review, the full medical records of the patient, including details of the hastened death. The registry should track complete demographic information and issue an annual report detailing its findings. This report should be accessible to the public. It is also recommended that existing hospital, hospice, and community clinic peer-review organizations include cases of aid in hastening deaths in their mandate of review. Continued on the following page . . .

Original Source Heilig S, Brody R, Marcus FS, Shavelson L, Sussman PC, et al. Physician-hastened death: Advisory guidelines for the San Francisco Bay Area from the Bay Area Network of Ethics Committees. West J Med. 1997 June; 166:370-378.

Resources

See checklist for physician use in assisted death cases on the following page.

G. Before aiding the patient in hastening death, there should be chart documentation of verbal counseling that the patient has WWW.SFMS.ORG

APRIL 2015 SAN FRANCISCO MEDICINE

Continued from the previous page . . . PHYSICIAN CHECKLIST IN ASSISTED DEATH CASES (to be completed before the hastening of a patient’s death) Patient’s name: ____________________________ Physician’s name: __________________________

Prior to assisting in the death of a patient, please confirm the following: • The patient is an adult resident of California. • As the patient’s physician, I am well aware of the patient’s medical history, condition, diagnosis, and prognosis. • The patient’s condition is terminal, with death otherwise expected to occur within six months of this date. • A second physician has confirmed this terminal diagnosis. • The patient is mentally competent and able to exercise rational thought processes in making decisions regarding their health care. • High-quality palliative care, by hospice and/or physicians qualified to provide such care, has been offered to the patient, with full understanding that such care might result in an improved quality of life in the patient’s remaining days. • If such care has been refused by patient, such refusal has been documented by signed consent form. • To the best of the physician’s knowledge, the patient’s choice to die has been freely made, independent of financial, family, health insurance, or other sources of coercion. • The patient has been offered consultation with an ethics committee. • The patient has been offered counseling by a psychiatrist, therapist, social service worker, clergy, or other. • The patient has been counseled to discuss his/her decision with any family members, loved ones, or others who will be affected by this decision. • The patient has made the required two signed, witnessed requests, at least 48 hours apart, for a hastened death. • The patient has been offered appropriate means of ending his/her life, with full disclosure of the process, pros, and cons of each, and has made an informed choice of which intervention will be utilized. • At the time of the procedure, the patient is still competent, has made a third, final request, with witness(es) present, and has been advised that the procedure may be halted at any time upon the patient’s request, with a return to optimal palliative care as an option. • A health care professional (physician or nurse) with expertise in this area has been identified who will remain immediately and continuously available to assure that distressing symptoms are minimized via appropriate palliative means.

Following death, the usual confirmation and reporting requirements are in effect, with the addition of the reporting form for physician-assisted death.

NARRATIVE SECTION (OPTIONAL): PLEASE UTILIZE THE BACK OF THE FORM AND/OR ADDITIONAL PAGES TO ADD ANY COMMENTS DEEMED APPROPRIATE REGARDING THIS PATIENT’S CASE.

POLST: New and Improved Policy Coming—Thanks to SFMS The CMA is now sponsoring AB637, which “would authorize the signature of a nurse practitioner or a physician assistant acting under the supervision of the physician and within the scope of practice authorized by law to create a valid POLST form.” This, we can confidently say, is the result of the SFMS delegation to the CMA, and the hard-fought battle to have the resolution below adopted. We feel it speaks for itself. —Steve Heilig, MPH Increasing Use of POLST Orders San Francisco Medical Society Adopted by the California Medical Association, December 2014

Whereas, the Physician Orders for Life-Sustaining Treatment order form is showing itself to be a useful advance directive for decreasing treatments unwanted by patients with life-threatening conditions; and Whereas, the requirement that a physician must review and sign every form prior to it being valid results in delays in implementation and less use overall, with attendant provision of unwanted treatment; and Whereas, in many cases the POLST-related discussion and counseling is carried out by a nonphysician clinician such a nurse or physician assistant, when a patient is being transferred from the hospital and the attending physician is not present and in settings such as the home or long-term care where the physician is not as often present; and Whereas, some states allow such clinicians to complete and sign the form, where the form is called MOLST (Medical Orders for Life-Sustaining Treatment), or COLST (Clinician Orders for Life-Sustaining Treatment), and several other states which have kept the name but allow APNs and physician assistants to sign the form with MD confirmation; and Whereas, allowing nurse practitioners and advance practice nurses to complete and sign the forms in discussion with patients would allow for better use, better care, and less administrative work for physicians; and Whereas, physician leaders in states where RNs and/or NPs can “POLST” patients do not report care problems or “scope issue,” and in this state, the majority of members of a statewide POLST-promoting committee endorse this change; now be it RESOLVED: That to improve use of Physician Orders for LifeSustaining Treatment (POLST) forms, CMA will advocate for the policy used in other states that appropriately trained nurse practitioners/advance practice nurses and physician assistants be authorized to complete and sign POLST orders, with review by the patient’s supervising physician as appropriate, for any patients unless otherwise specified by physicians or medical staff policies.

Physician’s signature____________________________ Date__________ 30

SAN FRANCISCO MEDICINE APRIL 2015 WWW.SFMS.ORG

End-of-Life Care

THE LONE RANGER IS DEAD On the Need for Teamwork in End-of-Life Care William Andereck, MD Every year at about this time, I look over the ethics consultations that were requested during the previous year by the doctors, nurses, social workers, and patients at CPMC. Today I see something new.

It’s been around for a while, but always in the background. Now it’s becoming the elephant in the room. It shows up looking something like this: The patient is a seventy-eight-year-old gentleman, with a past history of outstanding health, who suffered a severe heart attack while walking in the park. Subsequently he has developed kidney failure and lung failure, requiring support with a respirator and dialysis machine. His family is gathered outside the intensive care unit. They understand the seriousness of his condition but are fixed on any positive news. Each day there is a parade of specialists. Kidney doctors, lung doctors, cardiologists, neurologists, hospitalists, and intensivists all weigh in. Each doctor puts a slightly different spin on the discussion, oftentimes dependent on the organ they are representing. How can the family make any decisions about the treatments being offered to our patient if they can’t seem to get a consistent message from the myriad of caregivers, each expressing their independent opinions? Someone suggests the ethics consultation service be called to help the family understand their situation. In situations like the case described above, the first goal of the ethics consultant is to bring the multiple specialists into the same conversation about what the best approach is for this particular patient. This shared conversation usually results in a unified treatment plan, which is agreed to, at least in part, by all members of the medical team. When all is going well, a single physician will step up to become the primary spokesperson for the medical team, relaying information from all specialists through one source. We have found that ethics consultations don’t just end with the initial recommendation. Forging a consensus for treatment of this difficult patient can be just the beginning. The problem begins to crop up on Friday morning and becomes more noticeable as the day wears on. The best-laid plans of doctors and surrogates are about to be thrown in the tumbler, and reanalysis is in order. Next week, a different set of doctors will take over the management of the case. This new cast is equally bright, well intentioned, and communicative, but, in so being, they also immediately launch into their own treatment plans, often disregarding the difficult decisions hammered out last week. One result is the lack of continuity inherent in a complicated medical situation involving multiple decision makers, especially when different individuals are stepping in and out of critical roles. When I started my career at CPMC, things were differWWW.SFMS.ORG

ent. Think back to the old times, to Marcus Welby or Hawkeye. There was always the “attending”—that senior physician who had known the patient for years and was trusted by the family, a physician who took “ownership” of the patient. All big decisions were deferred to the physician who took ownership. Currently, we’re all having trouble figuring out who, among the many names in the record, the “attending” really is. Is it the hospitalist who admitted the patient through the emergency room, the head of the ICU who is now rounding on the patient, the cardiologist who has managed his heart condition? No one seems to have known the patient before they were admitted and, since that moment, the patient’s life has become dramatically different than it was before. Two things have happened. First, the doctor whom the patient has seen as an outpatient is missing from the scene during hospitalization. Relegated to the derogatory term of PCP (primary care provider), the outpatient doctor is invited to observe, but not direct, nor to bill for any time spent. Few doctors take the hospital up on this offer. Secondly, physicians, called hospitalists, are now directly responsible for your hospital stay. They are well trained in disease management and treatment. They are hampered, however, by their lack of knowledge of each individual’s personal perspective. Some are masters at quickly making a personal connection; others less so. The nature of their job at CPMC allows them to rotate on and off service. To the patient, this means a different doctor can take over at any time.

Each well-meaning doctor feels a responsibility to do his or her best for the patient. But I contend that the individual doctor assuming the care of a complex case must assume the previous decisions made by the treatment team that preceded him or her. The days when the patient’s personal physician would march into the hospital in the morning like the Lone Ranger, writing orders to be carried out while he or she went back to the office, are long gone. The current level of sophistication in the modern hospital is far too advanced to allow us to think anyone can manage it on horseback. Cooperation and teamwork are necessary to make it work in the hospital of the twenty-first century. There is a new responsibility for physicians and other medical professionals, something to be valued and promoted, arising from our new methods of health care delivery. That responsibility needs to be articulated. I am proposing a new moral respon-

Continued on page 34 . . .

APRIL 2015 SAN FRANCISCO MEDICINE

MEDICAL COMMUNITY NEWS Saint Francis Robert Harvey, MD

While Dignity Health Saint Francis Memorial Hospital provides the full gamut of excellent health care services, our Emergency Department (ED) and the Bothin Burn Center are distinguished by the volume of patients they care for and the range of services they provide. Given our central location in San Francisco, our ED is a first stop for urgent care, with more than one thousand 911 ambulance patients seen monthly. Saint Francis is also an around-the-clock entry point for diagnostic services, treatment, and inpatient care for a diverse patient population ranging from the residents of the neighboring Tenderloin to international tourists. Dr. Joanne Sun, ED medical director, along with Drs. Lucia Chen-Lustig, David Dallafior, Robert Kim, John Rampulla, and Jim Shieh, lead a team of physicians, nurses, and support staff to deliver timely and efficient care. Most patients are seen by a provider within less than thirty minutes from arrival. We also offer InQuicker, an online scheduling service where patients with emergency care needs can schedule an estimated treatment time prior to coming into our emergency room. Along with a masterful medical team and excellent service, Saint Francis’s ED features an upgraded facility equipped with state-of-the art technologies for airway and respiratory support, cardiovascular support, and ultrasound. Such caliber of care is also found in our Bothin Burn Center, with Dr. Jeffrey DeWeese serving as the center’s medical director, assisted by Dr. Richard Grossman. Recently, the center was given a second verification from the American Burn Association (ABA) and the American College of Surgeons (ACS). Achieving verification is no small feat. A burn center must meet strict standards for organizational structure, personnel qualifications, facilities resources, and medical care services. Participating in the rigorous assessment is voluntary, and the Bothin Burn Center has met the challenge every three years for the last eighteen. It confirms that we provide high-quality patient care to burn patients, from the time of injury through rehabilitation. 32

St. Mary’s

Robert Weber, MD

In today’s evolving health care landscape, where innovation, research, and the changing health care market drive much of the industry conversation, one may question how the art and science of compassion, particularly palliative care, fit in the modern era. In a way, today’s changing health care environment validates the critical importance of palliative care. Health care technology breeds new interventions in the way we treat medical conditions and diseases. Patients have a menu of treatment interventions to consider with their medical team, which sometimes causes patients to feel confused, stressed, worried, and a myriad of other emotions that may counteract the healing process. Moreover, such decisions about what interventions to use, and how much, become even more difficult when the prognosis is poor despite all our best efforts and optimal medical care. At St. Mary’s, we appreciate the role that our Palliative Care Department plays in the overall patient experience. For our hospital, the comprehensive palliative care we provide translates into improved HCAHPS survey scores and reduced readmissions. For our patients and their families, the department’s dedication to providing compassion and counseling during what can be the most difficult times in life is just as essential as the medicines, devices, and medical expertise that are part of the treatment plan. St. Mary’s patients have a full team of physicians, nurses, social workers, case managers, chaplains, and therapists, in combination with palliative care specialists, to help them and their families make difficult treatment decisions. Our palliative care specialists can help patients better understand their condition, manage symptoms, clarify expectations of current and future interventions, and explore what are the most important aspects of living with a serious illness. One fear many patients experience is being alone and unsupported. However, St. Mary’s Palliative Care partners with community agencies to provide the continuum of support for our patients through end-of-life care in a team-based, patient-centered environment that remains understanding and kind.

CPMC

Edward Eisler, MD

In early March, twelve patients participated in a rare, two-day, six-way kidney paired donation transplant at CPMC. Physicians here believe this procedure was the largest single-center kidney paired-donation chain conducted on the West Coast and the largest conducted in the forty-four-year history of the CPMC Transplant Center. The six-way donor and recipient matches were identified using BiologicTx Paired Donation kidney matching software called MatchGrid. MatchGrid is a sophisticated algorithmic program that enables multiple incompatible pairs to be matched with each other. The software was created by David Jacobs, who came up with the idea after he underwent a kidney transplant at CPMC in 2003. Dr. Martin Brotman, senior vice president of Education, Research, and Philanthropy for Sutter Health, has been awarded the California Hospital Association’s (CHA) 2014 Honorary Membership, in recognition of his forty-plus years of caring for patients in the San Francisco area. An interest in health care administration led him to CPMC, where he served as president and CEO from 1995 to 2008. Dr. Brotman currently serves as a board member of the CPMC Foundation, is a clinical professor of medicine at the University of California, San Francisco, and is chair of the American Gastroenterological Association Foundation. The Sutter Health organization will officially change from five regions to two new operating units (Valley Area and Bay Area). Each operating unit (OU) will be led by a president who will be part of a senior-leader partnership with an operating unit physician executive. The OU president will be responsible for translating system-wide strategies and priorities and overseeing their implementation and for partnering with physicians and other clinical leaders across the operating unit to ensure a seamless patient experience. The OU physician executive will also provide strategic clinical leadership for operations and serve as a key contact for our clinical partners, helping streamline their interactions with Sutter Health.

SAN FRANCISCO MEDICINE APRIL 2015 WWW.SFMS.ORG

Kaiser

Maria Ansari, MD

Palliative care is an area of medicine that has been gaining momentum for several years and one that we feel addresses a critical component to the well-being of our patients. We view our approach as an extra layer of support for patients and families with serious or chronic conditions, and it can include managing physical symptoms associated with an illness, addressing some of the emotional burdens, focusing on caregiving needs, and helping plan for “what ifs” as diseases progress. At Kaiser Permanente San Francisco, we’re currently rolling out a regional initiative at our medical centers called Life Care Planning, which is an evidenced-based model for helping patients and their co-medical decision makers plan for the future. Our goal is for all patients to have the opportunity to express their wishes regarding the type of care they will receive as they approach the end of their lives, so that health care providers can honor these wishes. In seeking to provide the best care possible for our patients, we have established wellcoordinated interdisciplinary inpatient palliative care teams, consisting of board-certified physicians, palliative care-certified RNs, social workers, and a chaplain. At present we are seeing about 80 to 100 new consults per month. In January 2015, we began, for the first time, seeing patients in an ambulatory setting called the Supportive Care Clinic, which is currently exclusive to oncology patients. Looking to the future, we are expanding our outpatient presence and hoping to work more with certain “high-risk” populations such as patients on (and considering starting) dialysis, patients with dementia, and patients with worsening heart failure. We are also hoping to expand our current home-based primary care system to include physician visits. We feel this is an excellent opportunity to begin some of these conversations in peoples’ homes, where they are most comfortable.

WWW.SFMS.ORG

SPMF

SFVAMC

Bill Black, MD, PhD

C. Dianna Nicoll, MD, PhD, MPA

At the core of our profession is the ability to treat our patients compassionately and honestly. Certainly that can be difficult when physicians are caring for terminally or severely ill patients and their families. Last fall, Sutter Pacific Medical Foundation (SPMF) partnered with Sutter Health’s California Pacific Medical Center Foundation and the Division of Graduate Medical Education at California Pacific Medical Center (CPMC) to expand our Palliative Care Division and start a new palliative care rotation for internal medicine residents. A former CPMC resident, Shoshana Ungerleider, MD, was instrumental in helping create the comprehensive palliative care education program. A team of clinicians from CPMC’s Department of Behavioral Health, along with Catherine Seeley, MD, SPMF director of palliative care, and Monica Rosenthal, MD, SPMF palliative care educator, developed a three-part program designed to strengthen residents’ skills in and capacity for working with severely ill patients. Residents spend half of a two-week rotation receiving oneon-one training in communication skills, learning from health psychology fellows and faculty. The residents’ communication skills are assessed by watching them interact with a simulated patient, practicing delivering bad news, and then discussing goals of care. The residents also participate in didactic sessions covering palliative medicine and shadow clinicians to observe communication skills. A separate part of the program focuses on promoting self-care skills that a resident needs when dealing with an emotionally charged situation. “It’s hard to be honest when you are sharing news that is difficult to hear or say, so the best way to help our physicians is to help them take care of their own emotions,” says Dr. Seeley. In this part of the program, facilitated by Dr. Rosenthal and by Joule Adler, MD, SPMF Department of Psychiatry, all residents meet regularly throughout their three years of training to discuss challenging situations they encounter. They collaboratively develop strategies to handle such situations in a way that fosters their own wellness.

The Hospice and Palliative Care service at the San Francisco VA Health Care System (SFVAHCS) aims to address the full spectrum of quality-of-life needs for veterans facing advanced illnesses, including symptom management needs, emotional and psychological support, family support, advance care planning, spiritual well-being, and helping veterans and families make difficult decisions about their medical care. Our Medical Center’s goal is to ensure that veterans and their family members have access to palliative care services at any point from the time of diagnosis or recognition of a serious illness, whether or not they choose to continue disease-modifying treatment, such as chemotherapy for cancer. In order to achieve this goal, SFVAHCS has been a national leader in developing innovative programs to improve access to palliative care. For veterans who are living in our community and are newly diagnosed with a serious illness, the SFVAHCS has embedded palliative care within primary care and specialty clinics. This palliative care consult clinic is staffed by an interprofessional team that includes a physician, nurse practitioner, and social worker who have specialized training in relieving pain, managing symptoms, and reducing the stress of serious illness. This clinic operates throughout the week to meet veterans where they are, working in collaboration with the veterans’ primary care providers and other specialty providers, such as those in oncology and liver clinics. For those veterans who are hospitalized within our Medical Center, we offer a palliative care inpatient consult team. This service sees patients at the highest risk of morbidity and mortality, including two-thirds of inpatient Medical Center deaths. In addition, for those veterans who are near the end of their lives, the SFVAHCS offers a ten-bed inpatient hospice unit to provide holistic, patient-centered care in the last months of life.

APRIL 2015 SAN FRANCISCO MEDICINE

UPCOMING EVENTS

The Lone Ranger is Dead Continued from page 31 . . . sibility for doctors, working in hospitals, to act as members of a team rather than as autonomous agents. This is a fundamental shift in what most of us, as physicians, think of as our primary duty. How can we think that what we see as best for the patient could become subservient to the goals already established by the physicians who came before? Giving up our rescue mentality and the aura of the Lone Ranger will not come easily. The complexity of the task will make it necessary, however. The challenge ahead is to maintain a level of personal continuity that maintains patient trust in the treatment team as a unit. To our fiercely independent medical practitioners, there is a lesson to be learned from the National Basketball Association. No matter how many superstars you have on your side, you cannot win unless they all work together as a team. Once we have a team in place, it is still necessary to identify the coach who leads and takes personal responsibility for making the best medical decisions consistent with the patient’s goals. This is the future, but it is already here. William Andereck, MD, is an internist and is codirector of the Program in Medicine and Human Values at Sutter Health, chair of the ethics committee at CPMC, and a former editor of this journal.

Breathe Again !! CALIFORNIA SINUS CENTERS & Institute We CARE for: Bacterial Infections / Sinusitis Culture directed treatment Functional Endoscopic Sinus Surgery Orbital Decompression / Graves’ Disease Image Guided Surgical Navigation Revision - complex cases Frontal Sinusitis Advanced Endoscopic Techniques Sinuplasty Sinus Surgery WITHOUT packing Nasal Obstruction / Septoplasty Allergic Fungal Sinusitis Sinonasal Tumors / Polyps Smell / Taste problems CSF leak repairs Mucoceles / Abscesses In-Office CT Scanner Urgent appointments Joint care: ENT - Allergy Pulmonary

Atherton (Stanford area) Walnut Creek (East Bay) San Francisco (Union Square) Winston Vaughan, MD Karen Fong, MD

CA-Sinus.indd 1

Kathleen Low, NP

Sacramento / Sonoma / Fresno

www.CalSinus.com

4/26-27: California Immunization Summit | Mission Inn Hotel in Riverside | The California Immunization Summit is an opportunity for physicians to learn about community-based programs that have increased vaccination rates, and how to adapt and apply key lessons from successful programs. This year’s program, “Ready, Set, Vaccinate!” includes keynote speaker William L. Atkinson, MD, MPH, Immunization Action Coalition Associate Director for Immunization Education. Other summit presentations and workshops will focus on vaccine communication, effective communication without confrontation, immunization law and public policy, and addressing parents’ concerns regarding the personal belief exemption. Visit http://conta. cc/1Irkd6N for event details. 4/28: Operation Access Bridging the Healthcare Gap Breakfast April 28, 8:00 p.m. to 10:00 a.m., City Club of San Francisco | Operation Access’s annual Bridging the Health Care Gap Breakfast honors that longstanding tradition of caring by celebrating the volunteer champions and partners who make good health possible for those in our community who cannot obtain insurance. This board-hosted event raises funds to support Operation Access’s surgical response programs that serve more than 1,000 community clinic patients each year in all nine counties of the Bay Area. For event information or to purchase tickets, please visit http://conta.cc/19LKX6s.

5/13: CMS Value-Based Payment Program Seminar | 6:00 p.m. to 7:30 p.m., Morrissey Hall at St. Mary’s Medical Center | All Medicare Part B physicians, including those participating in Medicare Accountable Care Organizations and other Centers for Medicare & Medicaid Services Innovation Center Models, will need to comply with CMS’ value-based payment (VBP) program in 2017. Gain an understanding of the VBP program and learn best practices on transitioning your practice to the new payment model at the SFMS May seminar. Keynote speakers David Saÿen, CMS Region IX Administrator, and Ashby Wolfe, Chief Medical Director of the San Francisco Regional Office, will discuss Medicare’s efforts to improve the quality and efficiency of medical care and provide actionable information to assist physicians with VBP adoption. The seminar is free and open to all SFMS members. Space is limited. Please RSVP to Ariel Young at ayoung@sfms.org or call (415) 561-050 x200.

5/29-31: Western Health Care Leadership Academy | May 29-31, Loews Hollywood Hotel, Los Angeles | The 18th Annual Western Health Care Leadership Academy continues its mission of providing information and tools needed to succeed in today’s rapidly changing health care environment. Hear from the experts and leaders of change, and attend a comprehensive slate of practice management seminars and workshops to position your practice for success. This year, attendees will have the opportunity to meet and interact with the program’s keynote speakers—New York Times best-selling author Malcolm Gladwell and Pulitzer Prize-winning science writer Siddhartha Mukherjee, MD. Visit http://www.westernleadershipacademy.com/ for event details.

11/15/13 2:54 PM

SAN FRANCISCO MEDICINE APRIL 2015 WWW.SFMS.ORG

Time to go shopping... ...for a better deal on workers’ compensation.

There has never been a better time to shop the sponsored workers’ compensation plans offered through the San Francisco Medical Society/CMA. That’s because workers’ compensation insurance rates in California continue to move upward. The Insurance Commissioner recommended an increase of 6.7% in pure premium rates for 2015 compared to the average premiums charged as of July 20141. Your plan may experience a higher or lower rate increase than recommended by the Department of Insurance. Don’t just sit back and accept higher rates! Call Mercer to see if you can get a better deal through the San Francisco Medical Society/CMA. Working with Mercer as the program administrator, the Society sponsors best-in-class insurance plans at competitive premiums. By becoming involved with the sponsored plans you will receive valuable protection for your practice and employees while supporting the good work of your Society! Take control of your workers’ compensation costs. Call 800-842-3761 now for your free, no-obligation quote. Or visit www.CountyCMAMemberInsurance.com for more information and to download an application or premium indication form.