Tuesday, September 21, 2010

One Failing of POLST - "Full Treatment" is Needed for All Patients

Medicine is much like politics. Both fields have an affinity to condense complicated multifaceted issues into value-laden phrases that add no actual value.  These phrases permeate every discipline in medicine, and, as seen in politics, can change the way people view issues (ie. incentivizing doctors to have advance care planning discussions with patients being transformed into a simple phrase - death panels).  Below are just several examples of value-laden yet valueless phrases in medicine and the reasons we use them:


  • Failure to Thrive: an expression of linguistic laziness in which the provider is too busy to express the underlying issues such as depression, weight loss, or mobility issues.  In adult medicine, it is only used in describing a constellation of symptoms in the very old in the hopes that no further investigation is needed, often with stunningly great success in its implementation. Antonym: acromegaly
  • Withdrawal of Care: an expression of extreme self-doubt as a healer in which the provider of care conveys a feeling that only treatments that are focused on cure can truly be considered care. The effect: family members feel abandoned if they choose anything but invasive life prolonging interventions. Antonym: "Full Treatment”.  
  • Full Treatment: a phrase communicates that anything less than intubation, defibrillation, a-lines, peg tubes, and rectal tubes would constitute less than full treatment. A phrase that assumes that aggressive symptom management in home hospice from an interdisciplinary team of nurses, social workers, case managers, chaplains, and volunteers would be less rather than more treatment than in a hospital setting. A phrase that is fragment of a concept - waiting desperately for someone to add its relation to a goal (full treatment to ensure that he/she is without pain or suffering? Full treatment to ensure that he/she makes it to the birth of his granddaughter?). Antonym: Comfort care (which I won’t define as I’m not sure exactly what it is).  Usage: see POLST section B

Why do we medical types love these words? Why do I hear the words “withdrawal of care” all the time in the ICU? Why is “Full Treatment” part of the POLST form - the very form that I hailed as the best thing since sliced bread in a previous post (I still think that way about the POLST despite this rant)? A classic children’s book, Fish is Fish by Leo Lionni , gives us a clue. Here is a summary (warning - spoiler alert):
Two friends, a minnow and a tadpole, are inseparable until the tadpole grows into a frog and leaves the pond to explore the world on land. When the frog returns to tell his friend of the extraordinary things he’s seen, the minnow, now a fish, imagines the animals that the frog is describing. The fish, though, can only comprehend these animals as taking a fish-like form (a bird is imagined to be a fish with wings).  The lesson – people construct new beliefs/knowledge/skills based on their current beliefs/knowledge/skills. 

“Withdrawal of care” and “full treatment” are both relatively new concepts with good intentions, however they are derived from traditional models of what "treatment" and "care" means. The traditional models are still the basis for most of our beliefs and govern most of what we do in medicine, including how health care providers are reimbursed. If a physician can bill handsomely for it, than, as you can pretty much guess, it probably would be included as "care" or as a "treatment". If not, like a social work or chaplaincy visit, than it probably wasn’t important anyway and shouldn't be considered "care".

The truth for patients though is much different than the reality that our health care system attempts to create.  Fully treating patients requires that we attend to the physical, social, psychological, and spiritual needs of both the patients and their loved ones.  This care is more likely to occur in programs like hospice or PACE that have wandered away the stagnant pond of the traditional health care model.

So how can we avoid value-laden phrases that add no value? Fort a start, it would be helpful if we stopped adding them to important end-of-life documents.  This wouldn't be so hard. For instance – here is section B of the POLST form with and without a pithy phrase (see picture for full POLST form):
[] Full Treatment: Includes care described above. Use intubation, advanced airway interventions, mechanical ventilation, and cardioversion as indicated. Transfer to hospital if indicated. Includes intensive care.
[] Include all care described above. In addition, use intubation, advanced airway interventions, mechanical ventilation, and cardioversion as indicated. Transfer to hospital if indicated. Includes intensive care. 

Now which one of these two options did you think tells you more about someone’s treatment preferences? If you answered “they are both the same” than the addition of the phrase “Full Treatment” is at best a waste of ink. If you thought the addition of “Full Treatment” gave you a better idea of what a person would want then we have a much bigger problem than our domestic ink supply. 

by: Eric Widera

11 comments:

Alex Smith said...

Acromegaly - Ha! Love it!

If we're going to pick on "Full Treatment" then we should also pick on "Comfort Measures Only." Meaning: we will deprive or deny you treatment. Antonym: Continuous CPR. Better term: at the Brigham we said "Intensive Comfort Measures."

Eric Widera said...

Good point Alex. I think the main point of my post was really to address the importance of words, any words, and how we can better frame issues to patients and their loves ones when making these decisions.

I posted it within 12 hours of hearing Angela Fagerlin from University of Michigan talk about the power of numbers and how we can frame risks and benefits in unbiased ways (thanks for the invite Alex). I actually dont know if someone is looking into the words and labels we use in advance care planning, and whether there would be a better way to describe the three options as a short phrase that limits bias (or whether we should just use the actual descriptor paragraph). Anyone know?

Also, does anyone have a better label than Full Treatment?

ken covinsky said...

When I was shopping for a new television last month, I presented my television insurance card to the salesman and was told in return for my deductible, I could either have the basic model (audio only, do not turn on picture), the limited model (do not provide color) or the full model (Full color, off button disabled). Of course I chose the full model. Why would I want anything less?

We do need to think about the message we may be unintentionally sending with terms like "full treatment." Kind of sounds like the best treatment.

Cyndi, RN, OCN, PCRN said...

How about "Aggressive Curative Care" vs "Aggressive Collaborative Noncurative Care"?

But I like the idea of just descriptions without "tags"...
When you try to stuff something into a little box, sometimes the lid just doesn't close right...

Lyle Fettig, MD said...

Eric,

Thought provoking post.

I’d be curious how the use of “care” as a noun has evolved in use over time in the medical arena. From Merriam Webster, perhaps the most applicable definition is “painstaking or watchful attention.” I had a patient a few months ago who introduced our team’s chaplain and I to a family member as the “intensive care team.” (The patient was nowhere near the ICU.) She quickly realized that this wasn’t quite right, but I told her, “you know, you’ve correctly described what we aim to do.” I believe that’s happened once before as well.

With respect to POLST, I absolutely agree that the second option is better and would probably change “all care described above” to “all medical treatments described above.” Just the phrase “all care” is eye catching. Who doesn’t want “all care?” In my mind, use of “Medical treatments” further clarifies that what the person is agreeing to is a plurality of therapies and NOT to whether providers will provide painstaking attention or not.

Eric Widera said...

Great discussion!

Cindy: You just created a new side section of GeriPal - the quote of the week. I had to find a way to highlight "when you try to stuff something into a little box, sometimes the lid just doesn't close right..." I love it!!!

I'm not sure about the word aggressive though - I think it fits in with other terms like fight and battle that Patrice Villars has commented on in a previous post (very much war oriented speech). Intensive probably would be a more neutral word if you had to use a label.

Lyle: The Intensive Care Team seems about right for a interdisciplinary hospice or palliative care team. I guess it would cause to much confusion. I also like the suggestion to change it to "all medical treatments described above" as it more accurately describes the treatments in the above sections.

Lastly, I read the best case presentation today from an article in chest. They stated the medical team "met with her children to advance her level of care to comfort measures". Not bad.

Patrice Villars said...

Great points. I lean towards 'comprehensive care' but it still doesn't say much. At least it insinuates a sense of team and 'whole person'. While I am the first to argue that palliative care includes aggressive and intensive team work (e.g. managing acute pain crises, respiratory failure, PTSD flashbacks), 'aggressive' connotes intrusive, almost violent acts and 'intensive' feels intrusive, less than gentle or calm.

Christian Sinclair, MD said...

Great post Eric,

I love the posts here on GeriPal about the words we use. You have a few really great ones that should be compiled on one post with links since I usually spend too much time going back to find them at later dates.

Here is a post I wrote about DNR vs. Allow Natural Death that may be of relevance for those who have not seen it on Pallimed.

At my CME this weekend a pediatric surgeon got up to discuss why laproscopy in pediatric cases is poorly researched but assumed to be much much better. It led to a fascinating discussion about biases in medicine.

Frankly I think HPM and medicine as a whole need to start examining our own biases. But there is a danger in starting to point fingers at ourselves and asking tough questions about even the words we use all the time. Like politics, Does the public see this as a good thing (examining biases, getting closer to transparency/truth) or does it start to show the rough uncertain underbelly (are you trying to con me, do you not believe what you say, etc.)?

I have not yet seen the POLST in action and I have to say even though many of my dear colleagues support it and are working on local KS and MO versions, I am very suspect to successful and widespread implementation. And my major concern is with language such as 'Full treatment.' I chafed at that the first time I saw it but have been quiet about it until now. So thanks for giving me some courage to speak up.

Per my linked post as above Eric, I think you have to define the treatments by their goals and not whether they are full (or empty!). It is all about the anticipated achievable outcome and it is up to doctors and patients to have that discussion about what is 'anticipated' and what is 'achievable' otherwise any terms we use are shallow and open to biases.

Ken, I like your TV analogy. we fall for bells and whistles all the time in sales. "A 12 Megapixel camera! It must be Fantastic!"...if you plan on enlarging you photos to 4 foot by 6 foot. Pick the camera/TV/DVD/computer/AC unit you need not the one you want or that sounds good. You could also insert the maxim that if it costs more it must be more valuable which could apply to your new LCD tv or ICU care or the latest and greatest drug.

Anonymous said...

A tag of some kind is needed as a shorthand for the care team. Where we go wrong is bringing this tag anywhere near the patient/family's decision-making process.
Our tag is I think less value laden: R for resuscitation in the ICU, with R1, R2, R3 indicating whether on not intubation or chest compressions will be done; M for medical care aimed at curing the health condition, with M1 and M2 indicating whether or not the patient would usually want to be transferred to a higher level of care; and C for control of symptoms being the main goal.
Relatively unwieldy, but not a lot of attached baggage I think.

Eric Widera said...

I just re-read Christians post and fell in love with this quote:

"Ambiguity in medical orders is a situation ripe for error. For this reason medical orders regarding such momentous life and death decisions should not be ambiguous."

Thanks for the link Christian!

Karl said...

These are musings worth considering next time the California POLST comes up for modifications, but that won't be for awhile. I think it's up to us as physicians to explain what these terms mean, even if the language on the form reflects some inherent bias. I mean, the very name POLST suggests that CPR, categorically, is "life-sustaining" when we know perfectly well that only a small minority of patients actually have their lives "sustained" by this act of violence. (Other states use POST or MOST--Physician [or Medical] Orders for Scope of Treatment.) It's up to us to explain to our patients that it's not like on TV, where the 90-year-old gets CPR one day and is dancing out of the hospital the next day, fully intact. But yeah, maybe leaving off the word "only" and instead calling it "aggressive" or "intensive" comfort measures. or something along those lines that might help people make a more informed decision.

Sorry I missed the Physician Champions call today.