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| Picture of this frog has no bearing on the post. I'm not saying residents are frogs in disguise. Seriously. It's just a cool picture, isn't it? Credit Wikimedia Commons |
On the other hand, hospital admission to a medicine service is one of the few times critical advance care planning conversations occur. This represents a major opportunity to communicate with patients about their goals, values, and preferences for end-of-life care. Unfortunately, even when these conversations take place, the medical residents sometimes do not document this information in the medical record or discharge summary in a place where it is clearly accessible for future clinicians.
In that context, Josh Lakin and colleagues at UCSF created a remarkable incentive program for residents to document advance directives in the chart. The study was just published in JAMA Internal Medicine. They set a goal of increasing documentation of the following for hospiatlized patients: 1) wishes for care 2) identification of health care proxy.
The intervention consisted of
- A discharge summary template with these fields
- A financial incentive ($400 for each resident if the entire program achieved a 75% documenationa rate)
- Feedback about each resident and admitting team was doing emailed out to all the teams biweekly
- Rates of documentation improved from 22% to more than 90% at the end of the year
- In a comparison group of a hospitalist-only service (no residents) who had the template but no financial incentive or feedback mechanism, rates stayed constantly low throughout the year.
by: Alex Smith
Comments
Thank you,
Barret
I'm sure that it is rare indeed when an elderly patient requests CPR after talking with residents who explain how risky and futile CPR is (generally) for the elderly.
Unfortunately, the elderly don't understand that NO CPR translates to Do Not Resuscitate Code Status and that DNR status is often inappropriately used to limit life-saving treatments that the Hospitals KNOW will not be reimbursed by Medicare and the private insurers.
The problem of DNR Code Status is long standing and there have been many studies, most of which indicate that the mortality rate among patients with DNR in their hospital chart is always higher ---even when adjusted for known variables.
Somehow, paying $500 to residents to influence the elderly to shorten their lives seems immoral to me.
I love your term, “behavioral economics to nudge people,” even though it takes 36 characters including spaces instead of 5 (for “bribe”), although I initially considered it a euphemism. What changed my mind about this value-laden word? The psychological herd effect; not to be the one who “jeopardizes the whole program being paid for not meeting the 75% target!” The psychological perception overcomes the economic one, since $400 is a small percentage of what residents now earn in a year. But this consideration makes one skeptical regarding on changing behavior after the intervention period. What might work? Testimonials from patients who say, “I am so glad my doctor asked me….”
Stan Terman
Patient feedback would also be helpful, and satisfaction (the major measure used by hospitals) just isn't enough. It's the wrong question. The right question, as you imply, is about preparation. Later, when things get rough, are they glad their doctor asked them some difficult questions and documented their preferences.