Problems and Solutions in End-of-Life Healthcare

Barry Patel, for HealthLeaders Media , March 20, 2009

So what is the solution? New legislation is not likely to solve the problems. Legislation has already been passed affirming the government's recognition of the need for proper end-of-life documentation. Solutions to the current deficiencies will be found through better enforcement and execution under the existing legislation. The solutions may be simpler than we think. Here are four key elements:

  1. Promote the value of the advance directive so that all patients, healthy or terminally ill, have a well documented, legally recognized advance directive.
  2. Create a system that makes the advance directive readily available and accessible whenever and wherever the patient may be hospitalized.
  3. Ensure that all people—friends, family, and caregivers—who are likely to be involved in a patient's care are informed about the patient's desires documented in their directive and understand the patient's choices.
  4. Establish a process to ensure that healthcare providers recognize and respect the documented choices. This would include using strong legal interpretation and support services where necessary.

Fortunately, there are resources and organizations available to help provide some of these components. For example, Caring Connections, a nonprofit program of the National Hospice and Palliative Care Organization, provides educational resources to patients about end-of-life care and helps patients and families better plan for this situation.

But it is not enough to simply print out an advance directive from the Internet and keep it in a file cabinet until needed in the future. What is needed is a system that covers all the gaps that exist today, which have traditionally prevented a patient from documenting and receiving the end-of-life care they would desire. This system must:

  1. Provide accurate, up-to-date resources to help patients express their wishes for end-of-life care and authenticate those wishes in legally appropriate documents. In addition, a central, secure repository for these documents should be created, accompanied by the means to inform patients of any changes in state laws that require them to update their directive so that it continues to be legally accurate.
  2. Provide a variety of ways to ensure availability of documents when and where needed, 24/7. Processes should encourage providers to place documents in patient charts and check the central repository to see if a patient has an advance directive.
  3. Provide an easy, yet structured way to help patients communicate and educate various people about their directive, including family, friends, and current caregivers—all of the people who would most likely be involved should their end-of-life episode occur.
  4. Provide provisions that the directive is respected, such as available legal counsel to assist families, should there be confusion or should a healthcare provider be uncertain of the member's documented wishes for end-of-life care.

These solutions would provide significant benefits to patients, their families, and their healthcare providers. Patients can feel confident that wishes for their own healthcare will be respected when they cannot speak for themselves. Families can feel empowered that proper supporting documentation exists to carry out a patient's healthcare wishes. Caregivers can provide care that is truly aligned with the patient's wishes. Not only can unnecessary healthcare services be avoided, but a patient's choices can be respected and honored.

People 75 years and older are the fastest growing segment of the U.S. population; this group is projected to more than quadruple over the next 50 years. A large percentage of this elderly population has chronic diseases that will necessitate appropriate planning for end-of-life care. This fact, combined with the ongoing growth in more expensive technologies, will continue to fuel the increase in healthcare costs. Medicare reform will need to consider comprehensive advance care planning. The benefits of doing so will be seen not only in judicial use of the healthcare dollar, but most importantly in respecting patients' end-of-life care wishes. What could be more important?

Barry Patel, Pharm.D., is president and co-founder of Total Therapeutic Management, based in Atlanta, GA. He can be reached at
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