In an interview last week, I asked the authors of this report why hospitals don't have standard process measures in place. I thought that at the very least, the Joint Commission would have some guidelines.
Wenger explained, "The Joint Commission speaks to a lot of aspects [of end of life care] but the Joint Commission doesn't really look at process of care." "They talk about making sure that patients and families are well-informed. But they don't get anywhere near evaluating the technical process of care provided, or deal with any of the quality indicators."
The authors say they know that most hospitals don't have such process measures in place, and that there is a lot of variation, even within a hospital, as to when a doctor would initiate such discussions. But their list of 16 might be a good place to start.
"The goal is to get them applied broadly," Wenger says.
I realize that sometimes there are insurmountable obstacles to having these conversations. The patient is not conscious and medical power of attorney can't be determined or can't be reached. Doctors often don't have the kind of time it sometimes takes to have such conversations, and which may have to be repeated for multiple family members. Moreover cultural issues and religious beliefs may persuade family members to continue to hang on for a miracle.
But the authors make an excellent point. More hospitals should put in place standards that trigger physicians to have and document these conversations. After all, the patients who requested their DNR orders should be able to count on this much from their caregivers.