EXPERT ADVISORY: Aligning Prognosis, Patient Goals and Policy for End-of-Life Care

By Cheryle Rodriguez

Peter Boling, M.D.,  professor of medicine and chair of the Division of Geriatric Medicine at Virginia Commonwealth University, writes of the need for continuity of care at the end of life in the Oct. 1 online publication of the Archives of Internal Medicine, a JAMA Network publication.

In the commentary, Boling said that based on data and observation, most patients in nursing homes are managed by doctors other than their primary care physicians and those who treated them in the hospital—resulting in fractured health care.

Boling also notes that end-of-life protocol is being recommended to patients with significant chronic illness even though reasonable vitality and quality of life remain, while in other cases there is a delay to address the reality that medical care is reaching its limits and that care plans should focus on comfort as life comes to an end.

Boling based his comments on a study that used the Health and Retirement Study database, which showed that approximately half of patients in a skilled nursing home return home when they leave the facility, despite having significant frailty. 

“Unfortunately, in some cases financial barriers may delay a switch to an appropriate palliative care and hospice focus in nursing home patients,” said Boling.

Additionally, he  said, “the Medicare skilled rehab benefit is too often used on admission to nursing homes for patients in whom the expected outcome is death because of incentives for the facility and financial burdens on the family that come from using the Medicare hospice benefit at the outset of nursing home care. Clinical practice and health care policy should perform better in this context and this ultimately ties back to alignment of incentives.”

Boling received national attention for his work in crafting language for the Independence at Home Act that advocated patient home care for individuals with functional impairment, high costs and multiple illnesses. 

Boling worked with a small group of colleagues and members of U.S. Congress to design and pass the Independence at Home Act of 2009—which created the Independence at Home (IAH) Demonstration—a national program now being tested at VCU and 18 other sites. The demonstration will evaluate the advantages of providing home health care for frail elderly patients, who are too ill or disabled to easily visit their physicians when they need care. 

Editor’s Note:  A copy of the commentary is available at http://media.jamanetwork.com.