Rose, an 87-year-old with advanced dementia, traveled back and forth between the hospital and nursing home four times in her final six months. John, a 64-year- old with stage IV lung cancer, died after spending two weeks in the ICU when his family decided to withdraw ventilator support.
Both Rose and John experienced what has been termed an “over-medicalized death,” or OMD: the unfavorable consequence of the excessive or inappropriate use of medical treatments at the end of life, often resulting in avoidable suffering and expense.
OMD has been called a “Triple Fail” event, when all three “Triple Aim” goals of improving patients’ experience of care, advancing population health, and lowering per capita costs simultaneously fails1. Examples of care considered “over-medicalized” include life-sustaining treatment within 180 days of death, an unplanned hospitalization or intensive care unit admission within 30 days of death or provision of cancer-related chemotherapy within 14 days of death.
It’s often easier to recognize an OMD retrospectively, when the patient has died despite receiving aggressive care, leaving health care providers, family members and those who are financially responsible for payment sometimes wondering if there might have been a better way.
History and Development of OMD
OMD started in the 1960’s when the place of death shifted from the home to hospitals, and the process of dying became a medicalized event, rather than a natural process of old age and disease. As the use of ICU care and the provision of other medical interventions at the end of life became commonplace, death often occurred only after all possible treatments were exhausted.
Too often, when a person with the advanced illness is engaged in heroic care, the realization that they are actually dying goes unrecognized by the medical community, the patient, and their family. Consequently, the pain, symptoms, fear, and despair that often accompany the dying process frequently go unacknowledged and unmanaged, as attention remained focused on the promise of medical interventions and treatments.
This is often seen in the cancer community where patients receive chemotherapy until their final days, entering hospice only after they are actively dying. It is also applicable to patients with dementia, heart failure, or pulmonary, renal or liver failure that are referred to hospice in the final weeks of life. Integrating palliative care earlier for those with advanced illness, regardless of the place of care or treatment plan, helps to ensure that suffering doesn’t go unnoticed and untreated.
Entering a New Era
Avoiding over-medicalized death is possible, but not without its challenges. While some people will opt to do everything possible to prolong their life, others would prefer instead to die in their home surrounded by their loved ones. However, it is difficult to determine which patients would benefit from potentially life-prolonging treatment and which will die despite these interventions.
This is precisely where the use of predictive risk modeling is so valuable. It is a method used to detect an adverse outcome early in a population based on the statistical modeling of routinely collected data. Turn-Key Health, an emerging company that is focusing on Advanced Illness Management for seniors, has developed a predictive risk model to predict whether a person will have an OMD. Essential reading: “Over-Medicalized Care at the End-Of-Life in the United States: Addressing the Economic and Social Consequences”
Using claims data from health plans or ACOs, the sophisticated algorithms can identify patients who are likely to receive non-beneficial care. Turn-Key then deploys Palliative Illness Management (PIMTM) teams through its community-based network partners. This specially trained team of professionals including nurses, Nurse Practitioners, Social Workers, Chaplains and others engage with these patients in the home and over the phone. Performing specialized assessments and offering expertise that is welcomed by both the patients and their families, goals of care are established, discussions and shared decision-making progress, and attention is given to physical symptoms and psychosocial and spiritual needs.
This keen sensitivity and responsiveness to the issues that really matter to patients and families result in a better quality life for all while reducing health care expenditures associated with non-beneficial and burdensome care in the final months of life.
Our hope is that PIMTM will allow patients like Rose and John to avoid unnecessary suffering and live out their final days with dignity.