“why won't you let me die?” surgery, palliative care, and the 30-day rule (fr425) ethics...

Vol. 45 No. 2 February 2013 383Schedule With Abstracts

School of Medicine, Chicago, IL. Diane WayneNorthwestern University Feinberg School ofMedicine, Chicago, IL. Eytan Szmuilowicz, MD,Northwestern Memorial Hospital, Chicago, IL.(All authors listed above had no relevant finan-cial relationships to disclose.)

Objectives1. Describe the themes associated with resident

code status determination.2. Identify differences in code status decisions

between control and intervention groupresidents.

3. Identify missed opportunities in resident-ledcode status discussions.

Background. Although residents frequentlydiscuss code status with hospitalized patients, lit-tle is known about the content of resident-ledcode status discussions (CSDs).Research Objectives. To evaluate the contentof CSDs using a standardized patient (SP).Method. Fifty-one internal medicine internswere randomized to either intervention (n ¼23) or control (n ¼ 28). Intervention groupinterns received a multimodality CSD skills train-ing program. Six months later all interns com-pleted a 15 minute videotaped CSD witha single SP portraying a 47-year-old man hospi-talized with metastatic colon cancer. Digitalrecordings were transcribed verbatim, de-iden-tifed, independently reviewed, and coded bytwo coders using an open coding approach.Discrepancies were discussed and resolved byconsensus.Result. Interrater reliability for code status de-termination was high (Cohen’s kappa ¼ 0.89).Seventy-nine percent of controls compared to52% of intervention residents concluded thatthe patient wanted to be resuscitated. Four resi-dents did not determine a code status within theallotted time. Of the 34 residents who deter-mined the patient wanted resuscitation (fullcode), only 44% asked the patient about hisvalues/goals. Themes associated with determina-tion of full code included focusing on the me-chanics of resuscitation, framing the decisionas a patient choice to have ‘‘everything done’’or not, and equating the patient’s descriptionof himself as a fighter with a desire to be resusci-tated. Of the 13 residents who determined a pa-tient preference for do-not-resuscitate (DNR)status, 69% explored the patient’s values/goals.Intervention residents were more likely to haveexplored values/goals (74% vs. 39%; p ¼ 0.01)

than controls. Themes associated with determi-nation of DNR status included: discussion ofoutcomes of resuscitation, identification ofspecific patient goals, and physician recommen-dation.Conclusion. Residents’ code status determina-tion is influenced by what residents focus on inthe discussion.Implications for Research, Policy, orPractice. CSD skills training programs shouldinclude key content domains such as explora-tion of patient values/goals.

SIG Symposium

‘‘Why Won’t you Let me Die?’’ Surgery,Palliative Care, and the 30-Day Rule(FR425) Ethics SIGFrancis (Frank) Mueller, MD, St. Helena Hospi-tal, St. Helena, CA. Christine Toevs, MD, Alle-gheny General Hospital, Pittsburgh, PA. JeffreyZesiger Visiting Nurses Association & Hospiceof Cooley Dickinson, Northampton, MA. LinaShihabuddin Short Hills, NJ.(All authors listed above had no relevant finan-cial relationships to disclose.)

Objectives1. Understand through case presentations the

role of the 30-day rule as a quality measurefor surgeons.

2. Appreciate the intended and unintendedconsequences of this rule on palliative medi-cine patients and their surgeons when prac-tice guidelines become elevated to qualityindicators.

3. Explore the role of AAHPM in changing thisquality metric as an index case with possibleextension to influence on other qualitymeasures.

Surgeons have tracked long-term outcomes ofsurgical patients since the early 1900s and theadvent of morbidity and mortality (M&M)conferences. Surgical outcomes including com-plications and death are discussed, evaluated,and recorded for 30 days after a surgical proce-dure. The Centers for Medicare & Medicaid Ser-vices (CMS) now tracks individual surgeonmortality rates for a variety of specialties, mostspecifically cardiac surgery. These mortalityrates, categorized at least by institution, arenow publically available on the Internet.

384 Vol. 45 No. 2 February 2013Schedule With Abstracts

Surgeons often operate at the end of life. TheLancet reported that 18% of Medicare patientswho died in 2008 underwent an inpatient sur-gical procedure in the last month of life1.Surgeons often do not want to withdraw life-sustaining treatments, even if they are not inline with the patient’s or family’s goals. Surgeonsare frequently not supportive of advance direc-tives (ADs) preoperatively and may not operateon patients who have an AD limiting care inthe post-operative period2.The purpose of this panel discussion is to discussthese limitations and influences on the patient,the families, and the surgeons. We will presentcases as starting points for discussion of the in-fluence of surgical quality metrics on palliativemedicine and end-of-life issues. We will also dis-cuss the options for AAHPM to potentially influ-ence these metrics and improve patient-centeredcare without limiting potentially lifesaving surgi-cal procedures.1. Kwok AC, Semel ME, Lipsitz SR, et al. The in-

tensity and variation of surgical care at theend of life: A retrospective cohort study. Lan-cet, 2011;379(9800):1408-1413.

2. Redmann AJ, Brasel KJ, Alexander CG,Schwarze ML. Use of advance directive forhigh-risk operations: A national survey of sur-geons. Ann Surg. 2012;255(3):418-423.

Methods that Work in Rural Communities toProvide Palliative Care: Lessons From 24Communities (FR426)Rural SIGJulie Mayers Benson, MD, Lakewood Health Sys-tem, Staples, MN. Janelle Shearer, BSN RN,Stratis Health, Bloomington, MN. Lyn Ceronsky,DNP FPCN GNP, Fairview Health System, Min-neapolis, MN. Cindy Sauber, BSN, LakewoodHealth System, Staples, MN.(All authors listed above had no relevant finan-cial relationships to disclose.)

Objectives1. Describe successful strategies to start or

strengthen a palliative care program in ruralcommunities.

2. Discuss ways to incorporate the NationalQuality Forum’s Preferred Practices into thedevelopment of primary palliative care in ru-ral communities.

3. Identify an approach to assessing communityresources and increasing community capacityto support palliative care.

Palliative care service models specific to ruralcommunities have not emerged. This pre-sentation will highlight a method for ruralcommunities’ to assess their unique set of re-sourcesdhuman capital, champions, systems, re-lationships, and financialdthat can be pulledtogether to support palliative care. Resultsfrom over 24 rural communities using this pro-cess will be shared. This field implementationhas shown that palliative care services can be of-fered through hospitals, nursing homes, outpa-tient services, and home health agencies inrural communities.Community capacity building, the NationalQuality Forum’s Preferred Practices, and techni-cal assistance for program development were in-strumental in helping these communities todevelop and/or strengthen palliative care pro-grams. Lakewood Health System will providea case study of how it increased palliative care ac-cessibility and built clinical skills among health-care professionals.Based on results from field implementation, thispresentation will share common challenges indeveloping palliative care services in rural com-munities. It also will explore the assets uniqueto rural communities. Tools for assessing yourcommunity’s gaps and opportunities, as well asclinical resources, will be shared.

Interdisciplinary Cases (FR427)

3:30e5 pm

Concurrent Sessions

Do Ask, Do Tell: Raising Money to SustainYour Palliative Care or Hospice Program(FR428)Sarah Friebert, MD, Akron Children’s Hospital,Akron, OH. Charles von Gunten, MD PhDFAAHPM FACP, University of California, SanDiego, San Diego, CA.(All authors listed above had no relevant finan-cial relationships to disclose with the followingexception: Von Gunten is on the speakers’ bu-reau and received an honorarium from SalixPharmaceuticals.)

Objectives1. Review the importance of funding mecha-

nisms beyond clinical revenue to create and