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Nurses play leading role in end-of-life care.

Nurses can play a key role in addressing one of the nation's most pressing issues. As our country faces the "fiscal cliff," the debate centers on raising revenues versus reducing benefits, especially in Medicare and Medicaid. Everyone wants to control health care spending, yet one critical approach is being overlooked.

Approximately thirty per cent of Medicare dollars are spent in the last six months of a patient's life, and the costs to Medicaid and private insurance are equally staggering.

But we clinicians know that too much of this "care" is futile, hurtful, and wasteful. While some will opt to "do everything" no matter how painful the treatment or how unlikely the chance for recovery, most people do not want to die in this manner. Advances in medical technology are truly miraculous, and we are reaping their benefits through longer and healthier life spans. But the end comes for everyone, and today more and more Americans are choosing to die at home or in hospice, surrounded by their loved ones. The medical and legal systems need to be prepared to support that choice.

Care at the end of life raises some deeply personal choices. Who should make them? Doctors and nurses? Government? Insurance companies? Hospitals? Ethics committees? Religious institutions? As both a physician and a legislator, I believe that the operative values should be the patient's. And the only way to ensure that outcome is through the completion of advance directives. When patients haven't expressed their wishes or designated someone who can act for them if they're incapacitated, controversy and painful family upheaval can ensue. Who can forget the tragic story of Terri Schiavo, the young woman whose family was torn apart as she succumbed to irreversible brain damage in 2005?


While it's important to encourage physicians and nurses to have those discussions, there is no need to wait for legislation. Advance directives, legal in every state, provide a way for people to make known the values and choices that should inform their care. Advance directives protect individual rights and cost little or nothing to carry out. They also support families by easing decision-making during what is often a stressful time. And what is particularly relevant to state, federal, and private insurance expenditures is that in most cases advance directives reduce costs. And they do so not by cutting services at the direction of government or insurance companies, but by respecting patients' individual rights and wishes.

As an emergency medicine doctor, I've seen what happens when there is no advance planning or discussion about end of life care. A frail, elderly nursing home patient is brought in by ambulance with shortness of breath, irregular heartbeat, and plunging blood pressure. The wasted and contracted limbs indicate years of incapacitation, and the medical record reveals a long history of dementia. As we work to restore stability, the patient suddenly goes into cardiac arrest.

Because there is no record of an advance directive or a "Do Not Resuscitate" (DNR) order, the ER team jumps into full cardiopulmonary resuscitation (CPR) mode. If "successful," the patient will endure pain and confusion that may last for hours, days, weeks, or a few months before dying. Whether the patient recovers from this episode or not, one thing is clear: this will be costly, both in human and financial terms.

The only ethical and legal way to avoid this situation is when patients have made their wishes known beforehand, appointed someone they trust to make decisions when they are no longer able to, and made that information readily available to health care providers.

We Americans cherish the right to make our own decisions. In light of this ardent individualism, it's puzzling that so few of us exercise this right when it comes to something almost all of us will face: medical care at the end of our lives.

Studies show that only about one-third of Americans have completed advance directive forms, and the rate of completion is even lower among minorities and the poor. But the studies also show that Americans want to be able to discuss these issues with physicians and nurses more than from any other source of information.

What if ninety per cent of Americans had advance directives? What if completing these forms were as routine as renewing a driver's license or paying taxes? Doctors and nurses would begin to utilize them as a standard part of every medical record, and care would be more personalized and humane. And because most people choose not to undergo heroic treatment for every conceivable condition, billions of dollars would be saved. And for those who opt for those heroic treatments, their choices would be honored as well.

Historically, nurses have been leaders in addressing sensitive patient care needs. Nurses work in palliative care and are especially active in hospice care where their efforts are respected and appreciated. The public trusts nurses because nurses have the training to review complex issues with patients, and their input is valued.

Respecting individual rights is the best and right way to reduce health care costs, and this is one area where health care providers can find common ground. We must recognize that many of our patients want us to initiate end-of-life care discussions or for us to listen and participate fully when they bring up the topic. The issues are unavoidable and the implications are profound in both human and financial terms. We are, after all, the first generation in human history that likely has some say about how we die.

Nurses and physicians-and other members of the health care team-can work together in helping our patients through this challenging time, and by doing so, patients can obtain comfort and peace of mind. We have a key role to play, and the public is looking to us to take the lead. The tools are there; we just need to use them.

The author, Dan Morhaim, M.D., is a board-certified physician, House Deputy Majority Leader in the Maryland State Legislature, faculty at The Johns Hopkins Bloomberg School of Public Health, and author of "The Better End: Surviving (and Dying) on Your Own Terms in Today's Modern Medical World" (Hopkins University Press),
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Title Annotation:Legislative Update
Author:Morhaim, Delegate Dan
Publication:Maryland Nurse
Date:Feb 1, 2013
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