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Incentives may encourage end-of-life discussions

By Genevra Pittman

NEW YORK (Reuters Health) - Offering medical trainees a financial incentive to write hospital patients' end-of-life wishes in their medical records led to a spike in the proportion of records with such notations, a new study found.

Past studies have suggested that although many elderly people prefer to die at home instead of in the hospital receiving aggressive treatment, some never have a discussion about end-of-life care with their doctors or have such wishes recorded (see Reuters Health story of April 1, 2013 here: http://reut.rs/ZYM88U).

"The conversation is the most important part of this process," said Dr. Joshua Lakin, who led the study while at the University of California, San Francisco.

"Everyone feels that that conversation piece leads to more likelihood of having health care delivered that's in line with (the patient's) wishes."

As part of the new study, internal medicine residents at UCSF each received $400 if, as a group, they recorded discussing end-of-life issues, including designation of a surrogate decision-maker, with at least three quarters of hospital inpatients.

Residents received reminder emails about the program, followed by feedback on a team and individual level as the year went on.

Lakin and his colleagues reviewed the medical records of 1,474 patients, or just over half of those discharged during the study period.

They found the proportion with end-of-life wishes and a surrogate decision-maker documented in their files increased from 22 percent at the start of the program to more than 90 percent a few months in, then held steady through the end of the year.

The researchers noted in their JAMA Internal Medicine report that they did not have long-term data on how patients fared, nor did they track whether residents continued making end-of-life notes in medical records after the incentives ended.

Dr. Mary Tinetti, chief of geriatrics at the Yale University School of Medicine in New Haven, Connecticut, said she is "ambivalent" about the idea of using financial incentives - in part because doctors shouldn't be forcing discussions on patients who don't want to have them.

Tinetti, who wasn't involved in the new study, also said it would be ideal if such discussions could happen before patients end up in the hospital, for example with a primary care doctor.

Still, she told Reuters Health, "I think the positive thing about this is how successful they were in going from so low a number to such a high number of patients who expressed their wishes and had those wishes transmitted."

Lakin said patients and families shouldn't be afraid to start the conversation about end-of-life care themselves.

"If more people go to their physicians and pastors or whoever they trust and say, ‘I want to have this discussion' … that's also an important thing," Lakin, who is moving to a position at the Dana-Farber Cancer Institute in Boston, told Reuters Health.

In another study published this week in the Journal of Clinical Oncology, Swedish researchers found that end-of-life talks with the teenage children of terminally ill parents were tied to greater trust in the care provided.

Of the 622 young people surveyed, 82 percent reported moderate or very much trust in the care given to their parent. Those who had not received any information about their parent's disease and death were more than twice as likely to report distrust as those who had discussed those issues with a doctor before losing their parent.

Distrust in the health care provided was also linked to a higher risk of depression years after the death, Tove Bylund Grenklo from the Karolinska Institute in Stockholm and her colleagues found.

SOURCES: http://bit.ly/13ncrE6 JAMA Internal Medicine and http://bit.ly/12VmKjL Journal of Clinical Oncology, online July 15, 2013.

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