One of the most common fears about dying is the loss of control — control of pain, of dignity, of faculty and function. Despite that fear (or perhaps because of it), most people die in the hospital, even though survey data show that more than 70% would prefer to die at home.
My own institution, Providence St. Joseph Health, did a review of the last 30 people who died at each of its 35 hospitals. We found that 9% of patients who died were admitted to comfort care, and another 66% were converted to comfort care (usually within 3 to 5 days of admission); thus, 75% of patients who died in the hospital were expected deaths. Given that most people would rather not die in a hospital, we clearly had room to improve.
Yes, we plan to expand the conversation about end-of-life care with our patients using the Gundersen Health System “Respecting Choices” model and the Serious Illness Conversation Guide. But we realized we could act even more quickly with our own 80,000 caregivers (employees). How did we make that happen?
Like many large organizations, we have a self-funded insurance plan. And like most self-funded plans, we historically gave employees and their spouses an incentive to engage in wellness activities — they earn up to $1400 dollars (for a family plan) by completing a health-risk assessment. We retained that incentive option, but for 2016 enrollment we also offered an alternative educational activity on advance-care planning, involving three elements:
- Watch a four-minute video featuring Dr. Ira Byock, a palliative-care expert, the Providence Institute for Human Caring’s chief medical officer, and a driving force behind this initiative.
- Answer eight reflective questions on end-of-life care.
- Choose a personal plan of action from a range of choices (such as “I will start a conversation with my loved ones about this subject” or “I will update my beneficiaries in my insurance and savings plans”), with an option to write in one’s own choice.
Of the roughly 51,000 caregivers and their spouses who completed a health incentive for 2016, some 93% chose to do the advance-care planning activity instead of completing a health-risk assessment (only one paid incentive is earned). The newness of the activity might explain the very high uptake.
Our ultimate goal: Get our caregivers and their families thinking about how to maintain control over their end-of-life care and align it with their personal beliefs and preferences. By beginning with ourselves, we hope to gain a level of comfort and skill in discussing end-of-life care that we can then transmit to the patients we serve.