Gawande: Changes Needed to Reduce Costs and Suffering in Healthcare
Five Crucial Questions Help People to Live While Dying; Reduce Waste and Suffering
—Special to the Catholic Business Journal by Thomas M. Loarie—
Atul Gawande, MD, MPH, in his keynote speech last week to over 1700 hospital CEOs and executives, challenged attendees to rethink how we organize and deliver care. He identified current approaches to end-of-life care as a source of unnecessary waste and suffering.
At the 23rd Health Forum and American Hospital Association Leadership Summit, he outlined the problem of end-of-life care; “In the US, we are that we can grow old, to be frail and to get disease that comes with age… but we do not know how to manage this. People have priorities besides living longer. This varies by person, so the only way to find out is to ask. We only do this 33% of the time, and most often, it is too late. The result is care that is out of alignment with the patient’s priorities and this leads to suffering.”
Gawande learned through his research that people who are dying long to live for those things that make living important. “They want to be a person not a patient.” A person’s priorities may include having ice cream, having dinners at home with friends and family, reading books and many other things that they live for.
Alignment with an individual’s priorities leads to fewer hospital admissions, fewer people dying in the hospital, and more time in hospice care. These people lived 25% longer, and suffering was reduced as they refused additional treatments.
Through his research lab, Gawande is now training doctors to ask patients five questions about their priorities, and then testing and measuring what changes for patients when they do. The goal is to scale this approach so it becomes part of routine end-of-life care for patients.
The five questions are:
- What is your understanding of where you are and of your illness?
- What are your fears or worries for the future?
- What are your goals and priorities?
- What outcomes are unacceptable to you? What are you willing to sacrifice and not?
- What would a good day look like?
Asking these questions allows everybody involved to understand what the goal really is and what is it they are really fighting for? It’s for a life that contains certain things.
Gawande also touched on necessary and urgently needed changes to the delivery of healthcare. “We need to transform care from component success – drugs, devices, operations – to outcomes resulting from the integration of these components into an overall health objective. Real innovation will come from the connecting of the dots among diverse groups of clinicians, rehab specialists, and caregivers. This is a group activity.”
“We can no longer afford to settle for the judgement of an autonomous doctor who has fragmented knowledge. There are 66,000 ways the body can fail, there are 6000 drugs, and there are 4000 medical and surgical procedures. Teams of specialists will trump what we have done in the past. The payoff is huge.”
Atul Gawande, MD, MPH is a surgeon, writer, and public health researcher. He practices general and endocrine surgery at Brigham and Women’s Hospital. He is Professor in the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health and the Samuel O. Thier Professor of Surgery at Harvard Medical School. He is the best-selling author of Being Mortal, The Checklist Manifesto, Better, and Complications