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Texas Medicine: It sounds like you favor these tools and you see them of- ten. Can you comment on what other states are doing?
Dr. Byock: Yes, I do. And some states seem to be doing this better than others. But there’s more local varia- tion than statewide variation. Some institutions and health systems do it better, some communities. I was just up in Everett, Wash., a community that’s deeply engaged in having these conversations. And that’s reflected in the [federal] health service statistics: where people are spending their time, how many days in the ICU, how many days in the hospital, number of days in hospice care, where people die — all of those measures reflect that level of engagement.
Texas Medicine: Do you see a need for protection of physicians’ con- science in this arena versus govern- ment-mandated care?
Dr. Byock: Every state and every hos- pital I’m personally aware of has a pol- icy that allows physicians to decline to provide treatment they feel is not ben- eficial, and we have to be courageous enough to use that right at times. This is why we work in teams. When those things happen, this is a time when a palliative care team certainly should be involved. Pull in the people who do this day in and day out.
Texas Medicine: What do you think about the use of hospital ethics com- mittees in times of dispute?
Dr. Byock: That’s a good professional use of an ethics committee. I would only say that before the ethics com- mittee gets involved, or at least con- comitant with the ethics committee getting involved, get a palliative care team involved. Most places that have long-standing ethics committees have seen their consults diminish when palliative care is available in their hos- pital or health system. And the basic
62 TEXAS MEDICINE April 2015
reason is, if you can continue to keep a difficult situation within a clinical realm, responding to people’s distress with a clinical framework, it’s usually better than having to be framed as an ethical issue or conflict. So you can address the same situation, the same level of disagreement, or anger, or dis- cord, or misunderstandings in families by using clinical teams and clinical frames and skills. Often the outcomes are more satisfying than dealing with it through ethics. But it’s not always possible, and the short answer is yes, you can get ethics involved.
Texas Medicine: Back to the IOM re- port, do you see some good solutions in there or elsewhere?
Dr. Byock: There’s wonderful guid- ance in there. You can also look for guidance in some of the statements that have been coming out of the American Board of Internal Medi- cine, guidelines and best practices from the American College of Sur- geons, the American Thoracic Society, the National Comprehensive Cancer Network, and the American Society of Clinical Oncology in cancer care. There’s general agreement where we need to go and the importance of shared decisionmaking and value- based care. The “Triple Aim” really epitomizes where we need to go and is very consistent with the IOM rec- ommendations. What’s frustrating for me is that the IOM made many of these same recommendations in their 1997 report, Approaching Death. So the government, medical education, the insurance industry, and the long- term care industry have yet to really respond substantively. And we are at a crisis point, and the window of re- ally responding as a caring society is closing. n
Amy Lynn Sorrel is associate editor of Texas Medi- cine. You can reach her by phone at (800) 880- 1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email at
amy.sorrel@
texmed.org.
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