Meeting Members’ Wishes in the Last Year of Life: A Journey Toward Concordance in Southern California


David Glass; PhD Michael Kanter, MD; Paul Minardi, MD; Susan Wang, MD

Abstracts from the Kaiser Permanente 2019 National Quality Conference

From Southern California

Background: There is a large body of literature that posits that much of the medical care delivered during the last year of life is unneeded and unwanted. However, there is little evidence about how members view the amount of care, the types of care received, and whether that care matches their wishes. This study fills that gap. It provides insight into where Southern California does well and not so well from the member perspective, and why that occurs.
Methods: The results are based on 2 samples. The first was a survey with next of kin of 715 Southern California members (age 65 years or older) who died in April and May of 2017. The second involved administering the same survey to next of kin of 332 deceased members who died between June 2016 and May 2017 and whose costs during the last year of their life were in the top 10% of the costs of all members who died during this period. We examined the wishes, values, and health care experiences of the random sample of deceased members, then compared them with high-cost deceased members.
Results: The Southern California Permanente Medical Group (SCPMG), by and large, delivers care and treatments that strongly match the values and desires of its members at the end of their life. SCPMG does quite well on meeting members’ wishes overall, the amount of treatment, the specific types of treatments, avoiding delivery of unwanted treatments, and providing desired treatments. However, 3 areas stand out in which SCPMG might improve its performance: A) enabling those desiring to die at home to do so; B) avoiding cardiopulmonary resuscitation, mechanical respiration, or artificial feeding for those not wanting it; and C) managing the levels of pain. Surprisingly, those who received the most care (in the top 10% of costs) were less satisfied with almost all aspects of their care and treatments.
Discussion: A key quality metric is the degree to which members’ wishes and values are honored. It is reassuring that during the fraught period of the last year of life, SCPMG performs reasonably well and for the first time we have a comprehensive overview of our performance. There are several surprises underneath this broad finding, including 1) most members had engaged in end-of-life discussions with next of kin and physicians, contrary to claims that patients avoid these discussions; 2) most members said the amount of care was “just right,” again contrary to much of the literature; and 3) 38% of those receiving cardiopulmonary resuscitation did not want it.

Abstracts from the Kaiser Permanente 2019 National Quality Conference


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