Five Questions With: Dr. Joan Teno

"Unlike hospice, palliative care does not require the choice to forego treatment to cure the terminal condition."

Dr. Joan Teno is a professor of health services, policy, and practice and associate director of the center for gerontology and health care research at the Brown University School of Public Health and Brown Medical School. She is a health services researcher, former hospice medical director, and board-certified internist with qualifications in geriatrics and palliative medicine. She recently co-authored a study in the Journal of Palliative Medicine which presented research that the loved ones of the elderly are less satisfied recently than they were a decade ago with end-of-life care that their relation or friend received.

PBN: One in five respondents in your study indicated that care decisions that ran counter to the wishes of their deceased love one were made during their end-of-life care. What were the most common decisions that were in this category?
TENO:
In this study, we asked questions that we have used in the past to examine change over time. Thus, my answer regarding most common decisions is based on the prior research – they include concerns about the aggressiveness of care and decision to hospitalize a patient. Surprisingly, CPR was not the issue.

PBN: What was the single most surprising finding in the study for you?
TENO:
After a lot effort, we are not improving bereaved family member’s ratings of the quality of care.

PBN: You have spoken about hospice being applied widely enough but not completely enough. Do you find that the central problem with hospice is that it is introduced too late to do all the good that it can do?
TENO:
You are right – one of the key issues is that persons are referred “too late” to hospice and that an important intervention is to use Palliative Care Consult Services that are not available in nearly all Rhode Island hospitals. Unlike hospice, palliative care does not require the choice to forego treatment to cure the terminal condition.

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PBN: Is it a reasonable expectation, in a somewhat fractious and difficult period for health care generally, that end-of-life care should stay at the same level, or even improve?
TENO:
Our focus should be on improving the care. Payment policy has a huge impact. Right now, our payment policy is focused on rewarding procedures and days in the ICU – rather we should reward quality of care – such that persons receive care consistent with their goals of care that are based on understanding their prognosis and likely outcomes of care.

PBN: Pain management is listed in the study as a major source of disappointment. Why is pain management so difficult when it comes to end-of-life care?
TENO:
This is really a disappointing finding. It does not have to be difficult. In the early 2000s, we worked to improve pain management in nursing homes – reducing serious pain by substantial amounts. The key is aligning incentives to reward quality, not quantity.

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