England's Approach to Improving End-of-Life Care: A Strategy for Honoring Patients' Choices

July 19, 2011

Authors: Bradford H. Gray, Ph.D.
Contact: Bradford H. Gray, Ph.D., Senior Fellow, The Urban Institute, bgray@urban.org
Editor: Deborah Lorber

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Overview

In the U.S. health care system, and in those of many other countries, the care of dying patients is generally not performed well, with pain and other distress frequently undertreated and patients’ preferences not respected. England's evidence-based End of Life Care Strategy could prove instructive. This issue brief discusses the origins, content, and implementation of the Strategy, as well as its potential impact. Both England and the United States struggle with similar challenges, including looking beyond the province of hospice and palliative-care specialists and initiating palliative services before the patient's final days. Aspects of the English approach that may be useful in the United States include strategies to help physicians recognize when patients are entering a trajectory that may end in death, the use of "death at home" as a metric for measuring progress, improving the skills of clinical and caregiving personnel through Web-based training, and developing a national improvement pathway.

Citation

B. H. Gray, England's Approach to Improving End-of-Life Care: A Strategy for Honoring Patients' Choices, The Commonwealth Fund, July 2011.

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Featured Comment:

Pat Edens, of Global Oncology SP (July 27, 2011):

I read with interest the Brief on "Care at the End of Life: What the U.S. Can Learn from England." End-of-life care is a difficult concept for U.S. hospitals to grasp, as there is no formal associated revenue. Better coordination through an End of Life Care (EOLC) program may control utilization rates and use of resources, impact the length of stay, and influence clinical outcome. To validate the return on investment of development, an assumption about cost aversion is made. Cost aversion is tangible cost removed from an episode of care by more appropriate utilization of resources. Because the patient is integral in the decision making process when participating in an EOLC program, do not resuscitate orders (DNR) may increase leading to cost aversion of approximately $5,000 per resuscitation averted. Moving a DNR patient from the Medical ICU to a medical-surgical bed will provide a better environment for the patient and family while averting at minimum $700 per day in cost. Providers must remember that ICU visitation and privacy are limited and patient families are often left with huge hospital bill co-pays. Ideally, a near-death patient should not be in the acute care setting. Patients seen by the EOLC team on prior admissions are more likely to have Advance Directives, and when they present at the ER in distress, go to the Medical-Surgical Unit, not the ICU. A quick calculation of cost avoidance can be implemented using DRGs by identifying those DRGs into which a palliative care patient is most likely to be admitted. Take the average payment per day based on reimbursement and hospital current length of stay (LOS) and calculate the financial return if that LOS is shortened by one day due to appropriate patient management. Additional indicators can be monitored including pain relief, patient satisfaction with care, and decrease in co-morbidities or complication rates. While a dollar figure other than lowered costs cannot always be attached to an EOLC program, no one can ignore that it provides an advantage to the patient. Communication is critical in any chronic, long-term disease, especially toward the end of the disease. Providing an end-of- life program is the right thing to do for the patient, the family and the facility. Stanfill Edens, P, Harvey, C.D., Gilden, K.M. Developing and Financing a Palliative Care Program. American Journal of Hospice and Palliative Medicine, 25(5):379-384, 2008