How to Die Well in America: Physician-Patient End of Life Conversations

Increasing the rate and quality of physician led end-of-life conversations (EOLCs) in Duke Internal Medicine would improve our patients’ quality of life and and be financially prudent. Unfortunately, internists at Duke Hospital often do not have adequate EOLCs with patients, driving up end-of-life care costs and depriving patients of opportunities to state their care preferences at end-of-life, make peace with death, or have meaningful final conversations with family members. The lack of EOLCs in Duke Internal Medicine is due to insufficient EOLC support systems, accountability systems, and community engagement. Fortunately, there are five options, outlined below, to address these inadequacies and increase the rate and quality of physician led end-of-life conversations in Duke Internal Medicine.

The Value of EOLCs and Duke Internal Medicine’s Current EOLC Policies

EOLCs have been shown to improve patients’ quality of life during their dying process, decrease mental health burdens on their survivors, and lower costs of care for both medical facilities and patients. The need to facilitate EOLCs is particularly great with primary care and internal medicine physicians, who are the most likely to have an established rapport with patients as they face serious illness and death. Additionally, many cardiologists, oncologists, and other specialists who treat patients at the very end of life perceive themselves as serving a technical role within their specialty, and this leaves internists, as general practitioners, to facilitate end-of-life planning and conversations with patients.

A shortage of EOLCs is a national problem, and has been written about extensively by scholars and policymakers. Duke Internal Medicine is not currently a leader in EOLCs. The Duke Institute for Care at End of Life, a group founded by internists and palliative care physicians, was closed a decade ago, after only 7 years in existence. North Carolina at large is behind many states in quality of end-of-life care – North Carolina’s palliative care received only a 65.3% rating by the Center to Advance Palliative Care, due largely to low rates of referrals to palliative care services by internists, while multiple states received scores of 90% or above. Duke also is failing to:

1. Implement EOLC training programs for its internists
2. Use the latest in technological advances in supporting internists to have EOLCS
3. Utilize recent Medicare provisions to standardize the timing of advanced care directives
4. Employ data science to monitor EOLC metrics and hold physicians accountable
5. Build community partnership to grow EOLC involvement and awareness

Fortunately, Duke Internal Medicine has the resources to become a leader in EOLC policies in North Carolina and in the nation. Outlined below are five options that correspond to the five failures above. Implementing any option would improve the quantity and quality of physician-led EOLCs here in Duke Internal Medicine, but implementing multiple options together would have the greatest impact.