The New Jersey Health Care Quality Institute has released the “End of Life Care Strategic Plan for New Jersey.” From the executive summary:
“New Jersey performs poorly on end-of-life care compared with almost every other state in the nation. The statistics translate into real people treated with unnecessary and unwanted medical care at the end of their lives. Too many people who want to die at home instead die in Intensive Care Units (ICUs). Too few benefit from hospice care — or benefit too late. . . . Our plan focuses on four key areas:”
Technology. We need a financially sustainable statewide electronic Practitioner Orders for Life Sustaining Treatment (POLST) registry so physicians and advanced practice nurses, in consultation with patients and caregivers, can document their end-of-life care wishes in a state recognized POLST form that is accessible to emergency and medical staff no matter where the person may be. We should connect Advance Directives and POLST forms to Electronic Health Records (EHR) systems, incorporate electronic reminders into the EHR to prompt providers to conduct advance care consultations with identified patients, and achieve wide-spread use of technology to identify those patients in greatest need of an end-of-life care plan. These steps are all achievable in the near term.
Payment. We must increase reimbursement and expand how we reimburse for valuable end-of-life consultations to promote greater use of this service. This should be done in our state Medicaid program and State Health Benefit Program. In addition, we must rethink reimbursement policies and rates for palliative care. Moreover, alternative payment models should reward providers that perform well on end-of-life care quality measures.
Education. Physicians and nurses in practice as well as those in medical and nursing school need education and coaching on how to have these difficult discussions with their patients and their caregivers. The medical and nursing schools in the state should develop a common curriculum to be implemented in their programs. Health systems and professional societies should provide and scale both web-based and in-person training, including simulation labs where providers can practice their skills with trained actors. Evidence based programs that address all of these education needs exist and can be implemented in short order.
Culture. The issue goes beyond the world of medicine. We need to change the culture around end-of-life care discussions. This includes an awareness campaign to educate our residents about care options at the end-of-life, including how to discuss care preferences with their providers and caregivers, and how to document decisions so that they will be followed. This work involves community leaders, clergy, social workers, public health departments, senior centers and libraries, and county surrogates. This work must be culturally sensitive and shared in multiple languages.