Improving End of Life Care in Veterans’ Affairs Hospitals

For the purposes of this study, the following discussion will focus on the current practices and policies of the Veterans Affairs Hospital at the New York University (NYU) Langone Medical Center as part of the New York Harbor Healthcare System. The NYU Langone Center has received numerous awards and recognitions over the years (NYU.edu, 2014). However, more can be done for the often-overlooked population of patients who are nearing the end of their lives. At the Veterans Affairs Hospital at NYU, services offered to patients identified as going through end-of-life issues include dignity interviews, options for donating healthy organs, options for ceasing dialysis, and more. However, a group of residents of the New York University Internal Medicine-Primary Care Residency program has shown that what is being done for end-of-life patients is not enough (Chang et al, 2011, p. 1). Andrew Chang and his colleagues have proposed numerous changes through the A07617 Palliative Care Patient Information Act that will do much to improve the quality of life for patients with terminal illnesses.

Assessment of policies and standards

The Veterans Affairs Hospital at the New York University (NYU) Langone Medical Center, as part of the New York Harbor Healthcare System, consists of three campuses: Bay Ridge in Brooklyn, St. Albans in Queens and the East Side of Manhattan (NYU.edu, 2014). There are currently forty-nine medical service physicians at the Veterans Affairs Hospital at NYU (NYU.edu, 2014). At this facility, there are three care facilities including medicine, surgery, and psychiatry (NYU.edu, 2014). Within the medicine department, there are 64 beds (NYU.edu, 2014). The Veterans Affairs Hospital at NYU averages 2,300 medical discharges per year (NYU.edu, 2014).

Within the medicine department, there are four practice teams: two based in general medicine, one based in geriatrics, and one based in mental health (NYU.edu, 2014). Each year, the Veterans Affairs Hospital at NYU handles referrals for patients to visit subspecialty clinics to better address their health needs pertaining to cardiology, hematology, gastroenterology endocrinology, pulmonary disease, oncology, rheumatology and infectious disease (NYU.edu, 2014). The Veterans Affairs Hospital at NYU has been selected as the subspecialty center for invasive cardiovascular procedures (NYU.edu, 2014) and has been awarded the recognition of being a Center of Excellence in the treatment of HIV, AIDS and dialysis (NYU.edu, 2014).

The Veterans Affairs Hospital at NYU has a special End-of-Life Fellowship Program geared towards training medical students through a six-week intensive summer program (NYU.edu, 2014). This program’s purpose is to introduce medical students to end-of-life care issues in a way that is not found in the classroom setting (NYU.edu, 2014). During this training program, students learn not just from seasoned doctors, but from experienced chaplains, bereavement counselors and hospice volunteers as well (NYU.edu, 2014).

The NYU Langone Medical Center as a whole makes great efforts in offering discussions and education focused on the unique aspects of end-of-life care. In October of 2012, The NYU Langone Medical Center partnered with Columbia University to offer a ninety-minute seminar discussing the clinical experiences and ethics of end-of-life care in other countries and how they differ from American services (NYU.edu, 2014). Furthermore, the Veterans Affairs Hospital follows the regulations of the A07617 Palliative Care Patient Information Act, signed by Governor Paterson on August 13, 2010 (Chang et al, 2011, p. 1). The A07617 Palliative Care Patient Information Act states that “If a patient is diagnosed with a terminal illness or condition, the patient’s attending health care practitioner shall offer to provide the patient with information and counseling regarding palliative care and end-of-life options appropriate to the patient” (Chang et al, 2011, p. 1).

Procedures and Current practice

The NYU Langone Medical Center, which houses the Veterans Affairs Hospital, offers a number of pertinent end-of-life services. Once the patient has been confronted with the fact that his or her life is coming to an end, the grief process begins. Clients cycle through the stages of denial, depression, anger, bargaining, and, finally, acceptance. It is the responsibility of nursing staff and medical professionals to assist patients in going through this process. It is common for chaplains, counselors and volunteers to be a part of this process (NYU.edu, 2014).

Once a patient has reached the acceptance stage, there are numerous issues to discuss. The NYU Langone Medical Centers offers patients at the end of life the opportunity to donate their healthy organs to needy patients (NYU.edu, 2014). Many hospital personnel have been trained in what NYU calls the "dignity interview" in which a staff member or student resident helps patients to make meaning of their life stories (NYU.edu, 2014). This dignity interview helps patients to remember how strong and vibrant they have been throughout their long lives and helps to put into perspective the fact that all humans must die, but it is how we lived that is important.

Patients approaching the end of life are given numerous choices in the effort to ensure that the patient feels in control and a part of the process. One such choice presented to patients is the option to withdraw from dialysis (NYU.edu, 2014). Dialysis is a process of cleansing the blood and serves only to prolong the inevitable - death. By giving patients the choice of stopping dialysis, patients take control of when they will die. Physicians and nurses also try to facilitate the discussion of what a patient would like to happen after his or her death (NYU.edu, 2014). By helping the patient to discuss this topic with family members, the patient is able to feel more connected with their family members in knowing that the patient's wishes will be carried out after he or she is gone.

Areas of improvement

Despite all the efforts made by the Veterans Affairs Hospital and the Langone Medical Center at NYU as a whole, there are still those who wish to enact changes at the facility. Andrew Chang and his colleagues of the New York University Internal Medicine-Primary Care Residency program are working to improve the quality of life and treatments for terminal patients. Chang et al state, “Every sick and dying patient deserves the right to speak for themselves. Nobody should have to live with pain and suffering or be forced to die alone and deserted in a hospital bed. Protect these patients by passing legislation that requires all hospitals to offer palliative care services” (Chang et al, 2011, p. 1).

Palliative care is a collaboration of efforts from physicians, pharmacists, nurses, chaplains, social workers, psychologists and other health professionals who work together to relieve the suffering of a patient in all areas of life - be they medical, psychological or emotional (Chang et al, 2011, p. 2). While the Veterans Affairs Hospital at NYU provides services to patients at the end-of-life stage, these services are not required. Therefore, some patients may be left untreated, neglected, or not given the full breadth of services. Chang et al (2011, p. 1) found that in the Internal Medicine-Primary Care department of the NYU Medical Center, “only thirteen percent of patients needing end-of-life care are receiving palliative care consultations.” That any patients at all are going without palliative and end-of-life care services is not acceptable, but with such a low percentage of patients found to be receiving services, action must be taken.

Another area of improvement for the Veterans Affairs Hospital at NYU is the quality of communication between physicians and patients. In a study by Lois Downey and her colleagues, researchers found that "clinicians erred more often about patients' wishes when patients did not want treatment than when they wanted it" (Downey et al, 2013, p. 9). This shows that patients who have come to a decision about their own medical care are not being treated as they should by medical professionals. The implications of these findings are severe in that "treatment decisions based on clinicians' perceptions could result in costly and unwanted treatments" that would only cause further suffering to the patient (Downey et al, 2013, p. 9). There must be better communication between clinicians and patients to ensure that patients are receiving the care of their choosing.

Action Plan

In agreement with the proposal set forth by Andrew Chang and his colleagues, the A07617 Palliative Care Patient Information Act ought to be expanded to require hospitals to have organized palliative care services. If a patient does not receive such necessary services, that patient or, after the time of death, the patient’s family should be allowed to bring forth legal action against the hospital on the grounds of negligence. With palliative care mandated, patients will receive thorough and organized end-of-life services. For instance, patients will experience optimized communication so that wishes pertaining to treatment are properly communicated and understood by all medical personnel. Greater emphasis will be placed on managing pain and symptoms, which includes the collaboration of professionals of multiple disciplines ranging from psychology to alternative medicines and more. Also, with palliative care, patients will begin receiving services as they are needed, unlike hospice services, which can only be applied during the last approximately six months of life. Palliative care services can begin as early as the initial stages of diagnosis. Palliative care “helps patients make decisions for themselves while they still can” (Chang et al, 2011, p. 1) and gives them more time to spend with their families and loved ones than in unwanted medical testing or procedures.

Conclusion

Thinking about the end of one's life is never pleasant. Medical professionals have a very difficult job of working with terminal patients. However, it is even more difficult for the patient who is saying goodbye to friends, family, and loved ones. Therefore it is absolutely necessary for medical professionals to be well trained and sympathetic when it comes to working with patients nearing the end of their lives. The NYU Langone Medical Center and the Veterans Affairs Hospital at NYU provide a number of important services to patients nearing death, but more can be done and must be done in order to make the process of accepting death as easy as possible. By expanding on the recent A07617 Palliative Care Patient Information Act, medical personnel can go a long way to improving the quality of life for these patients who will soon be vanishing from our world.

References

Change, A., Chau, C., Cho, J., Eckhardt, B., Eng, J., Shin, J., and Singer, K. (2011) Stop suffering for sick patients: Expand A07617 by requiring hospitals to have organized palliative care services. NYU Internal Medicine-Primary Care Residency Department.

Downey, L., Au, D. H., Curtis, J. R., and Engelberg, R. A. (2013). Life-sustaining treatment preferences: Matches and mismatches between patients' preferences and clinicians perceptions. Journal of Pain and Symptom Management, 46(1), pp. 9-19.

New York University. (2014). VA Hospital. NYU Langone Medical Center. Retrieved from http://medicine.med.nyu.edu/pulmonary/education/fellowship/clinical-fellowship-description/va-hospital

New York University. (2014). Veterans Affairs Hospital. NYU Langone Medical Center. Retrieved from http://www.med.nyu.edu/patients-visitors/our-hospitals/veterans-affairs-hospital