Clinical Geriatrics

To the Editor,

I just read with interest the article “Advancing Advance Directives” by Dr. Richard Stefanacci.1 I was somewhat surprised that the tone of the article seemed to be about reinventing the wheel. I have spent the better part of three decades in the healthcare arena as a licensed social worker, and we are a tool that is used in many areas to inform, educate, and, in many cases, help execute documents needed for advance planning on end-of-life issues.

While the physicians are already overtaxed with current tasks, I have a hard time reconciling why one more task that can be very time-consuming would be added to their list of reimbursable duties. While advance directives are a wonderful gift to the patient in knowing that his or her wishes are known, it is also a gift to many families in knowing what their loved one’s desires are regarding care. However, you cannot mandate someone’s personal beliefs. There are cultural beliefs that everything should be done to promote life regardless of the quality of life that is measured by others. I feel that those beliefs should be respected, as well as beliefs that differ. I felt that the citing of percentages in ethnic groups was not needed in order to educate the reader. Social workers, particularly in long-term care, have had decades of experience in assisting with this area of care. I personally have addressed groups publicly, as well as assisted physician offices, churches, or anyone requesting help with advance directives. The healthcare delivery system is broken, but I don’t think it is appropriate to infer that personal beliefs are to blame. It is the individual’s choice to have or not to have a feeding tube, ventilator, etc, and it should not be placed solely on the shoulders of the physicians to educate the patient about the risks and benefits from a clinical standpoint instead of the more holistic standpoint taken by most social workers.

With regard to hospice, I would like to state that long-term care has been and is providing end-of-life care with care and respect for the patient. This has been the practice long before the Pilot Projects of 1979. If you want to look at costs, I would suggest that the same dollars be spent increasing education and staff for the many facilities that have hospice come into their facilities to duplicate what is already being done by the staff of the facility. My guess is that the savings would be staggering. I do believe that hospice is very valuable in the community but is not effective in all settings.

Thank you for the opportunity to express my thoughts.

Name withheld
Columbia, SC

Dr. Stefanacci responds:

I sincerely appreciate the three areas of concern that were raised in this letter, and I believe that further clarification would aid this discussion.

To start, it should be stressed in all complex geriatrics care issues that care is best delivered through an interdisciplinary team. Advance directives are a clear example of where the interdisciplinary team can deliver better outcomes. As pointed out in the letter, social workers play a critical role; in our PACE program, social workers lead the process while utilizing the primary care physician team to provide clinical enlightenment. This provides our participants and their caregivers with a comprehensive picture to help base their decisions while having a process that is carefully driven by social workers to assure completion.

Regarding the second issue raised about the use of disparity data, it is critical to note that while disparity data are important to evaluate, they must be evaluated completely. As noted by the letter writer, disparity data may not mean that a disparity of caring exists, but rather may be the result of real differences among differing groups on their views. End-of-life care may, in fact, be one of those cases where disparity data are actually the result of better care than if the number among different groups were exactly the same.