Interview with Brad Stuart, MD

Brad Stuart, MD, is Senior Medical Director at Sutter VNA & Hospice, and the primary author of Medical Guidelines for Prognosis in Selected Non-Cancer Diseases, used to develop the national Medicare hospice eligibility criteria. He has received the Heart of Hospice Award from the National Hospice and Palliative Care Organization, and the California State Hospice Association’s Pierre Salmon Award. In 2007, he was voted “Physician of the Year” by the California Association for Health Services at Home. Dr. Stuart was featured in the HBO documentary Letting Go: A Hospice Journey, and has been interviewed on ABC’s Good Morning America. He wrote and hosted Care Beyond Cure: Hospice Helping Physicians Treat the Terminally Ill, a nationally televised medical continuing education video that won an International Angel Award for Media Excellence. He has published widely and lectured internationally on medical, psychosocial, and spiritual issues at the end of life. This is Dr. Stuart’s third appearance on an HFA teleconference.

Q. Part of your work with the Sutter VNA and Hospice Care was in piloting the AIM (Advanced Illness Management) Program. Can you talk more about that?

A. AIM originally began with funding from the Robert Wood Johnson Foundation in 1998; it was one of 22 grantees under their “Promoting Excellence in End-of-Life Care” program.  The Advanced Illness Management (AIM) program provides home-based palliative care and "transition management" for patients with advanced chronic illness. AIM home care and hospice nurses, social workers and other team members provide pain and symptom management, advance care planning, and end-of-life care to patients who are not yet ready for hospice, or have refused hospice enrollment. Sutter VNA and Hospice Care is a large (26 hospital) integrated system, and the largest nationally that is a non-profit based in one specific geographic area of Northern CA. Our new CEO is very enthusiastic about the AIM model, and we are now piloting a much bigger rollout of the program this fall.

The original program was focused primarily on nurse practitioners visiting homes under the Medicare Plus Choice program. As changes occurred in health care funding, it became necessary to make some changes in the program.  As the Primary Investigator, I realized that the program could be based in the Medicare Home Health option.  Even though Home Health is primarily focused on patient recovery and safety, I was seeing that approximately 5% of home care patients were actually ready for hospice.  I felt it would be more useful to expose people to the broader concept of care rather than waiting for hospice to come in—always keeping in mind that the ultimate goal is to get more people in to hospice, and in earlier,  through home care.

Q. Does the use of the AIM model actually encourage earlier use of hospice care?

A. Yes, one of the major outcomes of the program has actually been getting people into hospice earlier. And an unexpected outcome has been that we’ve witnessed a closing of the disparity between white and African American usage of hospice care. We did not initially stratify our data by race, but when we went back and looked, we saw that there was virtually no difference between white and African American utilization of hospice among AIM patients.  I think the basics of the program allowed this to happen.  We took staff to homes, to where people were. We started the conversations and had them repeatedly, and that combination got patients to hospice earlier. I think one lesson learned is the necessity of institutionalizing advanced care planning, so the doctors can get these conversations going earlier.

Q. Has the AIM program been replicated by other organizations?

A. Other programs have begun to adopt the AIM model, even in different healthcare settings. The Visiting Nurses Services of New York (VNSNY) have started their own AIM program, even though they focus solely on home care and hospice.  Sutter VNA has not standardized the model, but has tried to be helpful to other groups that are interested.

If you look down the road at health care reform, there will most likely be the need to provide more integrated care. AIM has been a little bit out front with this, building a business model even under the current reimbursement system.  So it can be shown that the model has financial benefits as well.

Under the current system, Medicare is a “loser” for hospitals, so hospitals are shifting costs to health care plans. This is a recipe for disaster, especially in our current economy. AIM targets the “sickest of the sick”. It works because it is needed; it is for those who are hospice-appropriate; it targets the most costly patients.

Q. What changes have you seen in cancer treatment over the past years, and how have those changes impacted the decision-making process for physicians?

A. There have been big changes in treatments, and the impacts of these changes are borne out in the literature. It is clear that cancer care has become more aggressive—this can be seen, for instance, by the number of lung cancer patients who are admitted to the ICU, or who are treated late into their cancer with ventilators or chemotherapy.  One researcher, Dr. Craig Earle, actually advocates that chemotherapy use in cancer patients with end-stage cancer be an indicator of poor quality care.

The implications for advance care planning, end-of-life care, and hospice are huge. The availability of late treatments, most of which are not effective at curing the cancer, makes it much more difficult for patients to get into hospice earlier.  The good news is that ~60% of cancer patients get into hospice. And a study by Stephen Connor has shown that patients with several major cancers live longer in hospice care.   

But the bad news is that with more aggressive treatments, the Length of Stay in hospice is getting shorter and shorter. In many ways, hospice has become an “emergency” service—physicians contact hospice when a patient’s pain and symptoms are out of control, but by that point the patient may only end up in hospice 1 or 2 days before death.  Approximately 10% of all patients enrolled in hospice care die within 24 hours. This is intensely tough on the staff, who does not have the opportunity to bring the full range of benefits to patients and families. And it’s tough from an economic standpoint. Hospice ends up being “tacked on” to the end of a long line of aggressive, but ultimately futile, treatments. Instead of hospice preventing utilization of other treatments, it just becomes another cost, as the first and last days in hospice care are the most expensive.

Q. Can you address the occupational stresses of health care professionals who work in end-of-life care?  

A. This is a huge issue in medicine. It’s understood that physicians don’t receive any real training in handling end-of-life issues, but it takes more than just training. In a recent meeting we had with the panel for HFA’s upcoming teleconference, Dr. Richard Payne asked, “Can you teach compassion?” I think that you can, but it boils down to having the courage to say the right things and the perseverance to make sure those things are heard, to the extent people are willing.

Nurses tend to do better, but dealing with the hard emotions that go along with caring for the dying,  and continuing to find it fulfilling, is a great challenge.  How do you learn to sit with something that can’t be fixed? So much of the protest we hear today against end-of-life planning is based in fear or anger, but in reality this work means being present for the most profound times in people’s lives.

Q. What are some personal or organizational techniques that you’ve found to be helpful?

A. I think we need to realize that the real work starts when options for cure have run out. For physicians, the real work is centered in ourselves, and the need to become more aware. For many physicians this work is not necessarily a “calling”—that’s why it takes practice. This awareness of our own fear, our own pain, is our real “practice.”  You can work to become more competent and more confident in helping patients face the end of life. And when you are in a room at a family meeting, that family can feel your confidence. When that professional confidence is there, the family can really hear what you are saying and they can really think about what decisions they need to make.

In talking to other professionals about having those difficult conversations, I try to start where they are comfortable. Try to get into why people became doctors. I firmly believe that everyone wants to be a part of the healing process. We all want to be healed, even when we can't be cured.  

Q. This will be the 3rd HFA teleconference on which you’ve been a panelist. What has that experience brought to your work, and what value have you found as a physician in participating in the program?

A. I love this particular topic [Cancer and End-of-Life Care]; it’s very timely and important. One of the great things about this teleconference is that it gives us the luxury to really talk about these issues in some depth. For someone like me in this field to have the time to really explore some of these issues—it’s very rare to have concentrated time to look at these important issues in depth, and I’m pleased to be a part of it again.

September 2009