Video Helps With End-of-Life Options

Physicians are often uncomfortable discussing end-of-life care options with terminally ill patients. Even when doctors raise the issue, they may gloss over the details. With little knowledge of their choices, patients often agree to aggressive treatment even when there's no hope of survival.

But a series of new videos are helping to jump-start the conversation -- and giving patients more power over how their last days will play out. About 200 hospitals, clinics and health systems, including Kaiser Permanente, are showing the videos to dying patients.

The videos, which were developed by Harvard Medical School doctors, present three end-of-life options: life-prolonging care, limited care or comfort care. Life-prolonging care extends life at any cost and includes CPR, intubation, mechanical ventilation and intensive-unit care. Limited medical care maintains basic physical and mental functions, with hospitalization, intravenous fluids and antibiotic treatments. It excludes CPR, intubation, mechanical ventilation and care in the intensive unit. Comfort care focuses on comfort and alleviating suffering, and typically includes medications to relieve symptoms. It avoids hospitalization, unless necessary to provide comfort.

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Mitsuo Oshiro, 81, of Kaimuki, Hawaii, watched the video in February after he was diagnosed with esophageal cancer. Oshiro knew he didn't want to die like his wife did in 2002 from lung cancer -- tethered to machines in the intensive-care unit. But he wasn't sure of his options.

Oshiro's daughter, Lena Katekaru, 53, sat with her father during the video. "While we watched the video, my father was nodding in agreement" to comfort care. They even watched a Japanese version. "I wanted to make sure he understood," Katekaru says.

The video portrayed each option "objectively," she says, including the possible cracked ribs during CPR and metal breathing tubes inserted down dying patients' throats during life-prolonging care. Oshiro opted for hospice care, which focuses on alleviating suffering rather than on treating his cancer.

Giving Patients More Say

Like Oshiro, most people prefer to die at home, surrounded by family and friends. However, people often die in hospitals -- even when an advanced-care directive spells out preferences for palliative care.

The Hawaii medical establishment is leading the charge on involving patients in advanced-care planning. The Hawaii Medical Service Association, the state's Blue Cross Blue Shield affiliate, is underwriting the effort to distribute the videos to every hospital, nursing home, hospice and doctor's office. The 30-plus videos are available in several languages and cover topics including advanced dementia, heart failure, advanced cancer and introduction to hospice.

The videos -- and the ensuing conversations with patients -- help the physicians as well as the patients. In the U.S., doctors are trained to take a no-holds-barred approach to prolong the lives of dying patients, using resuscitation and high-tech interventions. A lot of people end up receiving aggressive care "by default," says Dr. Rae Seitz, medical director of the Hawaii Medical Service Association.

Several thousand patients have used the videos during clinical field tests, says Dr. Angelo Volandes, a Harvard Medical School doctor and co-founder of ACP Decisions, the nonprofit that makes the videos. Researchers have found that dying patients who watch the videos are less likely to opt for aggressive care than if they're simply told their options during a conversation with their doctor. "Delivering medical care at the end of life that is aligned with patient preferences is a critical ingredient of high-quality medical care," says Volandes. The videos are available to patients only through a health care provider.

After watching the video with his daughter and doctor, Oshiro signed a "physician order for life-sustaining treatment" (POLST), a directive that acts as a medical order to doctors. The order, which is signed by seriously ill patients and their doctors, goes into the medical record. While advance directives provide guidance perhaps years before an actual event, a POLST is a medical order the health care clinicians must follow.