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Karen M. Wyatt, MD Gateway Alliance Conference August 8, 2013 WHAT REALLY MATTERS: A PHYSICIAN’S VISION FOR THE FUTURE OF CARE AT THE END OF LIFE.

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Presentation on theme: "Karen M. Wyatt, MD Gateway Alliance Conference August 8, 2013 WHAT REALLY MATTERS: A PHYSICIAN’S VISION FOR THE FUTURE OF CARE AT THE END OF LIFE."— Presentation transcript:

1 Karen M. Wyatt, MD Gateway Alliance Conference August 8, 2013 WHAT REALLY MATTERS: A PHYSICIAN’S VISION FOR THE FUTURE OF CARE AT THE END OF LIFE

2 I have no actual or potential conflict of interest in relation to this presentation. Karen Wyatt, MD August 8, 2013 DISCLOSURE:

3 Objectives: At the end of the presentation participants will be able to: Identify 4 factors within the Western medical model that create obstacles for physicians in providing effective end-of-life care. Recognize the unique challenges and opportunities for the future of end-of- life care that accompany the aging of the Baby Boom generation. Describe the components of an Integral approach to the end-of-life that can help meet the challenges of the future. Utilize Integral concepts to engage physicians in the creation of a new, shared vision for end-of-life care.

4 Who am I and why am I talking about the end-of-life and spirituality? Family practice physician Many years of experience as hospice medical director Storyteller and writer Lifelong seeker of spiritual wisdom

5 Workshop Outline: 1.The Current Problem: Difficulty engaging physicians in the end-of-life process results in late referrals and short lengths of stay 2.The Source of the Problem: How the Western medical model creates obstacles for physician engagement in the end-of-life process 3.What the Future Holds: 1.Integral Medicine is coming 2.Baby Boomers are changing everything! 4.A New Vision for End-of-Life Care: How to change our approach and increase engagement with Western medical providers using the Integral model 5.Q&A

6 Difficulty engaging physicians in the end-of-life process creates THE PROBLEM

7 The Problem: Physicians Reluctant to Engage in End-of-life Care – Unmet Needs of Patients 2011 Nebraska End-of-Life Survey Results: “70 percent of patients surveyed want their doctors to discuss their end-of-life care options, yet only 21 percent …had heard about hospice care from a doctor.” results/pdf_f5c93ec4-ce4f-5edb-9b46-5bb html

8 The Problem: Physicians Reluctant to Engage in End-of-life Care – Good News and Bad News Centers for Disease Control: Good News: “Hospice use at the time of death increased from 21.6% in 2000 to 42.2% in 2009.” Twice as many patients referred! Bad News: “28.4% of those hospice patients referred in 2009 received 3 days or less of hospice care.” Too little care to make an impact. Teno, et al.;JAMA. 2013;309(5): doi: /jama

9 The Problem: Physicians Reluctant to Engage in End-of-life Care – False Hopes Dana-Farber Cancer Institute: Of 1,274 stage IV lung and colon cancer patients in the study who were receiving chemotherapy “69% of the lung cancer patients and 81% of the colon cancer patients did not understand that the chemotherapy they were receiving was not likely to cure their disease.” Weeks, et al.; N Engl J Med 2012; 367:

10 The Problem: Physicians Reluctant to Engage in End-of-Life Care – Missed Opportunities Dana-Farber Cancer Institute: “Terminally ill patients who talk to their doctors about EOL care at least a month before they die are more likely to choose therapy that is less aggressive— therapy aimed more at making them feel better than at prolonging life.” Mack, et al.; J Clin Oncol Dec 10;30(35):

11 The Problem: Physicians Reluctant to Engage in End-of-life Care – Decreased Survival National Hospice and Palliative Care Organization: “the mean survival was 29 days longer for hospice patients than for non-hospice patients.” ConnorSR, et al. J Pain Symptom Manage Mar;33(3):238-46

12 The Problem: Physicians Reluctant to Engage in End-of-life Care – Diminished Quality of Life Harvard University: “Physicians who are able to remain engaged and ‘present’ for their dying patients – by inviting and answering questions and by treating patients in a way that makes them feel that they matter as fellow human beings – have the capacity to improve a dying patient’s [quality of life].” Zhang B, et al "Factors important to patients' quality of life at the end of life" Arch Intern Med 2012; doi: /archinternmed

13 …treating dying patients in a way that makes them feel that they really matter … improves their quality of life …

14 So why do doctors struggle to engage with their patients at the end-of-life?

15 The Western Medical Model has inherent obstacles to embracing the end-of-life and is one SOURCE OF THE PROBLEM

16 How Doctors Learn About Death & Dying Statistics from The National Report on The Status of Medical Education in End-of-Life Care*: Less than 18% of students and residents surveyed had received formal end-of-life care education 39% felt unprepared to address patients’ fears about death Nearly 50% felt unprepared to manage their own feelings about death 40% felt that dying patients were not considered good teaching cases and that meeting the psychosocial needs of dying patients was not a core competency *Sullivan, et al., J Gen Intern Med September, 18(9):

17 Obstacles to End-of-Life Care for Western Medical Physicians: 1. The Science of Medicine Measurable Objective Materialistic Outcome oriented (Focused on “Cure”)

18 Obstacles to End-of-Life Care for Western Medical Physicians: 1. The Science of Medicine Measurable Objective Materialistic Outcome oriented (Focus on “Cure”) 2. The System of Medicine Time limitations Lack of reimbursement Medicare regulations Malpractice litigation Lack of training in medical schools

19 Obstacles to End-of-Life Care for Western Medical Physicians: 1. The Science of Medicine Measurable Objective Materialistic Outcome oriented (Focus on “Cure”) 3. The Culture of Medicine Hierarchical Territorial and fragmented Poor communication between disciplines Unrealistic expectations (“Our job is to sustain life”) 2. The System of Medicine Time limitations Lack of reimbursement Medicare regulations Malpractice litigation Lack of training in medical schools

20 The “Hidden Curriculum” From the National Report on the Status of Medical Education in End- of-Life Care: “In the clinical arena, students are systemically protected from, or deprived of, opportunities to learn from caring for dying patients. When they do participate in this care, they lack role models with expertise to learn from, as well as feedback and support that facilitate clinical growth.” *Sullivan, et al., J Gen Intern Med September, 18(9):

21 Obstacles to End-of-Life Care for Western Medical Physicians: 4. Personal Experience Unhealed grief Denial of death Fear of the unknown 1. The Science of Medicine Measurable Objective Materialistic Outcome oriented (Focus on “Cure”) 3. The Culture of Medicine Hierarchical Territorial and fragmented Poor communication between disciplines Unrealistic expectations (“Our job is to sustain life”) 2. The System of Medicine Time limitations Lack of reimbursement Medicare regulations Malpractice litigation Lack of training in medical schools

22 The Doctor’s Quiet Grief Findings from a study of oncologists at 3 Canadian hospitals: > 50% struggled with feelings of failure, self-doubt, sadness and powerlessness Unacknowledged grief led to inattentiveness, impatience, irritability, emotional exhaustion and burnout 50% distanced themselves and withdrew from patients as they got closer to dying 50% reported unhealed grief altered their treatment decisions with subsequent patients (resulting in more aggressive treatment and reluctance to recommend palliative care or hospice) Arch Intern Med. 2012;172(12):

23 Negative Attitudes About Death and Dying: 4. Personal Experience1. The Science of Medicine “Death is an unacceptable outcome.” 3. The Culture of Medicine2. The System of Medicine

24 Negative Attitudes About Death and Dying: 4. Personal Experience1. The Science of Medicine “Death is an unacceptable outcome” 3. The Culture of Medicine2. The System of Medicine “Death and dying are not important”

25 Negative Attitudes About Death and Dying: 4. Personal Experience1. The Science of Medicine “Death is an unacceptable outcome” 3. The Culture of Medicine “Death is a failure” 2. The System of Medicine “Death and dying are not important”

26 Negative Attitudes About Death and Dying: 4. Personal Experience “Dying is a hopeless tragedy” 1. The Science of Medicine “Death is an unacceptable outcome” 3. The Culture of Medicine “Death is a failure” 2. The System of Medicine “Death and dying are not important”

27 WHAT DOCTORS NEED TO LEARN ABOUT DEATH AND DYING

28 What Doctors Need to Learn About Death & Dying 1. Death is inevitable 2. Death is a mystery. 3. Death makes life more precious. 4. Dying provides an opportunity for transformation.

29 “Integral Medicine” is on the horizon WHAT THE FUTURE HOLDS – PART 1

30 What is “Integral Medicine?” Based on the work of Ken Wilber “Integral” comes from the Latin word for “whole” Provides a comprehensive map for analyzing a patient, an illness, a problem or a system from multiple perspectives

31 The 4 Perspectives of Integral Medicine: Emotional/Spiritual Physical Culture & Community Social Systems

32 Obstacles for Physicians in Western Medicine to End-of-Life Care: 4. Personal Experience1. The Science of Medicine 3. The Culture of Medicine2. The System of Medicine

33 The 4 Perspectives of Integral Theory Applied to End-of-Life Care Issues for MD’s: Emotional/Spiritual 4. Personal Experience Physical 1. The Science of Medicine Culture & Community 3. The Culture of Medicine Social Systems 2. The System of Medicine

34 The 4 Perspectives of Integral Medicine Emotional/SpiritualPhysical Physical exam Diagnostic tests Medication Surgery Culture & CommunitySocial Systems

35 The 4 Perspectives of Integral Medicine Emotional/SpiritualPhysical Physical exam Diagnostic tests Medication Surgery Culture & CommunitySocial Systems Living situation Economic factors Insurance Healthcare policies Social delivery system

36 The 4 Perspectives of Integral Medicine Emotional/SpiritualPhysical Physical exam Diagnostic tests Medication Surgery Culture & Community Relationships Group values Cultural beliefs Meaning of illness Social Systems Living situation Economic factors Insurance Healthcare policies Social delivery system

37 The 4 Perspectives of Integral Medicine Emotional/Spiritual Emotions Psychological attitudes Spiritual Practice Intentions Physical Physical exam Diagnostic tests Medication Surgery Culture & Community Relationships Group values Cultural beliefs Meaning of illness Social Systems Living situation Economic factors Insurance Healthcare policies Social delivery system

38 The Characteristics of Integral Medicine Comprehensive Balanced Interdisciplinary Multiple perspectives Team approach Individualized care Whole-person care

39 Western Medicine is Out of Balance Emotional and Spiritual Physical CulturalSocial Systems

40 Integral Medicine v. Western Medicine Integral Medicine Characteristics: Western Medicine Characteristics: Whole-person careOrgan System-focused IndividualizedStandardized BalancedPredominantly Physical InterdisciplinarySpecialized Team approachFragmented ComprehensivePartial

41 Integral Medicine and Hospice Care Integral Medicine Characteristics: Hospice Care Characteristics: Whole-person care ✔ Individualized ✔ Balanced ✔ Interdisciplinary ✔ Team approach ✔ Comprehensive ✔

42 Hospice Care is Balanced and Integral Emotional/Spiritual Chaplains Mental Health Care Providers Grief Counseling Spiritual Support Physical Nurses Home Health Aides Medical Providers Symptom Relief Comfort and Dignity Culture & Community Volunteers Community Outreach Relationships Family Support Social Systems Social Workers Insurance Medicare Benefit In-home or Inpatient Facility

43 78 million Baby Boomers are approaching the last stages of life WHAT THE FUTURE HOLDS – PART 2

44 The Baby Boom “Tsunami” “For the next 18 years, one American will turn 60 years old every seven seconds.” “Every day 10,000 Baby Boomers become eligible for Medicare.”

45 Characteristics of the Baby Boom Generation: More likely to be college graduates than previous generations Independent and self-reliant Youthful mindset 20% of women are childless (double the previous generation)

46 Characteristics of the Baby Boom Generation: Savvy, discerning consumers Focused on longevity Interested in fitness and wellness Demand choice

47 How do Baby Boomers differ from their parents? Traditional Generation Values: Baby-Boom Generation Values: Conformity Following the rules Respect for authority Hierarchy Past-oriented

48 How do Baby Boomers differ from their parents? Traditional Generation Values: Baby-Boom Generation Values: ConformityIndependence Following the rulesIndividual choice Respect for authoritySelf-actualization HierarchyTeam approach Past-orientedGoal-oriented

49 How Baby Boomers are Changing the Culture of Medicine: Demand information and choices Demand convenience Do research on the internet - 74% use the internet daily (according to Pew Research Center) and 78% of users seek out health information online Comparison shopping – use online reviews and ratings to choose doctors and medical facilities Communicate and network with other patients

50 What needs to change? Culture of Medicine Values: Traditional Generation: Baby Boomer Generation: Hierarchical ✔✖ Authoritarian ✔✖ Territorial ✔✖ Lack of communication ✔✖

51 How Doctors are Reacting to Change: According to a survey by Deloitte Center for Health Solutions: 60% of physicians surveyed “said they expect many of their colleagues to retire earlier than planned in the next 1 to 3 years.” BUT they may not be able to retire: “Seventy-five percent of Americans nearing retirement age in 2010 had less than $30,000 in their retirement accounts.” - Teresa Ghilarducci, Professor of economics at New School for Social Research

52 Integral Medicine and Hospice Care Integral Medicine Characteristics: Hospice Care Characteristics: Whole-person care ✔ Individualized ✔ Balanced ✔ Interdisciplinary ✔ Team approach ✔ Comprehensive ✔

53 Integral Medicine and Hospice Care are Perfect for Baby Boomers: What Baby Boomers Want: Integral Medicine Characteristics: Hospice Care Characteristics: Whole-person care ✔✔ Individualized ✔✔ Balanced ✔✔ Interdisciplinary ✔✔ Team approach ✔✔ Comprehensive ✔✔

54 Challenges for Hospice in the “Baby Boom Tsunami” Increased patient numbers Increased demand for information and transparency Increased divorce rate among boomers resulting in more complicated family structures and issues to deal with Less interest in organized religion and more interest in “spirituality” Increased demand for alternative care modalities Increased number of single and/or childless patients Possible increased demand for physician-assisted suicide

55 Opportunities for Hospice in the “Baby Boom Tsunami” Increased patient numbers Likely to demand a rational, patient-centered approach to end of life care Preference for “natural death” Desire to “Age in Place” Likely to choose “quality” of days over “quantity”

56 Opportunity The greatest opportunity for the hospice and palliative movement in the coming “Baby Boom Tsunami” lies in the demand for change in the culture of Western medicine. The movement should step up to provide leadership and expertise in the evolution of Western medicine toward patient-centered, integral care.

57 How to achieve A NEW VISION FOR END-OF-LIFE CARE

58 A New Vision: Any new vision of end-of-life care must include greater involvement from physicians of every specialty … and the hospice movement must learn how to create and share that vision.

59 Obstacles to End-of-Life Care for Western Medical Physicians: 4. Personal Experience Unhealed grief Denial of death Fear of the unknown 1. The Science of Medicine Measurable Objective Materialistic Outcome oriented (Focus on “Cure”) 3. The Culture of Medicine Hierarchical Territorial and fragmented Poor communication between disciplines Unrealistic expectations (“Our job is to sustain life”) 2. The System of Medicine Time limitations Lack of reimbursement Medicare regulations Malpractice litigation Lack of training in medical schools

60 How to Engage Doctors in End-of-Life Care Obstacle:Solution: 1. The Science of Medicine Measurable Objective Materialistic Outcome oriented (Focused on “Cure”) Offer scientific studies that show the value of hospice and palliative care and patient preferences for end- of-life* Offer training in pain management *Find a Bibliography of End-of-Life studies and articles on my website at

61 How to Engage Doctors in End-of-Life Care Obstacle:Solution: 2. The System of Medicine Time limitations Lack of reimbursement Medicare regulations Malpractice litigation Lack of training in medical schools Provide patient education materials and resources on end-of-life care* Offer to evaluate patients for appropriateness for admission Offer trainings for office staff on dealing with terminal patients, grief *Find a list of resources on my website at

62 Online Resources for End-of-Life Issues The Conversation Project: offers a conversation “Starter Kit” to encourage families to discuss end-of-life issues. Aging With Dignity: Five Wishes – a questionnaire that allows patients to record their medical, personal, emotional, and spiritual wishes for the end-of-life; can be used as an advanced directive BE Ready: Checklist for End-of-Life Planning What Really Matters Radio Show: Lessons from the End-of-Life End-of-Life University Interview Series: Free interviews with experts about end-of-life issues

63 How to Engage Doctors in End-of-Life Care Obstacle:Solution: 3. The Culture of Medicine Hierarchical Territorial and fragmented Poor communication between disciplines Unrealistic expectations (“Our job is to sustain life”) Offer rotations in hospice care for medical students Provide CME lectures for medical providers on end-of- life issues and baby boomers Offer “Lunch and Learn” lectures for residents and interns about end-of-life issues Start a monthly “Death Café” discussion group

64 How to Engage Doctors in End-of-Life Care Obstacle:Solution: 4. Personal Experience Unhealed grief Denial of death Fear of the unknown Provide grief support for hospital and medical staffs Offer annual memorial service for all patients who have died Tell stories of hospice patients and their families Encourage hospitals to create “Death Rounds” to discuss difficult patient deaths

65 Transform the Negative Attitudes: 4. Personal Experience “Dying is a hopeless tragedy” 1. The Science of Medicine “Death is an unacceptable outcome” 3. The Culture of Medicine “Death is a failure” 2. The System of Medicine “Death and dying are not important”

66 Transform the Negative Attitudes: 4. Personal Experience “Dying is a hopeless tragedy” 1. The Science of Medicine “Death is an unacceptable outcome”  “ Death is inevitable” 3. The Culture of Medicine “Death is a failure” 2. The System of Medicine “Death and dying are not important”

67 Transform the Negative Attitudes: 4. Personal Experience “Dying is a hopeless tragedy” 1. The Science of Medicine “Death is an unacceptable outcome”  “ Death is inevitable” 3. The Culture of Medicine “Death is a failure” 2. The System of Medicine “Death and dying are not important”  “Death makes life more precious”

68 Transform the Negative Attitudes: 4. Personal Experience “Dying is a hopeless tragedy” 1. The Science of Medicine “Death is an unacceptable outcome”  “ Death is inevitable” 3. The Culture of Medicine “Death is a failure”  “Death is a mystery” 2. The System of Medicine “Death and dying are not important”  “Death makes life more precious”

69 Transform the Negative Attitudes: 4. Personal Experience “Dying is a hopeless tragedy”  “Dying provides an opportunity for transformation” 1. The Science of Medicine “Death is an unacceptable outcome”  “ Death is inevitable” 3. The Culture of Medicine “Death is a failure”  “Death is a mystery” 2. The System of Medicine “Death and dying are not important”  “Death makes life more precious”

70 End of Life Transformation Love Forgiveness Living fully in every moment Meaning and purpose

71 The “New Vision” for End-of-Life Care: 1. All patients have the opportunity to have suffering relieved and dignity maintained while receiving whatever level of care they desire at the end-of-life. 3. Care is provided in a seamless continuum from diagnosis to treatment to palliation to hospice, by a collaborative team with a shared goal. 2. The last 6 months of a person’s life are considered as important as the first 6 months and this is reflected in medical education and social policies. 4. Death and the dying process are valued and revered as transformative teachers of sacred life wisdom.

72 It’s up to us … … to lead the way!

73 To teach the world that you must hold Life and Death in the same hand …

74 For… Life is not possible without Death

75 To live in this world you must be able to do three things: to love what is mortal;

76 to hold it against your bones knowing your own life depends on it; and when the time comes to let it go,

77 to let it go. From: In Blackwater Woods By Mary Oliver

78 QUESTIONS OR COMMENTS?

79 End-of-Life University FREE series of online interviews Targeted for the general public 3 audio interviews per day X 4 days during Hospice Awareness Month

80 Connect With Me! Sign up for my newsletter at: Go to to download EOL Resource List and Bibliographywww.karenwyattmd.com/end-of-life me: Tune in to What Really Matters Radio Show Archives: End-of-Life University: Nov , 2013: Facebook: https://www.facebook.com/karenwyattmd

81 Thank you for this opportunity to share stories and thoughts with you! May you be blessed in your healing work! KAREN WYATT MD address: Website:


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