An Open Letter to President Obama on Health Care Reform

Who Are We?

Our societies include the professional and scientific societies representing critical care nurses and physicians, including the American Association of Critical-Care Nurses, the American College of Chest Physicians, the American Thoracic Society, and the Society of Critical Care Medicine. Collectively, these societies represent more than 100 000 health care professionals who work with critically ill patients and their families.

Why Did We Come Together to Write This Letter?

In summary, we are excited about the opportunities that exist for our health care reform process to dramatically improve the delivery of end-of-life care to patients with acute and critical illness in the United States. We are distressed to witness removal of improvements in end-of-life care from the agenda in response to misinformation and rhetoric being spread by those opposed to health care reform. Improving end-of-life care in acute and critical care settings represents a rare opportunity to improve quality of care and simultaneously reduce costs of care. We believe that our nation cannot afford to let improving end-of-life care become a casualty of the health care reform debate.

Why Is This an Important Issue?

One in 5 deaths in the United States occur in the intensive care unit (ICU) or shortly after a stay in the ICU. ¹ At the same time, the proportion of hospital deaths that are preceded by cardiopulmonary resuscitation (CPR) among those aged 65 and older is rising. ² Recent data suggest that when patients and families have earlier and more effective communication about end-of-life care, the result is higher quality end-of-life care that minimizes ineffective life-prolonging treatments and reduces costs. ^{3, 4} Therefore, improving the communication about, and the delivery of, end-of-life care offers us one of those rare opportunities to simultaneously improve quality of care and reduce costs.

What Actions Are We Requesting in This Letter?

We believe health care reform has the potential to dramatically improve the quality of end-of-life care in the United States and simultaneously reduce costs of care with some relatively simple and straightforward steps. These steps include:

• Promoting thorough and careful completion of advance directives under the guidance of knowledgeable and skilled clinicians in the outpatient and community settings with appropriate review when patients’ condition or circumstances change.

• Provide support for training clinicians in effective communication techniques.

• Developing incentives for clinicians, both in the inpatient and outpatient setting, to spend time talking with patients and their families and significant others about their values, treatment preferences, and goals of care at the end of life and document these discussions so they are available when needed.

• Developing incentives for hospitals and other components of the health care system to coordinate advance directives and improve communication about end-of-life care across institutions and settings, so that the wishes of patients can be followed.

Does This Involve Withholding Life-Sustaining Care From Those Who Request This Care?

Absolutely not. We support, for anyone who wants it, using all measures that are indicated and can successfully sustain a person’s life. However, much of the rhetoric opposing incorporation of end-of-life care into health care reform legislation makes the false assumption that such efforts will result in withholding life-sustaining treatments from those who want such treatment. On the contrary, we believe that health care reform can dramatically improve the quality of health care for patients with life-limiting illness or injury simply by ensuring that informed patients and families are able to get the care that they would choose if they were fully informed. We also believe that facilitating communication around these difficult issues will likely be a source of great comfort for patients and their loved ones.

Unfortunately, our current system does not allow many patients and families to make informed choices in a timely way, doesn’t train clinicians to facilitate these difficult conversations with patients and their families, and doesn’t encourage clinicians to take the time to conduct these conversations. Furthermore, our fragmented system means that even if a clinician does take the time to have such a conversation, the information learned from the patient about their values, goals, and treatment preferences are often not disseminated to other clinicians who care for that patient. We firmly believe that improving the quality of care we provide and reducing costs can be accomplished without withholding the desired level of care from anyone. But we do need to change the way our health care system is organized and the way that clinicians and hospitals prioritize end-of-life care if we are going to make dramatic improvements.

We respectfully submit that health care reform will be missing an enormous opportunity if we allow misinformation to remove improvements in end-of-life care from health care reform legislation. We sincerely hope that our United States Government has the wisdom and fortitude to combat misinformation and to retain efforts to improve end-of-life care in the legislation.

Sincerely,