American College of Physicians: Internal Medicine — Doctors for Adults ®


Who's responsible for the ethics in managed care?

From the May 1995 ACP Observer, copyright 1995 by the American College of Physicians.

By Deborah Gesensway

  • Previously published ethics case studies are available online.
  • For additional ethics resources, visit the College's Center for Ethics and Professionalism

Will the doctor-patient relationship, arguably the cornerstone of American medical ethics, survive the confines and conflicts of managed care? How will it evolve to meet the needs of the new health care system?

And, if organizations look to doctors to carry the ethical banner, argued Arthur Feinberg, FACP, medical director at the Center for Extended Care and Rehabilitation at North Shore University Hospital in Manhasset, N.Y., do HMOs have an ethical obligation to set up systems in which ethical behavior can occur? Must managed care organizations revisit their policies and incentives so they do not undermine physicians' ability to respect patient autonomy, to not harm patients and to distribute resources fairly?

About 50 internists from around the country struggled with these unresolved questions during a two-day pre-Session workshop on "Ethics for Internists."

"The doctor-patient relationship will have to be vigorously, loudly and publicly defended," said Mark Siegler, FACP, director of the Center for Clinical Medical Ethics at the University of Chicago. "It's going to be tough, but does the doctor-patient relationship have a future?" He thinks it will because medicine, in large part, is a primitive science, and physicians--the healers who exist in all societies--are to some degree "magicians … respected and wanted by patients."

It is going to be incumbent on physicians, however, to do more to point out ethical concerns raised by business practices in today's health care market. Physicians also must fight for mechanisms to counterbalance the conflicts of interest that threaten the doctor-patient relationship, concluded many of the seminar panelists.

"Managed care didn't cause many of these [moral quandaries being faced by physicians today], but forced us to look at them," said Gail J. Povar, MACP, professor of health care sciences and medicine at George Washington University. "The issue is to find ethically acceptable ways to cope."

Among the remedies Dr. Povar proposed was that physicians assume the role of defending the doctor-patient relationship. "We can't be cynical about our advocacy role," she said. Physicians also have an obligation to accept responsibility for being "competent and compassionate," she said, and can work within organizations to counter some of the inherent threats to ethical medicine. The actions organized medicine can take include:

  • Making sure that a plan's quality assurance methods look for under-service as well as over-service.
  • Doing away with gag rules, so that physicians feel free to talk about all options, so patients can pursue other financing mechanisms to pay for their care, if necessary.
  • Setting up real appellate processes, so that patients get true second opinions.
  • Making physician selection and deselection criteria explicit, so that physicians and patients have a reason to trust referral networks.
  • Increasing the amount of time physician "gatekeepers" spend with patients, because saying "no" always takes longer than saying "yes." Being an effective gatekeeper and a patient advocate, after all, can be mutually exclusive, Dr. Povar said.

Dr. Siegler added that accepting the job of researching necessary and unnecessary care, embracing an emphasis on outcomes research and writing patient-centered guidelines can also help physicians promote ethical reforms of the health care system.

Recognizing the realities of the marketplace is also important, said Susan W. Tolle, FACP, director for the Center for Ethics in Health Care at the Oregon Health Sciences University. It is imperative for the medical profession to begin to address mounting problems with continuity of care. In some communities, she said, employers are switching health plans for their workers as often as every 18 months, she said.

"How can you advocate for a patient when you don't know him?" she asked, particularly when all the pressures are for you to think in terms of your entire patient population or to think like the medical director.

When the data is not there--caring for dying patients

What do we mean when we say a patient is dying? Unfortunately for internists who have to treat dying patients regularly, the answer all too often is "We don't know," said Joanne Lynn, FACP, professor of medicine at Dartmouth Medical School.

"How is it that people die with congestive heart failure? I challenge you to find out," she told an Annual Session workshop on "Caring for Dying Patients." The dying process for various diseases is a field of inquiry that few--if any--medical researchers have taken on since the turn of the century, she said.

This lack of information, she said, makes it very difficult for physicians to "prognosticate dying," which means there is little to go on when trying to discuss treatment options with dying patients and their families, particularly those who want the doctor to do everything.

Dr. Lynn's research has included studying how 10,000 very ill patients in five hospitals actually die. As part of that study, she has been determining the different trajectories toward death that different diseases appear to follow. For example, she said, cancer patients have a "visible spiral" of decline, so that most physicians can predict when a patient has about a month to live. With congestive heart failure, however, she said, the trajectory looks more like a sine wave. "At what point is that person with CHF dying?" she asked.

Her study has also taken a look at what happens to people as they near death. For example, she said, although the vast majority of Americans, when asked, say they would like to die at home, in the end they usually die in the hospital. But patient preference, it turned out, made no difference. Instead, the main determinant of whether patients would die in the hospital had to do with the hospital system's commitment to getting the patient home.

"The more hospital beds you build, the more likely you are going to die in the hospital," Dr. Lynn said.

Despite these great barriers, she said, there are some ways physicians can improve the care they give their dying patients. These include:

  • Improving communication with patients and families. This is true particularly about advance directives, about the potential ill effects of some heroic measures, and about helping patients and their families accept the reality that death is near. The focus can be turned to palliative care if patients and families can be made to recognize that imminent death is a reality, not a probability. Dr. Lynn said that sometimes she finds it helpful to ask a patient, "Have you given any thought to the funeral?"
  • Improving communication with nurses and other health care providers. This is particularly important when you want caregivers to focus on giving care without giving up on the patient. Writing "DNR" on a chart communicates something very different to caregivers, she said, than a note that reads: "CPR is not to be done. Patient is dying. Attend to symptoms, family."
  • Doing more to relieve pain. Dr. Lynn said her study found that more than 85% of conscious patients in their last three days of life in a hospital reported suffering from pain. This can be controlled.
  • Making a follow-up call to the family. The end is usually chaotic, and families are often left feeling confused and sometimes angry. "It's incredibly powerful for a doctor to tell a patient's family that they did a good job," Dr. Lynn said. "It's incredibly thoughtless that we, in general, don't do a bereavement follow-up call."

Finding the right words

How to begin talking to your patients about the tough issue of advance directives

When it comes to talking to patients about the need for advance directives--including a signed living will, a legally appointed medical proxy (sometimes called "durable power of attorney" or a "surrogate") or even simply an oral statement about the patient's general values and wishes--the most difficult part can be starting the conversation.

Susan Tolle, FACP, director of the Center for Ethics in Health Care at Oregon Health Sciences University, gave internists attending a two-day pre-Session course on "Ethics for Internists" some opening statements that, in her experience, tend to break the ice. What works will vary from doctor to doctor, and Dr. Tolle recommends internists craft and practice for themselves a set of sentences they feel comfortable speaking. The idea, she said, is to be able to raise these touchy issues during routine visits, much as physicians would cover other preventive care issues with patients.

For Dr. Tolle, what works goes something like this: "I like to discuss with all my new patients the issue of advance directives. I have literature in my office that I can give to you. If you are ever hospitalized, you will be given the same literature, but I think patients should have a chance to review it and consider these issues before that time."

She also suggested this alternative: "Fairly recently the state established new laws on advance directives. I have information if you are interested. ..."

This method, Dr. Tolle said, lets a doctor show a patient that she is willing to talk about advance directives whenever the patient is ready to do so. On the next visit, she said, she usually follows up by asking the patient, "Do you have any questions about the material I gave you?" It's OK not to come to closure on the topic, she said, and doctors should refrain from pushing their patients too hard toward making decisions about advance directives that they are not yet ready to make.

She also recommends doctors bring up the subject with patients before they get sick, or if a patient is sick, not to frame the need for an advance directive in terms of the illness. For example, she said, phrase it in terms of a car accident, which can happen to anybody. Otherwise, the patient may believe you are subtly--or not so subtly--trying to send him a message about his true condition.

Another helpful hint, she said, is to focus on "who, not what"--meaning try to get your patients to start thinking about who they trust and feel knows them best and would want to speak for them if their medical condition necessitated a proxy. Patients tend to be less threatened by this kind of a discussion than by one about what types of medical treatments they might want if they are incapacitated.

Dr. Tolle also stressed the importance of physicians' knowing their states' laws on advance directives and medical proxies, because these vary widely and influence conversations with patients. Several organizations have lists of state laws. These include the various "Right to Die" patient-advocacy organizations and the Intergovernmental Health Policy Project at George Washington University in Washington, D.C. (202-872-1445).

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