By Dr. Melissa Gaines
As a physician specializing in geriatrics, hospice and palliative care, I work with vulnerable populations who are are nearing the end-of-life. Many days are difficult, but I am guided by an unwavering belief that each person deserves dignity at life’s end. That’s why the following question is important to me - Where do my patients go to die in Springfield, Missouri?
The answer? It depends.
In 2016, I moved my medical practice to Springfield from Wichita, Kansas, so that I could be near my own aging parents. As I got settled in to my new community, I was surprised with the limited options available in our region for end-of-life care. Through my education and experience as a doctor, I have learned that most patients prefer to die at home or in a home-like setting - not in a hospital. In fact, a 2018 study by the Stanford University School of Medicine reveals that 80 percent of Americans would prefer to die at home, but only 20 percent actually do so. Why is there such a disconnect between wishes and reality?
In some cases, it is a fear of being a burden to others. Here’s an example. At one point in my career, I was called to admit one of my medical partner’s patients, a 97-year-old gentleman with a serious infection. His vital signs were consistent with a prognosis of only days left to live. I discussed with him the details of his condition and the options available to him. He chose comfort measures. During our conversation, he expressed concern about being a burden to his daughter who was working full time. To minimize the anticipated burden, he requested to die in the hospital.
This request reflects the sentiment of roughly 10 percent of the patient population who ask to die in the hospital. Patients don’t want to be a burden on their families and/or there is a desire to protect young children from associating death with their childhood home. For others, returning home is not an option because there is no caregiver to provide assistance or skilled nursing interventions are needed and these services cannot be accessed in a home setting.
In the case of our 97-year-old patient, he actually stabilized after receiving comfort care in the hospital which illustrates that some patients can actually live longer with comfort measures. Eventually, our patient was discharged to a nursing home with hospice care.
Patients and their families may find it upsetting when a doctor issues the discharge order from the hospital. I understand this concern, but it is important to remember that hospitals cannot fulfill the role of a long-term care provider. There are limited facilities and staff, and it would be an injustice to patients who need the advanced level of medical and nursing care that a hospital provides.
Unfortunately, patients are often transitioned to and from nursing homes, rehab facilities and hospitals multiple times in the last few months or weeks of life. This disruption is a tragedy as the transfers are often based on complicated payment models and length of stay requirements outlined in insurance policies. The result is a level of care that is not consistent with a person’s end-of-life wishes or medical goals.
So where do my patients go to die in Springfield, Missouri? For many, it is not their home.
In a series of upcoming posts, I will share various scenarios that illustrate the challenges of ensuring that an individual’s wishes for end-of-life care are honored.
Dr. Melissa A. Gaines is an Internal Medicine and Geriatric Specialist in Springfield, Mo.
Note: Have you talked with your medical provider and family members about your preferences for end-of-life decisions? Document your choices in an advance directive and enjoy the peace of mind in knowing that others know how to honor your wishes.