Hospitalists have a positive impact on end-of-life care

By Kimberly Wong

Hospitalists—the physicians who focus specifically on managing the care of hospitalized patients—have a positive impact on end-of-life care, according to clinician researchers at UCSF Medical Center.

“Despite concerns that hospitalists might worsen care for dying patients because they don’t know patients as well as their primary care provider might, our study found that hospitalists performed well in controlling uncomfortable symptoms for dying patients and made considerable effort to communicate with patients and their family members,” said Andrew Auerbach, MD, MPH, a hospitalist at UCSF Medical Center and the lead author of the study.

The study appears in the May 15 issue of the American Journal of Medicine.

“This is comforting news for patients who are nearing the end of their lives in a hospital setting, as well as their families,” said Steven Pantilat, MD, director of the palliative care service at UCSF Medical Center and a co-author on the study.

According to the researchers, patients of hospitalists had fewer chart-documented symptoms of pain, anxiety and abnormal or uncomfortable breathing in the last days of life. In addition, hospitalists documented care-discussions in patient charts more often than community physicians (primary care providers) and were more likely to attend family meetings about end-of-life care.

The hospitalist model of care can represent a challenge to the care of dying patients because of the discontinuity it introduces into patient care, said Auerbach. For dying patients closeness with their primary care provider may facilitate discussions about end-of-life care and planning because the provider has knowledge of subtleties of patient preferences, culture or values.

However, despite this discontinuity of care, hospitalists may have other advantages in communication with dying patients and their families because they are in the hospital for more time each day, increasing the likelihood that family members will have contact with them, said Auerbach. In addition, the specialized training that hospitalists often receive in end-of-life care may translate into differences in use of effective therapies, he said.

The researchers analyzed records from 1997 to 1999 from Mount Zion Hospital which was, until 1999, a 280-bed community-based teaching hospital affiliated with UCSF.  The facility, now called the UCSF Medical Center at Mount Zion, provides inpatient and outpatient services, including the UCSF Comprehensive Cancer Center and the UCSF National Center of Excellence in Women’s Health.

Community based physicians cared for the vast majority of hospitalized patients at Mount Zion Hospital. In general, these doctors were outpatient-focused physicians who served as physicians of record for their inpatients while maintaining a clinical practice outside the hospital. Mount Zion hospitalists were UCSF faculty based at Mount Zion who served as attending physicians six to eight months per year. Hospitalists cared for patients without primary care physicians, patients whose primary care physicians were other faculty or residents, and patients whose community-based physician chose to use the hospitalist service.

Despite the findings, the researchers conclude that the study has several limitations. First, it describes care provided by a small number of hospitalists at a single site. Because researchers depended on chart information, results may be subject to documentation biases. The researchers did not have access to information regarding family member satisfaction. Nonetheless, in a hospital where all patients were cared for by the same group of nurses and residents, the presence of hospitalist physicians appeared to provide an advantage for patients who died in the hospital, said Auerbach.

This study was funded by the Agency for Healthcare Research and Quality (AHRQ) and the National Institute on Aging.