Stellar End-of-Life Care at the VA

VA imageIn observing for the book I am writing about the VA healthcare system I have been observing the most stellar end of life care given by the palliative care and hospice team at the San Francisco VA.  They are doing amazing things in reaching out to physicians to educate them about pain and symptom management for patients with chronic and terminal illness (as Nurse Practitioner Patrice Villars, writes , see A Rant on Terminology: we have to try to find another word for terminal don’t we?).  They are also trying to help physicians slow down the pressure they all too often place on patients so they can help veterans and their families  make more thoughtful decisions about their goals and needs when they are reaching the end of their lives.  I have spent the last two weeks watching physicians, nurse practitioners, social workers, bedside nurses, psychologists, chaplains and a host of others meet with patients and skillfully and graciously talk with them about some of the most difficult issues human beings ever face. In the process, they are also educating residents, interns, nurse practitioner and social work students, oncologists, ICU docs, and many others about palliative and hospice care.  Programs that recently aired on NPR  capture only a small amount of what the VA is doing nationally and locally through its We Honor Veterans’ program.

The hospice benefit for veterans is much more generous than in the private sector (another plus for the VA).  It’s essentially free with no out-of-pocket costs.  And The Community Living Centers (what the VA calls nursing homes — which by the way have far better staffing levels than most other nursing homes in the US) -have hospice beds where veterans can live out their lives until they die.  This is another example of what can happen when you have a genuinely integrated  system of care — the kind which totally lacking in the US in general.  It is of course constrained by not having enough beds and resources to accommodate all the aging veterans who need these kinds of services.  But in the richest country in the world that should be easily remedied.  Right?
Once again, as I hope to show in my upcoming book about the VA and as Philip Longman documented in his Best Care Anywhere, the VA is pioneering systems of care that should serve as a model for our whole nation.  Even the way the VA is trying to deal with wait times and mistakes in the system is interesting to consider given the huge number of problems in the private sector.  It’s interesting to me that when folks lambast the VA, they seem to assume that none of the problems they point to occur in our private healthcare system which is the mostly costly in the industrialized world, infected with greed, and just happens to kill something like 400,000 patients a year because of preventable medical errors and injuries.  For the latest scandal in US healthcare, check out the front page story in the New York TimesVA image about rising Medicare payments for stents put in patients, many of whom could be better managed by helping them learn how to change their diets and exercise.  One cardiologist received $18 million in Medicare payments in just one year.


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