Month: July 2020

Palliative Care and Artificial Intelligence for Predicting Death

nancyvalko Compassion & Choices, dementia, economics, end-of-life, law, medical ethics, palliative care

Working in areas like critical care, oncology (cancer) and hospice for over 45 years, I know that it is often hard to predict how long someone may live or when that person may die.

I have seen very ill or injured people with an optimistic prognosis  unfortunately die and I have seen people expected to die very soon who recovered and went on to live for years. Back then, we used pain and other specialists, social workers, ministers, etc. for all our patients when needed. Some of our patients went into hospice.

In recent years, a new specialty called palliative care was developed to improve the quality of life for patients who have a serious or life-threatening disease with the goal of preventing or treating as early as possible, the symptoms and side effects of the disease and its treatment, in addition to any related psychological, social, and spiritual problems.

So I was very interested to read a July 1, 2020 article in StatNews titled “An experiment in end-of-life care: Tapping AI’s cold calculus to nudge the most human of conversations about using cutting-edge artificial intelligence (AI) models in palliative care that scan patient hospital medical records and generate emails to doctors about their patients considered most likely to die within a year.

In the case of one doctor who received such an email,  she “was a bit surprised that the email had flagged” her patient who was in his 40s and seriously ill with a viral respiratory infection and too sick to leave the hospital. She thought “Why him? And should she heed the suggestion to have that talk?”

As the article states, those kinds of questions are increasingly cropping up among health care professionals at the handful of hospitals and  clinics around the country using such AI models in palliative care, stating that:

The tools spit out cold actuarial calculations to spur clinicians to ask seriously ill patients some of the most intimate and deeply human questions: What are your most important goals if you get sicker? What abilities are so central to your life that  you can’t imagine living without them? And if your health declines, how much are you willing to go through in exchange for the possibility of more time?“ (Emphasis added)

Some clinicians and researchers defend this AI by saying that doctors are “stretched too thin and lacked the training to prioritize talking with seriously ill patients about end-of-life care”.

Not surprisingly, the leaders of this palliative care AI discourage doctors from mentioning to patients that they were identified by an AI system because, as one doctor put it, ”To say a computer or a math equation has predicted that you could pass away within a year would be very, very devastating and would be really tough for patients to hear.”

Shockingly, while this AI is built around patients’ electronic health records, this article admits that some AI models also “sample from socioeconomic data and information from insurance claims.” (Emphasis added)

CAN AI RELIABLY PREDICT DEATH?

As the article admits, AI predictions of death “are often spotty when it comes to identifying the patients who actually end up dying” and that there has not been “a gold-standard study design that would compare outcomes when some clinics or patients are randomly assigned to use the AI tool, and others are randomly assigned to the usual strategies for encouraging conversations about end-of-life care.” (Emphasis added)

Nevertheless, using AI death predictions for earlier palliative care interventions is now also being tried for conditions like dementia. And last year in Great Britain, AI was touted as “better than doctors” in analyzing heart tests to determine which patients would die within a year.

ARE THERE OTHER AGENDAS?

The idea of basing medical decisions on a computer program to predict death is disturbing enough but there may be other agendas involved.

For example, in a May, 2020 Cancer journal article titled  “Leveraging Advances in Artificial Intelligence to Improve the Quality and Timing of Palliative Care”, the authors called palliative care “a discipline of increasing importance in the aging population of the industrialized nations.”  (Emphasis added

And according to a Hospice News article last year:

“Studies have found that palliative care saves health plans, health systems, and accountable care organizations close to $12,000 per person enrolled, as well as reducing hospital readmissions, emergency department visits, and hospice lengths of stay. “

Now Compassion and Choices (the former Hemlock Society) is not only fighting to legalize medically assisted suicide throughout the US, it has also been active in promoting training and expansion of palliative care with federal funding and now calls assisted suicide “one option in the palliative continuum” and that knowing assisted suicide “is an option is in itself palliative care.” (Compassion and Choices already maintains that VSED (voluntary stopping of eating and drinking) is already an ethical and legal means of ending life in the US.)

Even worse, a large and growing number of medical organizations-including the American Academy of Hospice and Palliative Medicine (AAHPM)-have endorsed or taken a neutral position on the issue of physician-assisted suicide.

CONCLUSION

An artificial intelligence program predicting death cannot replace the importance of an ethical healthcare provider who knows and truly respects the lives of his or her patients.

Good palliative care can be wonderful but, as I have written before, palliative care can go horribly wrong when misused.

We need to know the difference before we are able to trust that our own healthcare providers will  give all of us the care we need and deserve, especially at the end of our lives.

 

Home Health Care and Safety in the Age of Covid 19

nancyvalko Covid 19, economics, hospice, nursing

In the 1990s, I reluctantly had to leave my hospital position in oncology after an  operation on my right foot surgery that left me unable to stand on my feet for even just a few hours. I decided to go into home health  to support my children and possibly help my foot heal.

Surprisingly, I found that I loved home health nursing and I learned a lot that even helped my patients when I was finally able to resume hospital nursing some years later.

Home health nursing wasn’t an easy job even back then. I drove up to 200 miles some days to care for just about every kind of patient from medical patients just needing blood work to hospice patients and even a young man unable to move below his neck after a diving accident. But I loved the independence and really getting to know my patients and helping them in their own environment.

In May, I wrote a blog “Covid 19 and Nursing Homes” about friends of mine who refused to go to extended care nursing facilities because of the outbreaks of Covid 19 which are especially dangerous to the elderly. Instead, these friends chose to stay home with help from home health caregivers, family and/or friends.

I wondered how home health nursing was now coping with the pandemic.

HOW COVID 19 IS CHANGING HOME HEALTH CARE

A May 18, 2020 article written by 3 geriatricians and titled “How coronavirus could forever change home health care, leaving vulnerable older adults without care and overburdening caregivers” reveals how Covid 19 is now changing a sector of health care that has received little attention during the pandemic.

According to the article, over 5 million people in the US are currently receiving paid home care from personal care assistants, home health aides, nurses and therapists. But even before Covid 19, there were not enough of these health care workers.

As the geriatricians write:

 “(N)ow, not only must home care continue for older adults, and for those with disabilities, but many people with COVID-19 will need it too”.

While home health care reduces the stress on hospital systems, Covid 19 means that home health care is facing new challenges.  Because home health workers travel to multiple homes and people, this increases the risk of possible Covid 19 transmission both for the workers and their often frail and older patients. How can health care workers and their patients both stay safe during the pandemic?

The geriatricians researched the problem and came up with 10 recommendations to  deal with Covid 19 and also improve home health care.

These recommendations include access to personal protective equipment (PPE), regular COVID-19 testing for both staff and patients,  Centers for Medicare and Medicaid Services (CMS) expanding the definitions of “home health” and “homebound” to include “personal care” to help more patients, as well as increasing federal funding for community health workers.

They also recommend more flexibility using options like telehealth which has been particularly useful for one of my older friends.

ONE BIG REASON WHY I LEFT HOME HEALTH NURSING

Although this article did not address this issue, one of the big reasons I finally left home health when my foot improved was the danger of working in a large city like St. Louis that has several high-risk areas as well as the roving packs of wild dogs  that were a problem at the time.

I often saw patients in these areas and sometimes even during the night when I was on call for the agency. On occasion, even the police stopped some of us nurses when were going in to see a patient in these high-risk areas and they offered to wait outside until we returned. I especially appreciated this because as a single mother, I was concerned about what could happen to my children if anything happened to me.

Personally, I saw guns in some households, was cut off by some young men trying to stop my car, dealt with some suddenly psychotic patients, tried to mitigate domestic disturbances, etc. Some areas were so high-risk that I took the fire escape for safety reasons rather than use the elevator to get to my patients’  apartments.

It took many attempts before we nurses finally got our agency to help us get pepper spray and provide a security person to accompany us nurses to high-risk areas when we felt it was necessary.

But sadly, I could never consider going back to home health now with the protests, riots and escalating violence we are seeing in many cities like St. Louis and other areas.

I fervently hope and pray that the important issues that are tearing our country apart will soon be resolved for the safety of all of us.

Especially because I am a nurse, I do know how much every life matters.