F124 AgeTech 4/4: How do you wish to die? (Ryan Van Wert, Vynca)
In January 2021 a jury in Montana delivered what is believed to be the first verdict in a wrongful life case, awarding over $400,000 compensation for medical and emotional costs due to the unwanted treatment of Rodney Knoepfle. In theory, patients have the right and option to draft an advanced care plan, a written document with their preferences about advanced medical treatment, life support, and resuscitation in case of a serious health event. The challenge is for the right doctor to see them at the right time.
The lawsuit was a consequence of the fact that wishes regarding end-of-life care of a patient were not taken into account.
How to even think about an advanced care plan?
Several organizations such as The Conversation Project or PREPARE for Your Care offer guidance about how to prepare an advanced care plan. However, doctors might not find the plain in the patient’s record. In his opinion piece for HIS Talk dr. Ryan Van Wert, an intensive care physician, Clinical Assistant Professor at Stanford University and CEO and co-founder of Vynca cited some alarming numbers: When physicians were asked about the confidence of locating an existing advance care plan within the EHR, only 31% of physicians strongly agreed. There is a 37% medical error rate in end-of-life care plans. In the past, even when patients have taken the time to record their wishes, in many cases the documents have been inaccurate or inaccessible across the care continuum. Research shows that 84% of individuals who are 65 and older have not been asked by their physician to have an advanced care planning conversation.
Comfort care as the preferred choice of treatment
Ryan Van Wert.
Already years ago, in his clinical practice at intensive care Dr. Van Wert started noticing that people that ended up on life support and ventilators often had existing conditions, such as COPD, dementia or advanced cancer, but nobody had taken the time to have a dialogue with them about what their care preferences were. “At the same time, we know that most people with a serious illness when they're asked, prefer more comfort-focused care, supportive care. They want to be around family and certainly don't want to be in the hospital with a tube, that is uncomfortable and prevents them from communicating effectively.” Building on that realization, dr Van Wert founded Vynca. This is a platform on a mission to make advanced care plans available regardless of where the patient is treated.
End of life care preferences are of the biggest gaps in care in health care because so many people are faced with serious illness and are receiving unwanted care, says Dr. Van Wert and elaborates: “When we look at the overall economic side of things about a third of our Medicare budget, that is about $200 billion in the US is spent every year for care delivered in the last year of life. This is one of the largest areas of spending in our healthcare system. I would argue that this is one of the lowest quality care points in our healthcare system today, and yet, it's one of the most expensive ones. There's a clear disconnect between the quality of care that people are getting at the end of life from a macro level, the level of spend in our health system, and that was what really drove us to go after this need and try and solve it.”
Central point for advanced care plans
Vynca aims to be the central point of advanced care plans that is always available to the patient, his family and providers. “We take an approach of looking, for integration points within electronic health records. We have several state level partnerships where we serve as the registry for the state. We have a variety of ways of tying into the core healthcare technology infrastructure that allows us to create connection points. Today we serve patients in every US state. With Vynka, once the patients fill out an advanced care plan, they're automatically invited to share those preferences with their loved ones who then have 24/7 access to those wishes as well. This way we have multiple failure points that can be avoided,” explains dr. Van Wert, who in his clinical practice saw many situations where family members were faced with difficult decisions regarding care on their behalf of their loved one, without knowing an individual's preferences. As he warns, it is also very difficult for the health care provider to be in the decision-making situation.
With a lot of progress still to be made, things do seem to be improving. Dr Van Wert:
“When we first started working on this problem, the word death panel were still very common. And that created a lot of fear and made advanced care planning a hyper taboo topic. Over the last few years, CMS stood up and said physicians are paid to have an advanced care plan dialogue. So if we look ahead, five years from now, my hope would be that from a policy perspective, that we have continued that recognition of the importance of serious illness care, and that the reimbursement mechanisms to support the highest quality, serious illness care for individuals are in place so that these people can get the care that they want. And have their voices heard when they're faced with a serious illness or at the very end of life.”
Tune in for the full discussion.
Some questions addressed:
Deaths due to COVID rose to 500.000 people in the US alone by February 2021. Many people died much earlier than they would if the pandemic wasn’t here. Did you see any shifts in the perception of how death and end-of-life care should be considered/talked about in medicine and in society in general?
In the USA, there’s an established approach to the planning of end-of-life care. It’s called advanced care planning and there are numerous resources available about how to start these conversations, etc.
How long are the ACP documents?
In January 2021 a jury in Montana delivered what is believed to be the first verdict in a wrongful life case, awarding $209,000 in medical costs and $200,000 for “mental and physical pain and suffering” to the estate of Rodney Knoepfle in 2019. The lawsuit was a consequence of the fact that wishes regarding end of life care of a patient were not taken into account. How would you comment on this as a doctor and then also as the provider of a technical solution for the problem of ACP?
The inspiration for your company Vynca came from your experiences as an intensive care physician who witnessed cases in which patients with a serious, life-limiting illness received aggressive care in the ICU against their wishes. Can you describe how a case like this looks like? When do you as a doctor realize that a patient was treated against their wishes? What about family? Does it often happen that they do not know the wishes of a dying person?
How would you rate the state of palliative/comfort care?
Did you see any impacts of COVID on ACP and end of life planning?