Including a Chaplain &amp; Notary in End-of-Life and Earlier Difficult Healthcare Issues: The "Dream Team" for Value-Based Care
Authors: Stonestreet John 
Published: September 2020

How can we best prepare to affordably serve a rapidly aging population? Counterintuitively, the answer lies not in limiting, but in expanding, patient/family freedom of choice. This piece demonstrates how some of the most promising healthcare delivery innovations require little more than creatively re-imagining new processes for deploying existing resources. This is especially true in the area of doctor-patient/family communication surrounding end-of-life, or latter-stage treatment decisions. One of the greatest challenges physicians face is living up to their own ideals, let alone others’ expectations, for high-stakes doctor-patient/family communication, especially at the end of life. From emotional strains to time limitations, many factors complicate the pursuit of excellence in this vital endeavor. This piece makes a compelling case for the inclusion of third-party specialists to take some of the communication load off of overworked physicians in end-of-life discussions and earlier difficult healthcare issues. A more team-oriented approach to the interdisciplinary art of “Shared [medical] Decision-Making” may be a win-win for everyone involved. As a fortunate consequence, this approach to “Shared Decision-Making” organically results in more value-based and affordable healthcare. What is new here is not another oft-ignored recommendation for “Shared Decision-Making,” but a revelation of the process innovations through which it can finally be reliably delivered. On paper, “Shared Decision-Making” is the gold standard for doctor-patient/family communication, and researchers have long understood its implications for value-based care. It is a known fact that the more patients and families learn in advance about the likely outcomes of certain treatments at certain life-stages, the less likely they are to choose those treatments. And “Shared Decision-Making” is what gives patients and families the information they need to avoid treatments they may regret in hindsight. But no one has yet discovered the process innovations necessary to reliably ensure that “Shared Decision-Making” prevails as the “medical standard of care” for doctor-patient/family communication. In addition to the lack of process innovation, the path for universal adoption and rigorous implementation of “Shared Decision-Making” has been blocked by an assumption that it cannot be mandated. As such, it is tragically treated as a mere aspirational elective for physicians so-inclined. But if experts have long seen “Shared Decision-Making” as an ethical imperative for doctor-patient/family communication, like the “Institutional Review Board” was for research, then why can't we make it so? This piece shows how simple process innovation unlocks the mechanism necessary to transform “Shared Decision-Making” from an elusive ideal to a reliable standard. Using a real-life case from a well known Harvard physician, this article demonstrates how structural accountability provided by third-party communication specialists can transform end-of-life quality and cost outcomes for families, like the one in this case study, who are devastatingly disenfranchised by gaps in status-quo doctor-patient/family communication.