Choosing Wisely in Hospice and Palliative Medicine

Has this happened to you? Your elderly patient can’t sleep their last night in the hospital before being discharged home with hospice care so the on-call physician orders a sedative-hypnotic. When the patient becomes confused and agitated, a CT scan of the head is ordered. Or how about this one: Your patient with stage IV non-small cell lung cancer is referred for screening colonoscopy. I’m sure you have your own stories. Experts estimate that one third of US healthcare spending, over $700 billion annually, is for care that is non-beneficial or even harmful.

Seeing treatments and tests reflexively ordered when the potential for benefit is low or the risk of harm is high, particularly for the elderly and people living with serious illness, was a major source of distress to me as a resident. That distress, and a belief that evidence-based medicine could guide us to care that is more effective, accessible, compassionate, and sustainable, lead me to a career in palliative medicine. It is precisely this hope that underlies the American Board of Internal Medicine Foundation’s Choosing Wisely® campaign.

The goal of Choosing Wisely is to challenge medical specialties to come up with their “top five” list of treatments, tests, or procedures that should be questioned because best evidence shows they are non-beneficial or even harmful. As a recovering molecular biologist, I confess, I devoutly believe that science that informs our compassionate care is the best way forward. All this is by way of explanation for the madness that overtook me when I agreed to serve as Chair of the AAHPM Choosing Wisely Task Force.

The challenge was significant. We had a relatively short timeline to build expert consensus on our list of “Five Things Physicians and Patients Should Question” in Hospice and Palliative Medicine. Striving for an inclusive and transparent process, we also wished to incorporate member feedback into the list development process. Fortunately, I was blessed with a wonderfully talented group of Task Force members.

To start the process we elicited suggestions for the list from the AAHPM SIGs as well as Task Force members. We used these to develop a short list of recommendations and then sought feedback from Academy members. We received close to 700 comments from more than 300 members ―vital input that informed the Task Force’s final selection of AAHPM’s recommendations and drafting of the precise supporting language for each item on the list. Finally, last Thursday, our recommendations were revealed – along with those of sixteen other medical specialties – during a press event in Washington, DC. (Visit to access the complete lists from all participating specialty societies and watch a video of the Feb. 21 announcement and panel discussion.) Each society, traditional and social media, along with Consumer Reports, Wikipedia, AARP, NHPCO and other consumer advocates are all contributing to the broad dissemination of the campaign.

With the final list announced, the real work now begins: supporting critical conversations between physicians and their patients as they collaborate to ensure the best care possible. To support those conversations, AAHPM has developed a set of talking points for members (login to Members Only required). Our AAHPM Choosing Wisely Task Force has also written a Special Article describing our “Five Things” in greater detail. Look for it in the March issue of The Journal of Pain & Symptom Management.

I’d also like to invite you to attend the Advocacy Forum at the AAHPM & HPNA Annual Assembly in New Orleans next month where my fellow Task Force members and I will discuss our Choosing Wisely recommendations and how you might choose to discuss them with your patients and the public. (Learn more.)

I’d love to hear your thoughts about AAHPM’s Choosing Wisely recommendations. What do you think of the list? Will you use it in the care of your patients? If so, how? What other recommendations would you like to see on any future lists?

Whether or not your “Five Things” list would be identical to AAHPM’s final version, I hope you find it a useful tool to engage patients, families, and the public in choosing wisely.

Daniel Fischberg, MD, PhD
Medical Director, Pain & Palliative Care Department, The Queen’s Medical Center
Chief, Division of Palliative Medicine, and Professor, Department of Geriatric Medicine, John A. Burns School of Medicine of the University of Hawaii
Honolulu, HI

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