Joan Rivers' death and end-of-life care, informed consent and risk of routine procedures

The circumstances that led to Joan Rivers' death--and whether an error occurred at the outpatient center where she reportedly had an endoscopy to determine what was wrong with her vocal chords--are still unclear, according to the New York Magazine.

But the complications she experienced and her death raise important healthcare considerations for hospitals, clinicians and patients.

The 81-year-old comedian's heart stopped during the procedure while she was under anesthesia at a Manhattan clinic. Following the complication, she was hospitalized and put on life support. Last week, she died after her family agreed to take her off life support.

As all healthcare professionals know, all procedures--even those deemed routine, minor or elective--have risks. No surgical procedure is absolutely safe, says Michael Wong, executive director of The Physician-Patient Alliance for Health & Safety, which this week outlined four lessons learned from Rivers' death.  

This means providers must fully engage patients and talk to them about their conditions, treatment options and answer their questions so they understand the risks and benefits of a procedure before patients give informed consent and head to the operating room. This discussion, particularly when it involves anesthesia, should include where to perform the procedure. For instance, in Rivers' case, a hospital may have been better equipped to respond to the sudden emergency.

Rivers underwent the procedure on Aug. 28, the same day that FierceHealthcare ran a story illustrating how the use of a surgical checklist and a brief huddle before an operation improved patient safety at Memorial Healthcare System in South Florida.

Memorial's process, adapted from the aviation industry's crew resource management protocol, calls for the surgeon to follow a script, making sure to identify all team members and go over the operation and specific concerns. The team works through the details of the surgery before they begin. And if any team member has a concern during the surgery, he or she has the power to stop the procedure by simply saying, "Delta." Once the surgery is completed, the team debriefs and talk about what went right, what went wrong and any concerns.

"If someone wants to stop the operation for a patient safety concern, it's taken seriously," Joseph Loskove, M.D., chief of anesthesia for the system and regional medical director for Sheridan Healthcare told me.

Loskove says he sleeps better at night knowing that he takes part in a process that follows steps to prevent human error.

Rivers' death also opens the door for clinicians, patients and family members to discuss end-of-life care. The reason Rivers' daughter could make the decision to stop medical artificial intervention was because her mother planned and recorded her wishes ahead of time. She had an advance directive in place to allow her daughter to make the difficult decision on her behalf, Forbes noted.

But research funded by the Agency for Healthcare Research and Quality shows that less than half of terminally ill patients have an advance directive in their medical record. And only 12 percent of patients that do have them received input from their physician before signing the document. Furthermore, between 65 and 76 percent of physicians whose patients had an advance directive didn't know the documents existed.

The industry needs to increase efforts to better promote advance directives among physicians and patients alike, Adrienne Mims, M.D., MPH, chief medical officer and vice president of Alliant GMCF, the Medicare Quality Improvement Organization for Georgia, told Medscape in an article published earlier this year.

"We should be seeing better management of patients at the end of life, but we are not," she said. "Clinicians have not been trained for these conversations."

That may be about to change. In June FiercePracticeManagement reported that some medical schools participate in programs, such as "Respecting Choices," to help equip medical professionals to have timely and productive discussions about end-of-life care with patients and family members. There also are videos that doctors can use to help facilitate conversations with patients.

And as an incentive for doctors to initiate these conversations, Medicare may soon pay physicians to discuss advance care planning, including treatment options at the end of life, with patients and their families. Ilene (@FierceHealth)

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