Q&A with The Dartmouth Institute’s Newest Faculty Member Dr. Amber Barnato
As a physician-researcher Amber Barnato spends a great deal of time examining how we care for people at the end of life. The ultimate goal of her work, she says, is to identify what could be done differently “to increase our health system’s capacity to honor individual values, to treat people with compassion, and to prevent or mitigate distress.” In 2017, she was named the inaugural Susan J. and Richard M. Levy 1960 Distinguished Professor in Health Care Delivery in 2017. Learn more about her plans for continuing her groundbreaking research into end-of-life care here at The Dartmouth Institute.
Q: What prompted your interest in end-of-life care?
A: I started medical school with the intention to pursue a career in public health, based on an interest in prevention and wellness. But once I started my medical school clerkships, I unexpectedly found myself drawn to surgery. During my general surgery internship, I spent six of my 12 months staffing intensive care units where I experienced moral distress from providing technologically aggressive treatment to people who were dying. I considered leaving medicine altogether, but in the fall of 1995, I happened to hear an NPR story about the findings of the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT), a landmark study about serious illness and end-of-life care (led, in part, by faculty at Dartmouth). I came to realize that I wasn’t the only person worried about the problems of end-of-life care and that there were people doing research trying to make things better. So, I returned, full circle, to preventive medicine and public health training to pursue a career in health care delivery research.
Q: Your work is the source of the frequently cited statistic that “one in five Americans will die with ICU services” and the key finding that black patients’ higher use of intensive care at the end of life is largely attributable to their use of higher intensity hospitals. What do these findings say about the end-of-life-care that Americans are receiving?
A: Taken together, these findings suggest that patients are dying with more intensive care than they say they would prefer, and that hospital practice patterns, not patient values and preferences drive end-of-life treatment intensity. Despite increasing attention focused on advance care planning and integrating palliative care into practice, there has actually been a secular increase in end-of-life ICU use in the last decade. So, there is a lot of work yet to do.
Q: How do our health systems in the U.S. treat those with terminal illnesses compared to those in other countries? What could we learn from other systems?A: Most other high-income countries have similar rates of deaths occurring in hospitals, but lower rates of deaths occurring with intensive care, in part due to the lower supply of ICU beds in those nations. For example, the U.S. has approximately six times more ICU beds per capita than the U.K. And yet I believe we must move beyond descriptive epidemiology of location of death to more deeply understand patient and family experience of serious illness and the end of life. In this arena, there is a great deal that we do not know.
I would be remiss, however, if I did not mention the insight that I recently had during my participation in last December’s Dartmouth- and Mayo-sponsored Salzburg Global Seminar on Rethinking End of Life Care, which involved palliative care practitioners from low- and middle-income countries, such as Rwanda, Egypt, Indonesia, Uganda, India, and Columbia.
In many of these countries, access to morphine is so limited that many patients die in excruciating pain. So, internationally, a basic human right that we take for granted in the U.S.—that pain can be managed at the end of life—is not one that most people in the world have.
Q: What are the ‘next steps’ in terms of the research you’d like to pursue here at The Dartmouth Institute? What opportunities are you hoping will present themselves as a member of Dartmouth Institute faculty?I am increasingly interested in the interactions between local health care provider norms of practice and physicians’ unconscious judgments regarding whether a patient is at the “end of life,” and how those judgments influence patient and family expectations about medical treatment. I’d like to develop interventions involving principles from behavioral science to influence providers’ unconscious judgments. I am thrilled to have the opportunity to work with international experts in health economics, shared decision making, health policy, and delivery science at The Dartmouth Institute.