Compassus CMO Dr. Kurt Merkelz Changing Views on End-of-Life Care
Caring for elderly and end-of-life patients can be a tough road, but it's one Kurt Merkelz, MD, is grateful to walk. Now in his third year as senior vice president and chief medical officer for Brentwood-based Compassus, Merkelz is changing minds ... and practices .. around end-of-life care.
Starting Out
Born and raised in San Antonio, Merkelz was introduced to geriatrics as a teen while working as a patient transporter in hospital radiology. "I enjoyed talking to older people and was amazed at how alone and eager they were to talk," he said. "They wanted someone to share their story with, and it was something I felt compelled to do."
The aspiring geriatrician went on to study nuclear physics at San Antonio's University of the Incarnate Word and received his medical degree from the University of Texas Health Science Center. He completed residencies in family medicine and geriatric medicine at the University of Cincinnati and became assistant director of the school's international health program. The experience created a passion for disadvantaged populations, as Merkelz supported medical brigade teams in Central America, China, Africa and Honduras, among other places.
He went on to pursue additional education in public health policy and often treated elderly homebound patients throughout the city. It wasn't unusual for Merkelz to bring residents along on home visits to help them better understand the reality of senior care, particularly among the underserved. "Residents were alarmed at the type of conditions patients lived in that you'd never know just by seeing them at the clinic," he said. "It was eye opening."
Joining Compassus
Merkelz was soon recruited back to his hometown. He began work as assistant professor of Geriatrics at the University of Texas Health Science Center at San Antonio before launching his own practice, treating patients in long-term care, assisted living and skilled nursing facilities.
Six years later he joined Compassus as medical director for the company's Houston-area locations. In 2016, Merkelz was named the organization's first chief medical officer. The new role prompted a move to Nashville, where Merkelz implemented a refreshingly unique outcomes-based approach for 40,000 patients in 130 Compassus locations across 29 states.
"I was more interested in improving care delivery than I was in meeting organizational outcomes like length of stay or reduced readmission rates," he said. "Those things are important but should be looked at upstream from the needs of the patient. What do they need to succeed in management of health outside of the hospital setting? Clinicians know pharmacology and physiology, but there's often a disconnect between applying that and helping patients manage health concerns in their homes."
Under his leadership, Compassus has implemented priority areas rooted in concerns echoed by nearly all hospice patients: safety, autonomy, disease management and a desire to not be a burden. "They want us to value what they're able to do, and they want to keep doing what they can for as long as possible," Merkelz said. "Patients want to age in place, and they want a respect for quality of life. Those are outcomes I wanted to focus on."
His next step was to actualize practices into standardized care delivery. "The problem is there's no consensus," Merkelz explained. "When you're managing multiple chronic diseases at home, what you receive and how it's evaluated varies among clinicians. Trying to standardize care delivery among hospice patients was the most important task to addressing quality."
Setting Goals
For Compassus, that meant focusing on comfort, safety and quality of life, with less focus on absence of pain and more on helping patients live their last days to the fullest. "As an industry, there's under appreciation of all the complex components that go with end-of-life care, and so often we turn to the common denominator of pain," he said. "Patients all say they don't want to suffer, but there's so much more to life than not suffering, and there should be more value-add from hospice than dealing with alleviation of symptoms. Pain relief should be a base expectation, not a qualifier. What more can we bring?"
Too often, Merkelz said quality of life is defined by diminishing negative attributes (decreased pain, anxiety and nausea) rather than positive attributes: What gives meaning and purpose to who we are?
"There should be an actionable agenda for end-of-life care and serious illness management to drive the positive attributes of quality of life," he explained. "We need to help identify what's most important to patients and try to help them live life fully, and there are so many ways to go about that. It's often overlooked but so important."
He also educates providers on the true cost of pain meds, including side effects like numbness and sedation during those precious last days. He encourages providers to explore other modalities of pain management, particularly in the face of a national opioid crisis. And since hospice patients typically utilize the service less than three weeks, Merkelz also hopes to educate providers on the benefits of plugging in earlier in a patient's treatment, to provide transition care and crisis intervention during a time of high anxiety.
"What's important for patients is to have the opportunity to be able to reflect on life, have it be appreciated, and to be shown the value you had in life," he said. "At every life stage, we want to know we measured up. And at our final moments, we should be allowed to reflect, feel valued, have the opportunity to be human, and be recognized beyond our disease ... not be defined by it."
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