In healthcare, the oath is to do no harm, and it’s a virtue expected to be upheld by all physicians. With the mass of technology, procedures and medications, people are living longer, and often this battle against death simply translates to prolonged dying. Not only does this have an emotional cost, but it also costs families and hospitals financially.
Essentially, palliative care brings the humanity back into healthcare. It not only leads to better symptom management, improved quality of life and family satisfaction, but there is proof that it also helps reduce healthcare costs. A study at the University of Rochester Medical Center published in the June issue of Critical Care Medicine showed how earlier, or proactive, palliative care interventions can reduce the length of stay for seriously ill patients in the MICU by more than seven days without having an impact on mortality rates.
Historically, palliative care was strongly associated with end-of-life care. Palliative care specialists are typically consulted very late in a patient’s illness, often after the patient had already been in intensive care for weeks and other life-prolonging interventions were exhausted. In the past few years, providers in the hospital setting have begun to realize that patients should receive palliative care much earlier. Even though most people don’t know what palliative care is, hospital administrators, physicians and med students are awakening to its vital role in disease management.
“If you do palliative care in its purest form, palliative care would begin at diagnosis,” said Sally Aldrich, administrator of hospice and palliative care services at Methodist University Hospital. “Palliative care would become more of a treatment focus as the disease progressed where curative care would become less the focus. Palliation and quality-of-life become the greater focus.”
Palliative care has always been a misunderstood specialty, even within healthcare. While hospice is a piece of the puzzle, it is the end stage of palliative care. Palliative care includes a interdisciplinary team with expertise in quality of life issues such as symptom management like pain and shortness of breath, and communication with family. It is most often used with patients who have terminal illnesses or acute trauma who may survive a while but have a poor prognosis.
“Family conference and discussion is core to palliative care,” said Jane Owen, palliative care nurse practitioner for Methodist University Hospital. “That’s the big hole in healthcare today. The reality is, medicine and doctors and surgery don’t have the answers for everything.”
At Methodist, administrators recognize the need for synergizing the existing palliative care programs into the continuum of care within the hospital system, including Le Bonheur Children’s Medical Center. Methodist utilized the model from the Center to Advance Palliative Care (CAPC) as a guideline. Within the Methodist system are seven board-certified physicians for hospice and palliative care, advanced practice nurses, chaplains and social workers, which indicates a solidification of the programs. And it’s growing.
A study conducted by Methodist showed 179 palliative care referrals in 2005. In 2006, the number grew to 275. Since the strengthening of the palliative care program last fall and up to June 2007, there have been 1,029 referrals within the system.
According to a 2005 article in the Journal of Palliative Medicine, the number of hospital-based palliative care programs has grown rapidly in the United States. Today, more than half of hospitals with 300 or more beds offer palliative care.
There has also been an increased use of palliative care consultations on patients with declining trajectory diseases such as heart failure and emphysema. Still, the biggest hindrance to providing palliative interventions is referring much too late.
This lack of communication fragments care and often leaves families lost in the shuffle and unable to make crucial decisions, especially in the ICU setting when families are frantically awaiting news and are asked to make hard choices.
“It’s important the family feels they have someone there they can trust that will tell them the truth and will help them deal with the emotions while they resolve and make their decisions,” Adrich maintained.
On top of that, explained Owen, people need to know the natural process of a disease and how to plan for a natural death. For instance, a common procedure for elderly nursing home patients with dementia is to put in a PEG tube to avoid aspiration. However PEG tubes do not make the quality of life better, and in many cases, Owen said, simply makes things worse.
“We’re beginning to understand we’ve got all this technology but is that really what is in the patient’s best interest at this point in their illness?” Aldrich added.
Owen has what she calls “hard” discussions that get to the truth of the matter. If she gets the consult early enough, whether it’s acute trauma or declining diseases, she can talk with patients (if coherent) and families about their options and how those options fit into a the bigger picture of disease.
“If we can get better symptom management and get (patients) out of the ICU, then family can be with them and that’s a plus,” added Owen.
It’s important for palliative care specialists to convey that death is not the enemy. Impacting patients earlier and not just at the end, Owen maintained, helps people accept death better and the grieving process is easier.
“If you get palliative care on board earlier,” she advised, “we can pave the way for that so that people know what’s going to happen.”