As Americans age, pandemics and other crises loom, and consumers' expectations of personalized care continue to grow, clinicians must prioritize palliative care training to gain greater expertise in treating seriously ill patients.
While any clinician caring for the very ill can deliver palliative care, two hospital-based specialties are prime candidates to benefit from training in its use: hospital medicine (HM) and critical care medicine (CCM). Particularly during crisis situations (like COVID-19) when tensions and fears are higher than normal, it is imperative that these two specialties are well-versed in providing palliative care—and that they’re prepared to talk about options with the patient’s family in nontraditional ways (via FaceTime, phone, etc.) if visitation rules are altered due to crisis.
Before we get into a discussion of why we're calling out HM and CCM specifically, let's first clarify what palliative care is and isn't, look at some pertinent statistics, and a summary of benefits it offers hospitals and patients.
What Palliative Care Is and Isn't
The World Health Organization (WHO) defines palliative care as "care that improves the quality of life of patients and their families facing the problems associated with a life-threatening illness ... whether physical, psychosocial, and spiritual."
Palliative care is intended for patients who might be expected to face stresses and challenges in any area of their lives as a result of serious illness, The Hospitalist says, including those who experience “frequent emergency department visits, hospital readmissions, or prolonged ICU stays.”
Palliative care isn't the same as hospice care, however, although the two terms are sometimes used interchangeably. While both are intended to provide comfort, palliative care can begin at diagnosis and at the same time as treatment. Hospice care starts only after stopping treatment, often when the patient’s life expectancy is six months or less.
The main principles of palliative care, according to WHO, include:
- Providing relief from pain and other distressing symptoms;
- Affirming life and regarding death as a normal process;
- Neither hastening nor postponing death;
- Integrating the psychological and spiritual aspects of care;
- Offering a support system to help patients live as actively as possible until death;
- Providing a support system to help families cope during the patient's illness and in their grief.
WHO states that some 40 million patients worldwide need palliative care annually, but only about 14 percent receive it.
That's not the case in the U.S., fortunately. The availability of hospital-based palliative programs is growing nationwide, though some regions remain underserved, according to research by the Center to Advance Palliative Care. Currently, 72 percent of hospitals in the United States with 50 or more beds have a palliative care program.
Benefits of Palliative Care Treatment
The shift to value-based payments puts increasing pressure on hospitals to deliver high-quality, efficient services. Research shows that early implementation of palliative care helps improve quality of life and family well-being and leads to a reduction in both medical costs and length of stay.
Palliative care is advantageous not just to patient care, but also to hospital financials. One study revealed that patients who received palliative care and were discharged had an adjusted net savings of $1,696 in direct costs per admission and $279 in direct costs per day, with considerable reductions in laboratory and intensive care unit (ICU) costs compared with usual care patients.
A 2018 study found a statistically significant reduction in future acute care utilization and costs following palliative care consultation for goals of care, with more than $6,000 saved per patient.
Length of Stay
By taking time to elicit patients' preferences, palliative care programs tend to reduce the amount of time that patients spend in the hospital, Today’s Hospitalist says.
One study showed that patients who received palliative care in the emergency department had an average length of stay 3.6 days less than patients who received palliative care consultation after transferring to the ICU or medical/surgical department.
What's the reality given these numbers?
Research by the polling firm Public Opinion Strategies found that 92 percent of patients say they would be highly likely to consider palliative care for themselves or their families if they had a severe illness.
Yet, 60 percent of patients who would benefit from palliative care are not receiving it, even though most healthcare organizations have end-of-life care programs, as previously stated.
One way to change that imbalance is by educating hospitalists and intensivists on the use of palliative care and employing specially-trained palliative care teams when necessary. Conversations about end-of-life care goals and options are vital interventions where both specialties should gain expertise.
Hospital Medicine and Palliative Care
Despite the availability of palliative care programs, in many areas (rural areas especially), hospitalists care for critical patients, either because the facility doesn't experience enough critical volume or sufficient staffing draw to warrant a full critical care team. As such, once faced with a seriously ill patient, hospitalists need to have a working knowledge of how and when to implement palliative care.
Improving communication with patients and pressing palliative care training for physicians continue to be areas of emphasis among hospitalists – so much so that in 2017, the Society of Hospital Medicine named it a core competency, and The Joint Commission now certifies it.
Training empowers hospitalists to address many basic palliative care needs with patients and their families, such as pain and symptom management, code status, and shift to comfort care, reserving the palliative care specialist for more challenging cases.
Hospitalists and Palliative Care Team Coordination
Palliative care specialists play an essential role in supporting hospitalists and improving the quality of care for hospitalized patients and their families.
Since hospitals care for patients with advanced and terminal illnesses routinely, it stands to reason, then, that hospitalists would benefit by coordinating treatment with palliative care teams, for these reasons:
When initial treatments fail to remedy pain and other symptoms, palliative care team assistance in symptom management can not only improve patient satisfaction but also lead to enhanced hospitalist satisfaction with their ability to deliver quality patient care.
As caring for patients suffering from serious illness — many with varying degrees of physical, emotional, social, and spiritual requirements — can often be exhausting for hospitalists, palliative care teams help to ease overall clinician stress by aiding in debriefing, voicing different coping strategies, and recognizing the numerous challenges that come with caring for these patients.
Also, palliative care professionals are especially adept at relaying unpleasant information and helping patients and families accept the truths of their illness and decide their ultimate goals of care.
Critical Care Medicine and Palliative Care
CCM providers have so much going on — and many of their patients are dying when they admit them — that inevitably, many of the care decisions fall to the family. Not only does this present challenges but also a need for intensivists to get thorough palliative care training and the support of palliative care teams when possible.
Palliative care in the ICU involves symptom control and end-of-life care for patients, communication with family, and setting goals to provide dignity in death and ensure decision-making power. Once patients and families are made more aware of the options available, they may choose to opt-out of treatments deemed either unnecessary or too strenuous, effectively reducing overall costs and length of stay.
After learning the hospice eligibility criteria, ICU physicians can make apt referrals to hospice. They can also improve patient care by learning to calculate and control physical symptoms more common among patients nearing the end of life. All clinicians must have the knowledge and skills to communicate with patients and families about death effectively.
ICU patients and their families tend to exhibit higher levels of anxiety and depression due to the concept of death becoming less a possibility and more an inevitability. That means physicians should start palliative care assessments as early as possible to allow more focused interventions to anticipate and minimize needless suffering.
Palliative Care Treatment Resources
Many resources are available to help guide the development of palliative care procedures, whether with a full palliative care team or among existing hospitalists and intensivists.
Here is a list of helpful resources to consider when researching palliative care:
This curated toolkit provides communication scripts, symptom management protocols telehealth information, family support resources, and more to help providers navigate palliative care amid this pandemic.
The Center to Advance Palliative Care offers an in-depth toolkit containing a range of resources for hospitalists caring for seriously ill patients. They cover topics such as improving quality of care, pain and symptom management, care coordination, and delivery of care transitions.
The Society of Hospital Medicine's Center of Quality Improvement and The Hastings Center developed this resource to help improve care for gravely ill patients. It focuses on communication about prognosis and goals of care by hospitalists with the whole care team.
A resource that explains why intensivists and critical care specialists need palliative care education.
This article addresses the concept of dignity for patients dying in the ICU.
This website provides information for families on palliative care and includes a provider directory.
SCP Health Resources
SCP Health offers the following resources for providers regarding palliative care:
- Preparing for Difficult Palliative Care Conversations
- Equip Your Physicians to Deliver Compassionate, Comprehensive Palliative Care
- Developing Your Palliative Care Skill Set
- Palliative Care Discussions During COVID-19