Bob Wachter describes a wonderful clinical service at UCSF---one that is well organized, delivers excellent care and is rated highly by patients, families and house staff. He calls it the palliative care service but doesn’t quite define what it is, leaving me wondering about the whole concept. Think I’m nit picking? Try asking your colleagues, or searching the literature on what palliative care really is. Good luck in getting a coherent answer.
Even the usually straightforward Wikpedia is vague, describing palliative care as something which is delivered in the context of both curative care and hospice care. So what is it, exactly?
Bob’s post is not explicit but from his title (My Patients Are Dying… And I’ve Never Been Prouder) he’s talking about end of life care. But Mount Sinai School of Medicine Professor R. Sean Morrison, MD, who has written a great deal about palliative care, said in a recent Medscape video editorial that “Unlike hospice, hospital palliative care is not dependent on prognosis.” Moreover, in an earlier NEJM article Morrison’s description of palliative care does not preclude curative care as implied by this statement: “Palliative care should be offered simultaneously with all other medical treatment.” In this recently published study the majority of patients on palliative care services were discharged alive. So, again, what is it?
The closest thing you’ll find to a definition (and it’s not really satisfactory) is something like the one in the NEJM article:
Palliative care aims to relieve suffering and improve the quality of life for patients with advanced illnesses and their families through specific knowledge and skills, including communication with patients and family members; management of pain and other symptoms; psychosocial, spiritual, and bereavement support; and coordination of an array of medical and social services.
OK. Palliation means making the patient’s illness get better while paying attention to the surrounding psycho-social and spiritual issues. It’s what we should be doing for all our patients all the time, so why does a hospital need a special service? (The focus on patients with advanced illness doesn’t really narrow things down much; most hospitalized patients have advanced illness). My reading suggests that palliative care is simply hospital medicine raised to a higher level of excellence, efficiency, organization and patient centeredness. It sounds a lot like what the Institute of Medicine has been harping at all of us to do. The idea of a palliative care “program” suggests a separate team to deliver this excellent care while the rest of us settle for mediocrity! Palliative care claims to have distinctive attributes, but they really shouldn’t be distinctive. They should be the norm.
A common thread in many descriptions of palliative care relates to the quality of communication. Discussions go beyond DNR status and whether the patient has a living will to the education of patients and families on the big picture of the patient’s health and realistic expectations concerning the limitations of treatment. This leads to greater patient satisfaction, more informed and rational decision making, and often the avoidance of ICU care, feeding tubes and other technologies which, in many patients, serve only to decrease quality of life. While these interventions are ineffective in many patients they are costly, which is probably why palliative care programs save hospitals money. Lots of money. But again, why should good communication with patients and families require a special care service?
Like so many other concepts in medicine, the word “palliative” has been hijacked. The idea of palliative care has been administratively defined by people with agendas. For clinicians it’s been an exercise in obfuscation.
The excellence and the efficiency of what is called palliative care is something to get excited about. It’s something we should all strive for. I would like to see our hospitalist program spearhead a multidisciplinary effort to take these ideas to a new level of excellence for all of patient care. But I don’t think I’d call it palliative care. I’d call it something else. I’m not sure what, but something with more meaning.