Monday, December 29, 2008

Top 10 issues in hospital medicine for 2008, issue 9: palliative care

Hospitalists talk a great deal about palliative care even though no one seems to know (or articulate) exactly what it is. This year Bob Wachter described the success of the program at UCSF and this study demonstrated that palliative care programs save hospitals money. Nevertheless the concept remains poorly defined. This, as I explained in a recent post, is a source of confusion for clinicians and may be a barrier to more widespread adoption. Characterizations are variable, ranging from descriptions of terminal care to definitive care for a variety of illnesses. To confuse things further proponents use nebulous terms like patient centered as if they are unique to palliative care, but which should characterize medical care in general. (I’m reminded of the woo-meisters who hijacked the notion of the whole person for their own promotional use, but I digress). What the various descriptions of palliative care have in common are attributes all of health care aspires to: quality of life, symptom relief (palliation means helping things get better, after all), excellence and efficiency (avoiding high tech, expensive care for those who won’t benefit). Palliative care, then, is just good old fashioned doctoring. Why does it require a special service?

Several commenters, trying to help carve out a definition, merely talked around the concept. This one came close:

The underlying premise is that the patient has a "life-limiting" disease (what used to be referred to as a terminal disease), but that unlike hospice, there is a role for palliative care early on in the disease course, mostly for symptom management and social & spiritual support, even as the patient receives disease-modifying or curative treatment concurrently….There are times when you would not get palliative care involved, for example, with a 20 year old patient with pyelonephritis or a 45 year old with an acute MI.

That still leaves COPD, dementia, cerebrovascular disease, heart failure, easily 90% of internal medicine, under the umbrella of palliative care. This is something the entire hospitalist service, not a just special team, should be doing.


Carey said...

Dr. RW, I found your insight about palliative care terrific. I, too, believe that palliative care should be something the entire hospital community embraces rather than leaving it for a specialized team and/ specialized cases. Clearly, there is a growing recognition that the traditional model is antiquated and inadequate yet we have very innovative solutions and processes of communication, collaboration and connection at our disposal for more widespread adoption and better patient outcomes. As mentioned, palliation means what many hope every medical encounter to be: helping things get better. This calls for different processes that health care is slowly aspiring to...I wonder what other barriers you see getting in the way of more diverse adoption of practices we call palliative care??

Anonymous said...

I agree good palliative care is simply good medicine - see Joanne Lynn, The Milbank Quarterly, Vol. 85, No. 2, 2007 (pp. 185–208) "Using Population Segmentation to Provide Better Health Care for All: The 'Bridges to Health' Model". She describes consensus best practice for population segments - most service delivery will always be via primary care providers. Specialist palliative care can help by consults on difficult cases, pushing the education agenda to optimize skills in relevant providers, doing research to advance practice & thru advocacy/policy initiatives.

Paul McIntyre
Halifax, Canada