Hospital-Based Palliative Care: Has the Time Come?

The scenario is painfully familiar: A 93-year-old woman in breathing distress is rushed by ambulance from her nursing home to a hospital emergency room in the middle of the night. She's later admitted into the intensive care unit, where her family can't see her, and she's hooked up to a ventilator. "I'm not a clinical person, but you would be amazed how many stories I hear about people who had advance directives that were ignored and how difficult it is, once someone is on the conveyor belt into the hospital," says Lynn Spragens, a national expert in palliative care and an independent consultant with the New York-based Center to Advance Palliative Care. Spragens contends that hospital-based palliative care programs help prevent such agonizing situations — and save hospitals money at the same time. Palliative care is an emerging medical specialty with its definition still in flux. While originally linked with hospice, palliative care is now forging its own way. "Palliative care programs should always work very collaboratively with hospice, but this takes it upstream," Spragens explains. Palliative care looks at medicine more broadly "because it's also about the beliefs and wishes. It's not just, 'What's your blood pressure?' That's where it shares some of its philosophy with hospice," she says. Yet, unlike a hospice program, patients receiving palliative care aren't required to abandon curative care and don't necessarily face a six-month prognosis. Instead, they may be battling several serious, life-altering medical problems that require management of multiple, simultaneous symptoms. In these circumstances, Spragens says, pain and symptom management "crosses over the various specialty lines." "You end up with three, four, five and sometimes even more specialists taking care of that patient, going in and, I crassly say, checking the body parts — someone working on the kidneys, someone working on the heart, someone working on neurological problems," she says. "When you look at the chart, you find that there's no one in charge of the patient. Who is convening rational decision-making? Who's there at 6 to 8 p.m. to talk to the family? Does the family understand what's going on? Are they getting a consistent message from each of the specialists?" That missing oversight responsibility is the legitimate role of a palliative care specialist or team, to ensure the patient is comfortable and all communication channels are open. "It's not because we have bad nurses and bad doctors," Spragens says. "It's because people are too busy, and they're all focusing on their primary role. So a lot of things get lost in the middle." The Center to Advance Palliative Care promotes creation of permanent palliative care programs in hospitals and has published a how-to guide for launching and administering such programs. Spragens explains that hospital-based palliative care should be team-based, with at least part of one physician's time dedicated to the program. In addition, a nurse practitioner, nurses, a social worker, a chaplain and perhaps even a clinical pharmacist should be on board. "One critical thing is that it's not just a physician, because a lot of the complications in these patients are psychosocial issues and a lot of barriers to care are lack of honest communication between the nursing staff and the physician staff," she says. The palliative team would be available on a consult basis at the behest of an attending physician or the patient's family doctor. Hospitalists may request palliative care, as well, or a nurse may suggest palliative care as an option by writing a note in a patient's chart. The idea, says Spragens, is "to build trust and support" by working in collaboration. Certainly such a program would be a hospital expenditure. Yet Spragens says, "Every time you expedite clear decision-making and put a clear plan of care in place and make the communication around the plan consistent, you actually end up saving money." How? The patients with complicated cases who might require palliative care are usually in two groups: 1. Elderly patients on Medicare, or 2. Younger patients with serious diseases such as cancer who are covered by a commercial payer or Medicaid. Medicare, Medicaid and even commercial payers base reimbursement on DRGs (diagnosis-related groups) or other risk mechanisms. "Just because the hospital is running up charges, that doesn't mean the hospital is getting paid extra to do unnecessary tests," she says. "The hospital isn't being paid more because you're in an ICU bed rather than a med-surg bed." Spragens says hospital administrators are persuaded by the numbers, but often they recognize that "it's just the right thing to do." In particular, nurses embrace a palliative care program because it reduces their "moral distress," which Spragens defines as when nurses, usually those in intensive care, are torn between patient needs and physician demands. "A palliative care program can enhance nurse retention and morale, and that's a motivator for administrators," she says. Spragens predicts that the demand for palliative care specialists will grow four-fold in the next eight years. "In a perfect world, I wish we didn't have to be this specialized, but given the world we're in, having people who can wear this hat and be specialized and have the time to link it together and show respect for all the players is a really valuable role," she says. "When I'm in the hospital, I hope it's there."