Care with Compassion
By Susan Meyers
The Case for Palliative Care
Hospitals are generally equipped and staffed to provide acute care, but often fall woefully short when it comes to managing chronic illnesses. And, as the patient population ages, some hospitals are finding that they are not prepared to handle the social, physical, emotional and quality-of-life issues presented by a growing influx of chronically ill patients with complex diseases.
“In a nutshell, hospitals are losing a key element of providing quality care, and that’s compassion,” says Bill Petasnick, CEO, president, and member of the board of directors for Froedtert Hospital, Milwaukee. He is also chair-elect of the American Hospital Association Board of Trustees. In answer to this unmet need, Froedtert Hospital, the major teaching hospital for the Medical College of Wisconsin, organized one of the first palliative care programs in the country in 1993.
“As an acute care hospital, we see a lot of very complex patients,” Petasnick says. “We felt that a palliative care program would allow us to provide a full continuum of care and meet the needs of patients who are chronically ill in a more caring way. Palliative care provides a compassionate and cost-effective means of providing care in the most appropriate venue, with the most appropriate support, and in a way that is more conducive to a patient’s quality of life.”
Michael Wiener, a trustee with Mount Sinai Medical Center in New York City, which started a palliative care program about 10 years ago, agrees. “Every major clinical medical center today is pushing the envelope in terms of technology and scientific advances,” he says. “The other side of medicine are the patients and what we are doing to keep them comfortable. Palliative medicine cuts a wide swath across hospital care. It helps fulfill the humane part of health care and should be brought to the same level of importance as clinical technology.”
According to the Center to Advance Palliative Care (CAPC), located at the Mount Sinai School of Medicine in New York City, 70 percent of hospitals in the United States with 250 or more beds have a palliative care program, and 55 percent of hospitals with more than 100 beds report having a program. The number of existing programs has more than doubled in the last six years—from 632 in 2000 to more than 1,300 programs today.
CAPC was started in 1999, originally funded by the Robert Wood Johnson Foundation. The organization has played a leading role in helping to increase the availability of quality palliative care programs, providing health care professionals with the tools, training and technical assistance necessary to start and sustain successful palliative care programs in hospitals and other health care settings. Validating the value and rapid growth of palliative care medicine, the National Quality Forum, Washington, D.C., recently released suggested best practices for palliative care programs, and last September, the American Board of Medical Specialties recognized hospice and palliative medicine as a an official subspecialty.
“If a hospital does not currently have a program, its board should be talking about how to develop its own program, or at least how it can be affiliated with a palliative care program in the area,” Petasnick advises.
“Increasingly, it’s the minority of hospitals that don’t have a program,” says Diane E. Meier, M.D., director of CAPC and the Hertzberg Palliative Care Institute at the Mount Sinai School of Medicine. “The public is more aware of palliative care, and they are asking for it. Hospitals that haven’t developed a palliative care program will fall behind both in terms of the quality of care they provide, as well as their efficiency and competitiveness.”
What It Is, What It Isn’t
One of the biggest impediments to hospitals’ acceptance of palliative care is their lack of understanding about what it entails, Meier says. Palliative care first involves relieving pain and suffering to ensure the best quality of life possible for patients and their families. “There has been widespread documentation and recognition of the high level of pain and suffering experienced by patients with chronic, complex illness,” Meier says. “Palliative care seeks to relieve that suffering by offering a great deal of genuinely patient-centered care involving listening and responding to physical, emotional and practical needs identified by the patient and family.”
While palliative care and hospice overlap in their patient-centered philosophy of care, they are different in that palliative care is provided at any time during a person’s illness—often from the time of diagnosis—and is frequently delivered along with curative and life-prolonging treatments. Hospice care is designed for terminally ill patients who are no longer seeking curative therapies and who have a life expectancy of six months or less.
Palliative care is usually offered to patients by a team of physicians, nurses and social workers. This team might also include chaplains, massage therapists, pharmacists, nutritionists or any other appropriate care provider. Spiritual support, counseling and complementary medicine are also important components of many programs that can bring additional relief to patients and families. The care team can help ease case management burdens on primary care physicians and other staff and provide assistance with care coordination between the hospital and home and among care providers, as well as time-intensive patient-family communication.
Several years after a hospital has begun offering palliative care to patients, the need for a dedicated unit may be necessary, as some patients will likely require care from nurses and doctors specially trained for palliative care, notes Meier. Dedicated palliative care units include space for families, to give them privacy for meetings, meals and rest.
Quality of Care
When Mount Sinai introduced its palliative care program in 1997, it anticipated receiving about 50 referrals in its first year but was quickly deluged with 250. Now the hospital follows well over 1,000 new patients each year and is in the process of developing a dedicated inpatient palliative care unit.
“Our palliative care program has made an enormous difference in the quality of care for those patients whose life has been compromised by the chronic suffering associated with long-term illness,” says Kenneth Davis, M.D., president and CEO at Mount Sinai Medical Center. “These are complex patients, and it takes skilled clinicians who have a clear understanding of how to decrease suffering and maximize a person’s quality of life to provide optimal care.”
“Clinicians trained in palliative medicine have critical skill sets, including sophisticated pain and symptom management, well-honed communication skills, and expert knowledge about the continuum of care outside the hospital,” says David Weissman, M.D., director of the palliative care medicine program at Froedtert (which he helped initiate and develop) and professor of medicine in neoplastic diseases at the Medical College of Wisconsin. “While some of these skills overlap with geriatrics, oncology and critical care, their additional knowledge focuses on the needs of patients with serious, complex illness.”
The palliative care team at Froedtert acts as a consultative service that consists of physicians trained in providing palliative care, nurses, psychologists, pharmacists, nutritionists and chaplains. The hospital has established a dedicated “virtual” unit on the internal medicine floor, to which palliative care patients with special needs can be admitted and followed closely. The program currently serves approximately 1,000 patients each year. “It was difficult getting it started at first,” Weissman says. “But once other physicians and clinicians started seeing the value and benefits of the care we provided, it began to catch on fairly quickly.”
And those benefits are many. According to Weissman, palliative care consultation teams are better at: identifying and treating physical and psychological pain and symptoms than clinicians used to providing acute care only; helping patients and their families set goals; making clinical decisions and discharge plans; communicating and assisting primary care teams in determining care alternatives and levels of care; offering support and counseling to patients, families and health care professionals who are struggling with difficult care decisions; and increasing overall patient, family and professional satisfaction.
Financial Benefits
Palliative care should also be viewed in the context of the spiraling price of care for high-cost, high-technology tests and treatments of little or no benefit, which often cause unnecessary stress and suffering without significantly influencing the course of a patient’s illness. Weissman estimates that Froedtert Hospital saves between $200 and $500 per day per patient as a consequence of avoiding unnecessary tests and procedures.
“Palliative care does not restrict health care services but allocates them where they are most needed,” Weissman explains. “We have a huge aging population, health care costs are out of control, and the overutilization of health care resources is widely recognized, especially in patients near the end of life. As medicine has become highly fragmented and over-specialized, we are seeing an ever-increasing use of high technology and the higher costs that accompany it. The palliative care team helps patients and families establish important values and achievable goals for the medical care they are receiving by initiating open communication about the pros and cons of different treatment choices. The trade-offs are put out on the table. Once this has been done, we can discuss which tests and procedures might really be helpful, and which are not. The end result is that you will see a dramatic drop in health care utilization and cost.”
“The secret is communication,” Meier says. “Often, no one sits down and actually talks to patients and families about the options before them. Once this education happens and they understand the reality of their illness, the process of care changes, with many patients choosing care in the setting of their home. Multiple studies show a very large cost avoidance associated with palliative care for hospitalized patients.”
Starting Your Own Program
According to CAPC, developing a palliative care program requires a relatively low start-up investment and can have an immediate impact on overall resource use and intensive care unit (ICU) utilization. Direct program costs are more than offset by the financial benefit to the hospital system. CAPC states that hospitals with palliative care programs reap the following benefits that help reduce health care costs:
- Patients receive appropriate levels of care. This often reduces length of stay, especially in the ICU.
- Proactive care plans expedite treatment. Hospitals plan daily resource use by following the agreed-upon care protocol, often reducing costs for redundant, unnecessary, or ineffective tests and pharmaceuticals.
- A hospital maintains or improves its quality of care while increasing bed capacity and throughput and reducing costs through shorter lengths of stay and lower ancillary and pharmacy costs.
Starting a palliative care program often requires a great deal of reflection before hospital leaders can support it, Weissman notes. This includes: realizing that quality care of complex patients is part of the hospital’s mission; wanting to be seen as a local leader in compassionate, patient-centered hospital care; recognizing that palliative care can reduce costs and improve capacity; having a board member who has/had a personal experience with a friend or relative with a chronic illness; and enlisting a local champion who advocates for improved care for the chronically ill.
The emergence of a physician champion to advocate, help develop and lead the program can be a key component of a palliative care program’s success, Weissman says. Successful programs also employ a physician trained in palliative medicine. Palliative medicine postgraduate fellowship training programs have grown substantially over the last few years. There are more than 50 fellowship programs currently available throughout the country, as well as short-term preceptorship programs.
Froedtert Hospital, with the Medical College of Wisconsin, has been a primary player in designing and implementing education strategies for health professionals in pain management and palliative care. Weissman, who is recognized internationally for his work in this field, has received funding from the Robert Wood Johnson Foundation to improve medical residency training through the National Residency End of Life Education Project. Since 1998, 394 residency programs have participated in a one-year curriculum reform project to develop new educational programs in palliative medicine throughout the country.
The National Quality Forum, which has established a set of 38 best practices (www.qualityforum.org) for improving palliative care programs, suggests that health care organizations that provide palliative care offer the following services:
- Comprehensive, 24-hour availability of palliative care through an interdisciplinary team of trained and certified palliative care professionals.
- Timely communication of patients’ goals and care plans in transfers between health care settings.
- Assessments of patients’ pain, anxiety and other symptoms that respect their cultural and individual preferences.
- Social and spiritual care plans for patients.
- Continuing professional education and support for caregivers on topics such as symptom management and communication.
To help hospitals develop their own programs, CAPC has designated six hospitals as Palliative Care Leadership Centers (PCLCs). Froedtert and the Medical College of Wisconsin have served in this role for the past three years. The other facilities include: Fairview Health Services, Minneapolis; Mount Carmel Health System, Columbus, Ohio; Palliative Care Center of the Bluegrass, Lexington, Ky., University of California, San Francisco; and VCU Massey Cancer Center, Richmond, Va.
Hospital teams can apply for a two-day training session and an ongoing mentorship with these hospitals. The two-day training session walks teams through the development and implementation of their own strategic plan, an organizational model that fits their hospital or health system’s needs, staffing plans, instruction on how to collect and interpret financial data, and the implementation of marketing strategies to promote and grow their program. After the on-site training, the PCLC staff continues to provide one-on-one mentoring for a full year to assess progress, trouble shoot and provide resources.
“This leadership training can be a real boost for hospitals contemplating starting or strengthening a palliative care program,” Weissman says. “It gets them organized, answers all the common questions and provides a structure for how to think through the common barriers to program implementation and growth.”
Ellen Katz, a trustee of Mount Sinai Medical Center and a strong proponent of palliative medicine, says that once someone sees palliative care in action, it's hard to imagine health care without it. “It’s a critical component of hospital care if you want to provide the best care possible to your patients,” she says. “It allows clinicians to play a kinder, more sensitive and supportive role in caring for patients and their families. Everyone wins because everyone gains a better sense of satisfaction—from the patients and families, to the professional caregivers.”
Susan Meyers is a writer based in Omaha, Neb.
This article 1st appeared in the May 2007 issue of Trustee Magazine.
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