Sunday, December 6, 2009

The downside of the growth of palliative care

As palliative care matures, I become increasingly concerned about the downside of our growth.

Let me say more.

A couple of stories from the last few months: One of my faculty told me that she got a consult for patient who was made "comfort measures only" and did not have any issues but "they thought we would be mad if we were not consulted". Conversely, I have had many consults for patients where the primary team feels like the patient is dying so they should be transferred to our service. And consults by medical house staff to give bad news or talk about resuscitation preferences (cause we are better and more experienced at it).

My worry: We may be deskilling other doctors. Unfortunately, if the patient is viewed as dying, the primary teams feel that they should back off and ask palliative care to "take over". So house staff and junior internal medicine house staff do not have the opportunity to have these conversations and receive feedback. And as concerning, rather than integrating palliative care into the mainstream of medicine, we ghetto-size it.

Now some caveats. My experience is that of a mature palliative care program and thus may not reflect others experience. Second, from a patient point of view, it may well be better that we are consulted and have these conversations. Third, my whining is probably no different than any other consult service (I can imaging the cardiologist complaining about "silly" consults for afib that they believe that the internist should be able to handle).

Still, I think this should remind those of us who do palliative care at academic centers that our role is as much educational as clinical care. Thus doing more consults is not the only metric by which we should measure our success. We should ask that the residents who consult us come to the meetings and - as much as their skills allow - participate. We should debrief with them after the meeting so that they know what were were trying to do and can learn the communication tasks. And we should think about innovative ways to support teams and promote their skill sets.

So does this resonate for others? Let me know






7 comments:

Alex Smith said...

Bob, I completely agree with your concerns. I had very similar experiences in Boston. We had an inpatient palliative care unit. Patients on that unit were cared for by physician's assistants and attendings - no housestaff. That said, there was plenty of palliative care to go around in that hospital, so the consult service was actively engaged in helping residents care for patients. Still, we were really worried about depriving residents of the teaching/learning that comes with caring for patients on the inpatient service.

One could express similar concerns about outpatient palliative care for symptom managment - we "take over" those aspects of care, potentially depriving the primary doctor or nurse of that learning experience.

Thinking about the best interests of patients, taking over makes sense in the short term. But if we don't train housestaff and outpatient providers in "primary palliative care," we may ultimately harm patients more than help them.

Dan Matlock said...

I have felt this way as well. It seems palliative care arose by necessity to fulfill an unmet need. It is interesting to think that by being available, we are creating more need. In an ideal world, most palliative care consults would not be necessary because all physicians would be skilled in taking care of patients.

I have had similar feelings about geriatrics. While all specialties likely feel this way, I think geriatrics and palliative care have a stronger arguement because most patients get old an all patients die.

Eric Widera said...

I worry about this too on the consult service, but not so much when patients are transitioned on to our hospice unit for end of life care. The type of care that the interdisciplinary hospice team can do can't be taught to residents in a hospital setting unless it is accompanied with significant system changes. This type of care requires the whole team to be content experts with less reliance on the traditional MD lead service. This type of care also gets patients out of the hospital environment and into, hopefully, a more home like setting. If we really want to teach residents how to optimally care for patients at the end of life, maybe we need to rethink where they get trained to do this.

ken covinsky said...

I'm intrigued by the concern posed by Dr. Arnold. It seems clear that Pallliative Care experts will manage a difficult conversation and family meeting better than those of us who are not trained in Palliative Care. So, perhaps a patient and family are well served when the Palliative Care service takes over this function.

But in our teaching program, is there a risk that our residents will view the Palliative Care Service as the go to team to manage difficult conversations? Will our busy residents will use this service as a way of avoding sensitive and difficult conversations?

It would be great to hear the thoughts of others who are part of these teams on this issue. When as the Palliative Care consultant do you choose to lead family meetings? When do you coach the housestaff to lead the meeting themselves? Which of these tasks takes more of your time?. How hard is it for you to watch as us novices lead the conversation, knowing you can do better?

Ann Neumann, on her otherspoon blog (see link below) notes her concern about the "ghettoizinng" of Palliative Care. How can consult teams provide this service, yet train our students and residents to view these skills as core competencies for them?

Chrissy Kistler said...

Recently, I had a colleague who works in a Nursing home tell me about a 90'ish patient who had been a long-time patient of a local MD, developed a hip fracture or some urgent issue, went to sub-acute rehab, and after discharge from rehab went home. The family and the patient decided they didn't want any more aggressive interventions and wanted to try hospice.

At this point they asked their long-time MD to okay the hospice and the hospice group tried to get orders from the MD who declined. They then went to my colleague who'd cared for the patient at the NH and she agreed to do it.

Now, she's a relatively newly trained MD, and the other MD is not, but I just had to wonder what was it that made this physician decline to participate in hospice care: lack of skill? time commitment? lack of remuneration? Personal beliefs? There are lots of supposed reasons, but I wondered if maybe the other MD felt it was better left to the experts?

hospicephysician said...

Great topic, here's my 2 cents!
1. If a seasoned physician has not developed "palliative care" skills already, they will not nor do they probably care to develop them at this point in their career! We all know studies show CME's and other efforts don't work. The honest truth is that physicians will change their behavior if standards of care change or if it impacts them financially. So to answer the "deskilling" question! I have an emphatic "NO". We are not deskilling these physicians because they didn't have the skill to begin with.
2. Hell Yes!!!! Palliative Care should be consulted for patients that are "comfort care only." We have a different approach, demeanor etc than most other physicians. By our communication style and natural inclination to educate we can make a BIG difference in how that family views the death of their loved one (a memory that they will carry forever!!!) As a fellow, I used to gripe about being required to see my Hospice patients that were actively dying comfortably and without any issues. On these visits however, I learned that there are so many educational opportunities for these families. They are worried about whether they made the right choice, were they "killing" their loved one with morphine, what should they expect etc. etc. Most of the time, those of us with confidence in our field, can make loved ones feel comfortable. If you went to a surgeon you would want him to be confident about his knowledge skill and put you at ease that you are in the right hands.
3. In regards to communication, breaking bad news etc. Again, we are not deskilling physicians, most of them have been practicing for years and don't know how to communicate nor wish to do so. I also think that patients are well served to have the Palliative Care team do the "Goals of Care" family meetings. Yes, if possible the attending and other involved physicians should be present. Can we hope that some of the techniques and skills rub off on them, yes. But, my view is that I care more about the physician realizing the importance and benefit of the Palliative Care team in the care of their patient and the benefit the PC team can have to the physician. I want them to have an epiphany and say, "Oh, now I get it!" I would much rather have a physician learn to consult more appropriately and in a more timely fashion than worrying about whether they will be able to break bad news or have a better family conference in the future...
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hospicephysician said...

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4. Now to help clarify all of the above. The real jackpot in education is during the training years. I had a medical student who just started her 4th year and was thinking about Hospice and Palliative Medicine as a possible career. She spent 5 weeks with me and to see the transformation in her was both amazing and jaw dropping. The change showed in her post test scores, post rotation exit interview, reflection project and comfort with End of Life and tada...difficult conversations. This can also be replicated during the resident and fellow years. However, the importance and time have to be given by the teaching program. I've seen some resident programs think that shadowing a palliative medicine physician for a day would make an impact in their practice, well most likely not. However, a medical student, resident or fellow who is involved in a month long rotation, where they do palliative care consults, rounds, family meetings etc. most likely will learn skills and carry them forward. I guess the core of what I'm trying to say, is we should be worried less about teaching established physicians and pour more time and resources into teaching physicians during the early years, when what they learn during those stages will be carried forward to their future practice.
5. Lastly, your right the number of consults should not be a measure of our success but an example of some metrics that will show our success is the metrics that show how we are better at managing symptoms, how we can impact patient and family satisfaction, how we impact staff satisfaction and how we can impact cost avoidance (just to name a few). In an academic setting metrics to show the impact of a palliative care teaching service on the medical students, residents and fellows will also show the importance of our specialty in their education.
...Ok, I'm done...sorry about the rant but this was a great topic. I appreciate everyones input.
P.S. sorry if there are any spelling or grammatical errors.