Monday, July 16, 2018

How to Respond to an Inpatient Palliative Care Consult Request

by: Alex Smith, @AlexSmithMD

Each July we post something about an introductory topic for the new fellows.  See our prior posts on:
This year we're going to discuss how to field a palliative care consult.  I'd like to focus specifically on the moment you call back the intern who paged you to request an inpatient palliative care consult.  Other articles have addressed the comprehensive role of the consultant in general, or in palliative care in particular.  This post will focus specifically on that initial phone call.  Some features may apply to outpatient care, and to geriatrics.

Here are 7 questions I usually ask the referring clinician on the initial call:
  1. "What's the story?"  Why was the patient admitted to the hospital?  What treatments has the patient received, and what treatments are planned?  This is what most people get from interns when they field a consult.  This is the normal "minimum" level of information
  2. "Is the patient making decisions?"  This is an important data point.  DO NOT take it as fact that the patient has capacity to make decisions if the intern says they are making decisions. This question is important because it tells you if the primary team thinks the patient has capacity to make decisions, but you need to make your own assessment.
  3. "How can we be helpful?"  I prefer to phrase it this way, rather than, "What is the consult question?"  This is in contrast to other fields, say GI for example, where consultants like to have a very specific consult question.  But sometimes the consultant has a general sense that they need help, rather than a specific question.  Now think about all of the evidence we have for palliative care - palliative care for lung cancer, for GI cancer, for heart failure, for bone marrow transplant - do you recall these studies specifying "palliative care was initiated for patient's whose physicians had a specific consult question."  NO!  These studies were initiated for all patients with that specific serious illness, regardless of whether the referring physician had a specific consult issue at hand.  We should probe generally in a non-judmental way about the primary team's objectives in calling a consult, but not judge if they do not have a specific question. We can almost always find a way to be helpful.  Sometimes palliative care is called when the team (not the patient) is distressed.  Don't block palliative care consults.
  4. "What do you think about the patient's prognosis?"  I ask this question primarily to get the interns thinking about prognosis and the importance of prognosis for decision making.  
  5. "Are there family or friends involved?"  Often interns who are well trained to attend primarily to the medical history neglect to mention the social circumstances in which their patients lives are embedded.  Who is visiting?  Where does this patient live?  What kind of housing arrangement?  
  6. "How long will he/she be in the hospital?"  People forget to ask this question.  I can't tell you how many times we've fielded a long consult request, only to discover the intern intends to discharge the patient this afternoon, and can we please address pain, goals of care, and a discharge plan the day we meet the patient?  Yeah right.  Good to know what you're getting into and set expectations right off the bat ("We can't do all that, but we're happy to meet them and get to know them so we are familiar with them for the next visit.")
  7. "Does the patient know we've been consulted?"  Ideally the patient will have heard and agree that palliative care is going to consult.  Like psychiatry, there are some patients who strongly do not want to see palliative care because of the associations they have with the field.  Asking the intern to introduce the idea of a consult primes the patient for our visit.
What do you think?  Am I too lenient in #3?  Do you require referring clinicians who are not clear about the answer go back, think about it as a team, and formulate a specific consult request?  Do you lack the resources in your hospital to not block palliative care consults?  Do you worry about violating the bounds of the consultant role without a clearly defined question?  What other questions do you ask?  Respond in the comments.

Thanks to Olivia Gamboa, Lynn Flint, and Eric Widera for thoughts on this post.


Eva said...

Great questions, but I'm not sure I agree with the last. In my experience, if palliative care is introduced by someone not well versed in how to explain the specialty, the patient and/or family will be given the impression that we are either the same as hospice or are going to talk about death. Our team very much prefers to introduce ourselves. Even for those who "think" they know what palliative care is, the vast majority will welcome the service once it is explained properly.

Ginger.marshall said...

Excellent questions. If I am speaking with a medical student or resident I have also found it helpful to ask "Is your attending physician aware of the consultation?"

Christian Sinclair said...

I also ask "How can we help?" or some such phrasing. I want to know where the pain point is. If they begin telling me about how busy they are, or about a challenging encounter it helps me understand what is uncomfortable for them.

If the consult is oriented towards goals of care (and not symptoms only), I will usually ask about the goals of care. "So, what are the patient's goals?" If they say they have not had any chance to discuss that yet, and they were 'waiting for palliative' I offer invites to the learners and then even encourage them to have the GOC conversation so I can observe and jump in if needed (with appropriate prep and support).

Unknown said...

This is very informative. Thank you all for organizing this information.
I would add the question, "Describe any social or family dynamics."
Most times, our colleagues will omit any anger or frustration displayed by the patient or family members.
They not omit this in the documentation but also on verbal description due to its uncomfortable nature.
There were times when we unknowingly walked into a very tense room unprepared.
One family member was physically violent.
Knowing the dynamics are a very important part of the encounter.

Jeff Kowaleski said...

Thanks for sharing your approach to the initial phone call, Alex. I learned a very similar approach as a fellow that I continue now two years into practice using my own template sheet. I think this thorough, and dare I say “checklist” (!), approach validates: 1) how what we do in Palliative Care is unique; 2) that a lot of the info we need (prognosis, surrogacy/social situation, content of conversations, etc) is often not documented in the medical record; and 3) that we run the risk of causing harm to the patient/family or the therapeutic alliance with incorrect or incomplete information. Some specific responses:

I agree, Alex, the answers to question 2 can be very insightful about the primary team’s global thought process. There are only rare circumstances where I don’t ask this question.

You are not too lenient with question 3. Inquiring about how we can “help” or “be helpful” is often how I figure out what’s actually going on clinically/decision-making-wise AND how I learn what the team really wants us to do for them. Using a form of the word “help” is great because it’s non-confrontational, and it cuts right to the root cause for all consults: one provider needs another one’s help. I definitely second Christian’s strategy of digging deeper into GOC/MDM situations, and I often use a “so how have the GOC conversations gone?” I also ask if the patient/family is aware of the diagnosis/prognosis as often they have not been informed/updated. If the answer is no, I request that the primary team (or primary Oncologist, or whoever owns the diagnosis/prognosis) share that news before Palliative Care meets the patient/family.

In question 4 exploring prognosis, I often facilitate their thought process using “would you be surprised” questions and reframing prognosis into ranges.

RE: question 7, I agree with Alex about asking the intern about the patient’s/family’s awareness of the consult. If the patient/family is not aware, I ask the intern to ALERT them but not to EXPLAIN the field. I agree w/ Eva that explaining the field and our role in their care is part of OUR job.

Robert Taylor said...

This is excellent. I would add two additional thoughts.
1) I agree wiht Number 3, and I think for the initial consult you should focus on the referring team's agenda but also explore the patient and family's questions and respond to those by saying I will talk to your team about your questions and either they or I will get back to you on that; then bring those back the primary team to discuss - often they are surprised to hear the patient may be changing their goals.
2) I often start by talking to the intern or resident, but if there is any ambiguity it is always good to talk to the attending before the consult. I have almost never gotten anything but appreciation for such a step and often the attending not only has a different primary question than the resident/intern, but also has a better understanding of the patient's options, concerns, and goals.

Robert Taylor said...

Also, I do not think they need to introduce the consult - I would just explain the primary team requested our help.
Also I like to tell the patient/family we try to do three things:
1) address any symptoms/ suffering the patient may be experiencing
2) help them get answers to any questions they may have about their disease and treatment options (also we sometimes can help them formulate questions)
3) help them have a good plan for support when (sometimes if) they leave the hospital (this can lead to a cautious discussion of goals).

Anonymous said...

Hello there, thank you all so much for this information. As a NP new to the palliative care field, this has given me very good guidance in how to approach the primary care team and the patients and their loved ones. Thanks again.

Alex Smith said...

Thanks to all for your comments! Sounds like #7 is the most controversial, and with good reason. Asking the consulting clinician if the patient knows we're coming is a relatively recent addition to my practice (as in, last few months). It's absolutely true that it's our job to introduce and explain palliative care in depth. Interns, residents, and other clinicians may completely mis-represent palliative care. On the other hand, we can teach them how to briefly introduce the concept, tied specifically to issues the patient is facing, "We'd like the palliative care team to come see you. They are the experts in pain management." Or "We've asked palliative care to talk with you. They see patients with serious illness can help us with some of the conversations we're having about next steps. Would that be OK with you?"

People lose so much control when they are in the hospitalized patient role. Door always open, people coming in without permission, new faces every 10 minutes. Asking the referring clinician to tell the patient they recommend a palliative care consult, and to obtain their assent, gives patients a measure of control. It's a measure of respect. And it can help get the palliative care consult off on good footing.

This is a good discussion, please rebut!