Tapping into hospice and palliative medicine

PCPs benefit from services of underutilized specialty.

By Lynne Jeter

Not long ago, hospice referrals for end-of-life care were typically made only a few weeks before the patient’s death. Now, good hospice referrals are made six months to a year in advance to allow time for patients and their families to transition to the final phase of life. Palliative care comes in sooner for patients suffering from serious illness, with specialists having the advantage of focusing on the patient, not the disease.

“Hospice and palliative care deliver outcomes and experience of care at lower costs,” said Joe Rotella, MD, chief executive officier, Hosparus, in Louisville. “It increases quality of life and prolongs survival.”

“Just about any patient with a serious, life-limiting illness can benefit from palliative care,” added Robert Lehmberg, MD, assistant professor of hospice and palliative medicine at the University of Arkansas for Medical Sciences (UAMS). “It improves the patient’s quality – and sometimes length – of life.”

Hospice is definitely underutilized in the United States. According to Rotella, in 2010, 42 percent of patients who died received hospice care. Half of the hospital patients received less than 20 days of care. Derrick O’Connell, RN, chief quality officer for Esse Health, a St. Louis-based practice group with nearly 100 physicians and specialists agrees.

“There are barriers to hospice because of the inability to confront mortality as a psycho-social issue,” he said, “and barriers within the medical community to refer patients to hospice because physicians and their teams may feel they’ve failed in the medical management of a patient.”

Miguel A. Paniagua, MD, concurs. Because so many great technological advances in medicine have been made, he said a patient’s treating physician may view their death as failure.

Smooth Transition
O’Connell, a former hospice manager, said the emerging Patient Centered Medical Home (PCMH) model has a mechanism in place to assist primary care providers (PCPs) with the transition of patients to hospice and palliative care.

“Primary care providers and their teams can facilitate the documentation of advanced directives for each patient,” he explained. “Each patient is counseled on choices in the event of a life-ending medical condition or event. It’s important when provider teams recognize that the patient is nearing the end of their life cycle and can begin the patient-centered collaboration for appropriate end-of-life care with a statement like: ‘there’s nothing more medicine can do for you. We’d like to refer you to hospice care because they’re experts at keeping you comfortable at end-of-life care and can enable you to die with dignity.’”

Paniagua, associate professor and director of the Department of Internal Medicine Residency Program at Saint Louis University (SLU) School of Medicine in Missouri, said a smooth transition is easier when the primary care provider (PCP) team clearly communicates the end-of-life plan with patients.

“We similarly teach many hightech and high-reimbursing procedures in medicine, but in my view, the most delicate and nuanced procedure we can teach and learn is the bedside conversation about goals of care and treatment planning,” he said.

“Unfortunately, not enough emphasis is placed on teaching and learning this procedure, which leads to much variability in the way it’s delivered, as well as providers’ discomfort and unease with doing it.”

Hindered Progress
Paniagua also noted that mainstream media’s sensationalized coverage of euthanasia and physician-assisted suicide issues has hindered progress in the advancement of the specialty and public perception.

“In reality, (euthanasia and physician-assisted suicide) is such a

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miniscule practice, and in only three states,” he emphasized. “Too often patients feel they have no other way out of their suffering. More often than not, we providers don’t do an adequate job providing palliative care to most of the suffering.”

Lehmberg, who switched specialties to hospice and palliative medicine after a neck injury prevented him from continuing his nearly 30-year plastic surgery practice, said the most common misperceptions about the specialty are the differences between palliative care and hospice, and getting the team involved early enough to “truly assist the patients, their families and the treating physicians.”

“Most people, physicians included, think of us only in terms of hospice and end of life,” said Lehmberg. “However, palliative care improves the quality of life of patients and their families with life-threatening conditions through the prevention and relief of suffering, and also the treatment of pain and other problems – physical, psychosocial and spiritual.”

Rotella agreed. “We’re afraid to talk about death. We don’t always elicit or honor patients’ values and preferences,” he said.

Rotella notes that further barriers to offering hospice and palliative care include medicare regulations, exclusions and reimbursement mechanisms.

Why Palliative Care Helps Physicians
Palliative care may be extremely helpful to physicians and patients in conjunction with therapeutic treatments, such as chemotherapy and radiation, said Lehmberg, noting that requests for hospice and palliative care consultations for the UAMS Department of

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Hematology and Oncology has increased significantly – from 400 in 2007 to more than 2,200 estimated this year.

“As evidenced by our program growth, an awareness of the role of palliative care is increasing,” he said. “Still, I’d like to continue to contribute to a better understanding of our subspecialty and how we can help. Once a patient has been diagnosed with a life threatening illness, it’s really never too early to involve a multi-disciplinary palliative care team.”

Palliative care transitions to hospice care when the illness progresses to the point that therapeutic treatments are no longer applicable, explained Lehmberg.

“In palliative care, an experienced team is best at fitting in with the primary medical approach, not rivaling it,” said Lehmberg. “As consultants, the palliative care team complements the treatment and care provided by the primary physicians.”


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