Gary B. Rollman,
Emeritus Professor of Psychology,
University of Western Ontario
(In addition to links below, see weekly archives in the right column)
Tuesday, June 19, 2012
U.S. Hospitals Adding Palliative Care Teams at a Feverish Pace | Healthland | TIME.com
Fighting stage-four ovarian cancer, Carol Delzatto has had more doctor appointments than she cares to count. But this day, she is beaming as Dr. Pamela Sutton comes into sight, greeting her patient and calling her beautiful. Delzatto looks forward to her monthly meeting with the palliative care doctor, where she won't be pricked and won't be rushed, just listened to and offered help.
Hospitals across the country have been adding programs in palliative care — which focuses on treating pain, minimizing side effects, coordinating care among doctors and ensuring the concerns of patients and their families are addressed — at a feverish pace. The field has expanded so rapidly that a majority of American hospitals now have palliative programs, to the delight of patients who say they've finally found relief and a sympathetic ear.
Palliative care has its roots in the 1970s, but was slow to grow. Several pieces of research helped to advance the cause, though, showing widespread untreated pain in hospitals and nursing homes and the positive impact palliative programs had on such patients.
"She's not writing. She is just looking at me and listening and feeling," said Delzatto, 67, during her visit to Broward General Medical Center, where Sutton helped start the palliative care program more than a decade ago.
Dr. Diane Meier of Mount Sinai Medical Center in New York, who directs the Center to Advance Palliative Care, says one of the discipline's greatest benefits is that it looks at the patient as a whole.
"Patients see a different person for every single part of their body or every problem. The patient as a whole person gets lost," said Meier, who won a MacArthur fellowship for her palliative work. "The patient is a person, not a problem list, not a list of different organ systems with different problems, not a list of different diseases. So we end up serving in a quarterback role for the entire medical system."
In 2000, there were 658 palliative programs in hospitals, according to the Center to Advance Palliative Care, representing about one-quarter of American hospitals. By 2009, about 63 percent of hospitals had palliative teams, with a total of 1,568 programs recorded. The field is expected to continue growing as awareness and acceptance spreads, just in time to help baby boomers — the 78 million Americans born between 1946 and 1964 — as they move toward old age and begin developing more serious and life-threatening illnesses.
Though the programs and their scope vary widely, a common scenario might look like this: A patient is diagnosed with lung cancer, and a palliative care team's assistance is enlisted from the start, working alongside oncologists and other specialists. The palliative team may include doctors and nurses as well as a social worker and chaplain. Together, they coordinate care among the many medical professionals, have long consults with the patients and their families to answer questions, and may preventively prescribe medications for likely side effects of treatment, from pain to constipation to nausea.
The palliative team has a clear vision of the patients' goals and personal philosophies and, depending on these factors, might help steer them away from treatments that are determined to be more painful than they're worth. Though palliative doctors share some similarities with hospice doctors in this regard, their goal is still to cure, and their patients are not considered to be at the end of their lives, they are simply facing a serious illness.
Besides cancer, their help is commonly employed for treatment of heart and liver failure, HIV and AIDS, emphysema, sickle cell anemia, chronic obstructive pulmonary disease and a wide variety of other illnesses.
Palliative teams are sometimes met with doubt by both patients and their medical colleagues. Dr. Timothy Quill, a palliative care doctor at the University of Rochester Medical Center and president of the American Academy of Hospice and Palliative Medicine, concedes that patient recognition of what palliative care is remains relatively low and that resistance to the field remains among doctors untrained in the field.
Aside from misconceptions about palliative care being non-curative pain relief for patients destined to die, specialists may find a palliative team helps a patient reach a treatment decision that doesn't offer the most payment. Quill offers an example of a heart failure patient who may be considering getting a ventricular assist device.
"The economic incentives clearly favor doing aggressive medical interventions like this," Quill said. "Palliative care, it's all conversation. And conversation is not compensated in the same way that doing procedures is in our system right now."
Meier says resistance to palliative care tends to be generational, with many younger doctors embracing the field. Research on the subject has also helped prove its worth, particularly a 2010 study published in the New England Journal of Medicine.
That widely publicized report looked at terminal lung cancer patients and found patients who received palliative care as soon as they were diagnosed were in less pain, happier and more mobile than those who didn't receive such care, and the patients ultimately lived nearly three months longer.
Even with such scientific backing, and generally rave reviews from patients, even palliative care's most ardent backers admit it would not have spread as it has without showing cost savings to hospitals. Because a result of palliative care is shorter hospital stays, it can cut costs since many insurance plans pay a flat reimbursement for a treatment, not for the length of stay.
If a bed is freed up sooner, that means another paying customer can occupy it.
"By itself, better outcomes for patients would not be enough," Meier said. "In our society and current way of life, it is impossible to introduce any innovation whether it's surgery or drugs or any innovation if you can't show that it doesn't increase costs."
Broward General's adult and pediatric palliative teams saw more than 1,300 patients last year, but so far administrators have had trouble quantifying what the precise financial impact has been. Sutton and her colleagues have little doubt their work has resulted in fewer hospitalizations and shorter stays, but have found it hard to pinpoint the savings.
Sutton is focused this day on Delzatto, asking her about her sleep and bathroom patterns, and addressing her pain by writing prescriptions. Before seeing Sutton, the patient said she was suffering so greatly she was barely able to move. Now, she's able again to live fairly normally, browsing garage sales with a neighbor and walking the mall with her husband.
"The oncologists are focusing on chemo, the patients are focusing on cure and I think the conversations about comfort aren't happening," Sutton said.
Much of the appointment, Sutton just sits and listens, to Delzatto talking about her Mother's Day celebration, her new Kindle Fire and how she hopes to be able to go on a cruise later this year. And she hears Delzatto credit her with making her life livable again.