Dr. Rotella calls this cost-effectiveness a side effect of palliative care, when patients are empowered to make decisions about their own care. “That’s where you achieve the triple aim,” he says. “They feel better about it because they are in the driver’s seat. If a patient wants a treatment consistent with their values, we will advocate for it.”
One study found that patients at eight U.S. hospitals who received palliative care incurred significantly lower hospital costs than a matched group receiving usual care, with an average reduction in direct hospital costs of almost $1,700 for patients discharged alive and almost $5,000 per admission for patients who died in the hospital.3 Another study found that early palliative care interventions for cancer patients led to significant improvements in both quality of life and mood compared with patients receiving standard care, with less cost and fewer aggressive treatments at the end of life but longer survival.4
One of the main tools of the palliative care team is the family meeting.
Family meetings are scheduled to allow as many family members as possible to attend, and the primary-care team and relevant specialists typically are also invited. Many palliative-care teams use a standardized format that involves introductions, clarification of each participant’s understanding of the patient’s prognosis, and an effort to reconcile the patient’s hopes and values with medical realities and possibilities, Dr. Fischberg explains.
“That is such a critical component of our care, where we make sure the patient and family are fully informed and foster shared decision making that results in patients being more comfortable with care that better matches what they want,” says Dr. Rotella.
The palliative-care team typically becomes involved via a consultation request from a patient’s attending physician.
“A big part of our job is doing our homework,” Dr. Youngwerth says. “We’ll talk to the team about what’s going on. We want to get as much information as possible about the patient, about prognosis, about the perspectives of people caring for them. Don’t be surprised if the palliative-care team contacts you to get your input on the prognosis and other medical details in order to best inform their discussion with the patient and family.”
Then the palliative-care team will follow consult protocol in reporting back to the primary medical team.
Palliative-care teams can assist busy hospitalists with difficult patient conversations.
“When I’m on the hospitalist service, I’ll pull in the palliative-care team,” Dr. Youngwerth explains. “It’s not that I don’t have the skills; I don’t have the time.”
Conversations aimed at clarifying goals of care can take 90 minutes or more, but the palliative-care team will take as much time as needed to achieve clarification.
It’s important that hospitalists remain involved in these cases, says Christian Sinclair, MD, assistant professor in the division of palliative medicine at the University of Kansas Medical Center in Kansas City and president-elect of AAHPM.
“Just because you have access to palliative-care services, don’t miss the chance to enhance your own communication skills and your ability to address these issues head on,” Dr. Sinclair says.
American Academy of Hospice and Palliative Medicine is a participant in Choosing Wisely.
The Choosing Wisely program, initiated by the American Board of Internal Medicine Foundation, invites medical societies to identify five treatments that should be questioned by physicians and patients based on lack of supporting evidence in the research base. The Society of Hospital Medicine is also a participant in this initiative.
For AAHPM, one of its recommendations was: “Don’t delay palliative care for a patient with serious illness who has a physical, psychological, social, or spiritual distress because they are pursuing disease-directed treatment.” Other Choosing Wisely suggestions include not recommending feeding tubes for patients with advanced dementia, not leaving implantable cardioverter defibrillators (ICDs) activated when these are not consistent with patient/family goals of care, and not recommending more than a single fraction of palliative radiation for an uncomplicated painful bone metastasis.