Palliative care in U.S. hospitals is growing, with 1,568 operational programs in nearly 2,500 hospitals, according to the most recent tally from the American Hospital Association and the Center to Advance Palliative Care. And as palliative care becomes a staple of inpatient care, hospitalists across the country become more involved in end-of-life care planning.
At Kaiser Permanente’s San Rafael Medical Center in California, most of the 21-member hospitalist group has been learning palliative-care concepts through grand rounds, practice updates, and self-study. Hospitalists are incorporating the concepts into routine practice and doing palliative-care consults and family meetings, says Robert Lavaysse, MD, who started the inpatient palliative-care team at San Rafael. About 10 hospitalists will join nephrologists, oncologists, and pulmonologists and sit for board certification in hospice and palliative medicine (HPM), a subspecialty recognized by 10 medical boards of the American Board of Medical Specialties. The Oct. 4 board exam is the last time physicians can earn the recognition without first completing a full-year HPM fellowship.
At Monarch Healthcare, a large physician group in Southern California, a dozen employed hospitalists and “SNFists” have been working with the palliative-care team at the University of California Irvine (UCI) Medical Center, says Vincent Nguyen, DO, CMD, Monarch’s medical director for geriatrics and palliative care. The hospitalists, who work seven-on, seven-off schedules, are using “off” weeks to train at UCI. Nine have completed six weeks of training and plan to sit for the HPM boards in October. Dr. Nguyen also pulled in palliative-care experts for 26 hours of didactic presentations, and invited hospices from the community to hold their interdisciplinary team meetings at the medical group’s office so that interested hospitalists could sit in and observe how hospice cases are managed.
—Edward Merrens, MD, FHM, hospital medicine section chief, Dartmouth-Hitchcock Medical Center, Hanover, N.H.
“Every physician who has gone through this experience is utilizing it in daily practice and influencing their colleagues,” Dr. Nguyen says. He also says hospitalists need to learn to “slow down a bit” with seriously ill patients, many of whom are good candidates for palliative care. He suggests hospitalists make certain that patient goals of care are elicited and advance directives are captured, and that they are 100% ready for the next care transition.
At Dartmouth-Hitchcock Medical Center in Hanover, N.H., hospitalists and palliative care collaborate in many areas, says HM section chief Edward Merrens, MD, FHM. “I made it a priority to broaden palliative care’s role in the organization, across all subspecialties,” says Dr. Merrens, who started the program in 2004.
Palliative-care consults are embedded in the ICUs at Dartmouth-Hitchcock, and the palliative-care team is involved in the assessment process at its affiliated outpatient cancer center.
“If a cancer patient is admitted to the hospital for reasons other than to receive chemotherapy, we take on the care of that patient, which provides an opportunity for us to collaborate with the inpatient palliative-care team,” Dr. Merrens says. “We do an initial conversation with patients about decision-making and code status within our service, and then work closely with the palliative-care team.”
Palliative care is part of the hospital’s current conversation about preventing unnecessary hospital readmissions. One example is end-stage renal patients, who come from a broad catchment area, and have high rates of mortality. “[They] can get caught in a vortex of readmissions,” he says.
The collaboration is just one example of how the “robust” 25-member hospitalist program “covers virtually everything that hospitalists do,” Dr. Merrens says. “Palliative care is a big part of how we envision the right care for these patients. There are no miracles about what palliative care does, but [caretakers] take the time to sit down and have these conversations. As we continue to take care of sicker, older patients, palliative care will play an ever-larger role.”
Larry Beresford is a freelance writer in Oakland, Calif.