Paradigm shifts in palliative care


Paradigm shift

Another palliative care role that hospitalists often find themselves in is “comforter” of elderly patients.

Dan Burke Photography

Dr. Ryan Greysen

Ryan Greysen, MD, MHS, chief of hospital medicine at the University of Pennsylvania, Philadelphia, said hospitals must respond to a shift in the paradigm of elderly care. To explain the nature of this change, he referenced the “paradigm shift” model devised by the philosopher of science Thomas Kuhn, PhD. According to Kuhn, science proceeds in a settled pattern for many years, but on the rare occasions, when there is a fundamental drift in thinking, new problems present themselves and put the old model in a crisis mode, which prompts an intellectual revolution and a shift in the paradigm itself.

“This is a way of thinking about changes in scientific paradigms, but I think it works in clinical practice as well,” Dr. Greysen said.

The need for a paradigm shift in the care of elderly inpatients has largely to do with demographics. By 2050, the number of people aged 65 years and older is expected to be about 80 million, roughly double what it was in 2000. The number of people aged 85 years and up is expected to be about 20 million, or about four times the total in 2000.

In 2010, 40% of the hospitalized population was over 65 years. In 2030, that will flip: Only 40% of inpatients will be under 65 years. This will mean that hospitalists must care for more patients who are older, and the patients themselves will have more complicated medical issues.

“To be ready for the aging century, we must be better able to adapt and address those things that affect seniors,” Dr. Greysen said. With the number of geriatricians falling, much more of this care will fall to hospitalists, he said.

More attention must be paid to the potential harms of hospital-based care to older patients: decreased muscle strength and aerobic capacity, vasomotor instability, lower bone density, poor ventilation, altered thirst and nutrition, and fragile skin, among others, Dr. Greysen said.

In a study published in 2015, Dr. Greysen assessed outcomes for elderly patients who were assessed before hospitalization for functional impairment. The more impaired they were, the more likely they were to be readmitted within 30 days of discharge – from a 13.5% readmission rate for those with no impairment up to 18.2% for those considered to have “dependency” in three or more activities of daily living.1

In another analysis, severe functional impairment – dependency in at least two activities of daily living – was associated with more post-acute care Medicare costs than neurological disorders or renal failure.2

Acute care for the elderly (ACE) programs, which have care specifically tailored to the needs of older patients, have been found to be associated with less functional decline, shorter lengths of stay, fewer adverse events, and lower costs and readmission rates, Dr. Greysen said.

These programs are becoming more common, but they are not spreading as quickly as perhaps they should, he said. In part, this is because of the “know-do” gap, in which practical steps that have been shown to work are not actually implemented because of assumptions that they are already in place or the mistaken belief that simple steps could not possibly make a difference.

Part of the paradigm shift that’s needed, Dr. Greysen said, is an appreciation of the concept of “posthospitalization syndrome,” which is composed of several domains: sleep, function, nutrition, symptom burden such as pain and discomfort, cognition, level of engagement, psychosocial status including emotional stress, and treatment burden including the adverse effects of medications.

Better patient engagement in discharge planning – including asking patients about whether they’ve had help reading hospital discharge–related documents, their level of education, and how often they are getting out of bed – is one necessary step toward change. Surveys of satisfaction using tablets and patient portals is another option, Dr. Greysen said.

The patients of the future will likely prompt their own change, he said, quoting from a 2013 publication.

“Possibly the most promising predictor for change in delivery of care is change in the patients themselves,” the authors wrote. “Baby boomers have redefined the norms at every stage of their lives. ... They will expect providers to engage them in shared decision making, elicit their health care goals and treatment preferences, communicate with providers across sites, and provide needed social supports.”3

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