Palliative Consult
Hospital-based palliative care programs are gaining traction in the United States as studies show their efficacy in decreasing length of stay and improved quality of patient care.1,2 According to the American Hospital Association, 22% of all U.S. hospitals now have such programs.3 These programs—with their emphasis on coordinated, team-delivered care and communication—seem tailor-made for the expertise of hospitalists who are increasingly taking the lead to establish them at their institutions.
Through the SHM Web site (www.hospitalmedicine.org) and the Center to Advance Palliative Care (www.capc.org) ample resources exist for developing program infrastructure and acquiring on-site training (see www.capc.org/palliative-care-leadershipinitiative/overview).
There are unwritten protocols, however, that can make or break a palliative care service. Hospitalists involved with palliative care often find themselves relating to oncologists because many patients who have palliative care needs are undergoing inpatient curative treatments (such as brachytherapy) or are actively dying. Palliative care experts interviewed for this article agreed that in order to encourage referrals from their oncology colleagues, hospitalists must be attentive to oncologists’ concerns and to consultation etiquette.
“Palliative care has been something that oncologists traditionally think they do pretty well,” says David H. Lawson, MD, section chief, Medical Oncology at Emory Clinic. “I think there will be a lot of variability between oncologists about what they see as their province and what they see as open for someone else.”
—Diane E. Meier, MD
Assessing Oncologists’ Needs
During the organizational phase of a hospital-based palliative care service, it is advisable to meet with oncologists one-on-one, believes Charles F. von Gunten, MD, PhD, medical director of the Palliative Care Consultation Service at the University of California, San Diego, and director of the Center for Palliative Studies at San Diego Hospice and Palliative Care. “All consult services are fundamentally about providing advice to the managing physician when requested, about what is requested, and nothing else.”
He recommends that hospitalists involved in development of a hospital-based palliative care service find out how key oncologists at their hospital perceive the needs in the area of palliative care. “This may not match what the hospitalist thinks the oncologist needs, but that’s immaterial,” he cautions.
This advice squares with that of Steve Pantilat, MD, immediate past-president of SHM, and his team at the University of California, San Francisco. The palliative care service at UCSF is one of six Palliative Care Leadership Centers nationwide, so designated during an initiative launched two years ago by the Center to Advance Palliative Care. (The Robert Wood Johnson Foundation underwrites training activities at the six centers.) The issue in establishing palliative care services, says Dr. Pantilat, is “figuring out what would attract oncologists about such a program. What issues are most salient to them? Instead of saying, ‘I have a new service; would you please use it?’ You have to come in and say, ‘We’re thinking of starting this new service; how can we be of help to you?’ ”
Dr. Lawson agrees with Dr. von Gunten and Dr. Pantilat that hospitalists must develop communication with oncologists early during the start-up phase of a palliative care service. Hospitalists who offer palliative care services should also take time to familiarize themselves with patients’ treatment plans.
“I think there is going to be a learning curve for palliative care specialists,” says Dr. Lawson. “Part of that learning is to get some sense of how oncologists make decisions about whether to give chemo[therapy] or not. Oftentimes, there are pressures that might not be obvious.”
