Palliative Care a Win for Both Patient and Hospital System
This article is from April 2022
Palliative care is a phrase may strike fear and confusion in patients and their family members as it is commonly associated with hospice. To the average lay person, hospice equates to treatment support for dying. But the definition of palliative care is specialized support and treatment for people living with a serious illness. Care focuses on providing relief from the symptoms and stress of the illness to improve the quality of life for both the patient and family (getpalliativecare.com, 2022).
My 74-year-old mother was diagnosed with Carcinoid cancer nine years ago with an expected survival timeline from diagnosis of five years. She has received treatments during the nine years that have affected her overall health including her cardiac and respiratory function. She has received her cancer treatment from the same oncologist, who my mother and father trust and respect, and have trusted his guiding and recommended treatment plan throughout her diagnosis. Due to a recent and obvious decline in her health, the oncologist recommended palliative care services to my mother with an empathetic and clear explanation of what the services can provide. Her immediate reaction was to decline the program and she and my father took offense to this offering. As her daughter, and a nurse who has spent the last 15 years in case management, I had a conversation with her to explain the benefits but to no avail. It felt like the days of trying to teach my kids elementary school math while they told me I was wrong!
So, the topic to consider is, how do we involve palliative care and how can it improve the patients’ transition of care? During my years in case management, I have seen advances in the acceptance and expansion of palliative care in the acute hospital setting. In proactive and forward-thinking organizations, the palliative care team attends critical care and medical multidisciplinary rounds. During rounds, this team can assist in identifying patients that are appropriate for referral and participation in the program. The importance of these conversations during the acute hospitalization cannot be undervalued. Connecting with the patient and family prior to discharge builds a relationship that increases compliance with the program once the patient is discharged home. To some degree, you have a captive audience that is looking for answers and relief while they are suffering from their acute symptoms. Once they are home and back to their baseline, it can be more difficult to engage them in a conversation and plan of care development. Patients that qualify for palliative care often have chronic issues that they have been managing and coping with for years and at times, for decades.
Patients with chronic conditions are also the same patients that often-become frequent ED visits and/ or frequent readmissions to a hospital bed. Whether they remain in the ED or are admitted, these patients use hospital resources to meet social and medical needs that could have likely been managed by an outpatient palliative care program. And many times, the support these patients’ need are often related to social isolation. The lack of social connections can also lead to associated risks such as depression, anxiety, and suicide. Recently, I was involved in a palliative care meeting related to a frequent readmit patient with chronic conditions who also verbalized that he preferred being admitted to the hospital because he is lonely at home. Now you would first assume that he would always be discharged from the ED without admission, but this patient was a chronic drinker who also had lab values and chronic conditions that fell within a range that clinically qualified him for an admission. And per admission criteria, the ED physicians were not comfortable with discharging the patient to home from the ED. Once admitted, the patient manipulated and found every reason possible to avoid discharge. Because the hospitalist covering on each admission varied, the patient got away with this behavior for several months before a care conference was scheduled.
After several meetings with case management and palliative care, the patient did agree to outpatient services. A palliative care outpatient program physician and nurse practitioner connected with the patient in the acute setting and discussed goals of care and home visits that initially occurred every few days at discharge. Over the next several months, the number of ED visits and inpatient admission decreased for this patient.
This story was a success for both the patient and the hospital system that he was frequently readmitting to. Important to remember when developing a plan for a patient is to consider:
What are the patient’s goals of care?
What relief of chronic conditions and pain can be relieved to improve the patient’s quality of life?
What is their current support in their home and community and what are gaps that can be filled?
What emotional, spiritual, and practical needs does the patient need to be met?
In a quest for appropriate use of hospital level of care and outpatient treatment of patient’s chronic conditions, our health systems needs to consider not only the ailment affecting the patient but also the person being affected, what it means to them, and resources that can be used to improve their quality of life.