Palliative care is also a medical specialty that involves specialty training, including year-long hospice and palliative medicine (HPM) fellowships now offered at 112 sites accredited by the Accreditation Council for Graduate Medical Education. Subspecialty board certification is also available through 10 collaborating medical specialty boards within the American Board of Medical Specialties as well as by the American Osteopathic Association. Palliative-care programs are now certified by The Joint Commission, with similar recognition under development by the Community Health Accreditation Partner.
Palliative care is intended for patients facing challenges.
Palliative care is intended for patients who might be expected to face stresses and challenges in any area of their lives as a result of serious illness. This may include, for example, patients who experience frequent emergency department visits, hospital readmissions, or prolonged ICU stays, as well as cancer patients who are admitted to the hospital solely to address out-of-control symptoms resulting from their disease and its treatment.
“We can help with the burdens of any challenging symptoms,” Dr. Fischberg says.
Other examples of appropriate palliative-care referrals are when next steps for patients’ treatment are not clear, when there are questions about patients’ real goals of care, and when unmet needs such as unrelieved symptoms have put their families in a state of distress, whether physical, emotional, social, or spiritual. Patients may need guidance about weighing their care options.
Palliative care is also available for children and their families.
The philosophy and organization of palliative care for delivering compassionate care for children with chronic, complex, or life-threatening conditions are much the same as for adults. In 2013, the American Academy of Pediatrics issued a Pediatric Palliative Care and Hospice Care policy statement,2 which outlined core commitments in such areas as respecting and partnering with patients and families and pursuing care that is high-quality, readily accessible, and equitable.
As with adults, a referral for palliative care typically is most helpful for the more complex cases, says Joanne Wolfe, MD, MPH, director of Pediatric Palliative Care at Boston Children’s Hospital. The palliative care team can offer emotional support to the parents of children with complex illnesses and help them understand confusing treatment options. The children, too, need a sounding board.
“If I were teaching a group of hospitalists, I would emphasize foundational principles of palliative care, starting with relationship and understanding patients’ and families’ goals of care,” Dr. Wolfe says. If the family is struggling to cope with the illness and the hospitalist doesn’t have good answers, that’s when to call palliative care, she adds.
Palliative care’s role is not to talk patients and their families out of treatments.
The palliative-care team tries to enter cases without an agenda, Dr. Fischberg says, rather than aiming to get patients to stop treatments or agree to a do-not-resuscitate (DNR) order.
“We’re interested in what the hospitalist thinks about what best care for this patient looks like but also in eliciting the patient’s values and preferences,” he says.
Palliative-care professionals are skilled at delicately communicating bad news and helping patients and families clarify what their goals of care really are, says Robert Crook, MD, FACP, associate medical director of Mount Carmel Hospice and Palliative Care in Columbus, Ohio.
“It’s more about helping to improve communication between the primary-care team and the patient and family—not talking somebody out of something but helping them understand each other better,” Dr. Crook says.
Palliative care can reduce costs of care on average, but it does not achieve this by rationing care or denying treatments.
“We’re not there to cut costs or to get patients discharged sooner or to steer them away from costly treatments,” explains Dr. Rotella. “The last thing a palliative-care team wants is to be viewed as a care rationer. But if the patient understands what’s really going on, they often won’t want treatments that don’t help. So, in that way, we are part of the solution.”