As a hospitalist, I know that my patients care deeply about these issues and are quite eager to discuss them. Talking with patients about these issues is not just a good thing to do, but ultimately improves quality of care by promoting care that is consistent with patient preferences and emphasizes our commitment to respect patients and advocate on their behalf. I still remember early concerns about hospitalists that we would be cowboys more interested in procedures and yelling “Stat!” than in being caring providers who took time to get to know our patients. Yet an early study of hospitalists that I was involved in found just the opposite. Hospitalists recognized the importance of palliative care and good communication with patients. As I made rounds in the hospital in late March, many patients were watching the vigil outside the hospice in Florida and talking about the Pope. Many patients wanted to know my thoughts. Using the communication skills I have honed over the years, and my cultural background of always answering a question with a question, I turned it around and asked them, “What do you think?” I suspect that patients will be using Terri Schiavo as an example of how they do or do not want to live―and die―for a long time. I will do my best to use this shared touchstone as a starting point for understanding their preferences: “Tell me what it is about Terri Schiavo that worries you?” By helping our patients express their preferences and encouraging them to discuss these with their loved ones, we may ease the burden of families who would otherwise have to make a difficult decision without direct knowledge of the patient’s choice.
The second lesson for us to embrace is that palliative care is a core competency for hospitalists. Palliative care is already identified as a core competency in the Core Curriculum under development by SHM. As part of our goal of improving the quality of care for all of our patients, we have the opportunity to dramatically improve end of life care and to identify people who would benefit from palliative care earlier in the course of illness. This opportunity represents a sacred trust and speaks to the most basic role of the physician to “cure sometimes and comfort always.” Ultimately, the deaths of Terri Schiavo and the Pope, although fundamentally different from each other, and unique in many respects, reaffirmed for me the importance of my role as a hospitalist in providing the highest possible quality of care for people facing serious illness and death. With these skills, we will secure our place as leaders in quality care and reap the rich rewards of using our humanity to help patients and families at one of the most important, profound, and intimate times.
The third lesson for us as hospitalists is that more research is needed to define the optimal ways to care for hospitalized patients. While the case of Terri Schiavo raised particularly thorny family issues that might defy the ability of research to clarify, issues of how best to care for patients like Terri Schiavo and the Pope and the millions of people like them with heart failure, deep vein thromboses, aspiration pneumonia, gastrointestinal bleeding, cancer, and myriad other conditions can be, must be, and will be investigated. The only question will be, by whom? As the providers of an increasingly large percentage of hospital care, we are on the front-lines of recognizing the clinical questions that arise and understanding the systems of care in which solutions must be implemented. Therefore we must play a central role in defining the questions and discovering the answers. Further, because we need research not only in how best to treat patients but also in how to ensure that patients receive these treatments, we need to conduct this research in community hospitals, where the majority of patients are cared for, and not just at academic centers.