Patient and Family Preferences
Family members—especially women—shoulder most of the care of patients with serious illness. A minority of caregivers are over age 65 themselves and in ill health. When asked what they want from the medical system, family caregivers ask for help with transportation and personal care of their loved one at home, and for better home nursing support. They want 24/7 access to providers, better communication with their doctors, and to be remembered and contacted after the death of their family member.3-5 Caregiving itself has been shown to increase likelihood of premature mortality and lead to financial crisis.6
In the SUPPORT study, one-third of families lost most of their savings due to illness.7 Patients want pain and symptom control, avoidance of inappropriate prolongation of the dying process, and relief of burdens on family.8 Palliative care programs, both inpatient and ambulatory, can help provide families with needed services and improve communication at all levels.
The Demographic Argument
Hospitals need palliative care to effectively treat the growing numbers of people with serious, advanced, and complex illness. By 2030, the number of people over age 85 will double to almost 10 million.9 Many of these patients will have multiple chronic conditions, making their care complicated and expensive. And for many chronic conditions, including heart and lung disease, diabetes, and hypertension, death is not predictable.
Therefore, people need better care throughout the multiyear course of advanced illness. And while the Medicare Hospice Benefit is helpful for care of the dying (defined as people with six months or less to live) we need additional approaches for the much larger number of patients with chronic, progressive illness, years to live, continued benefit from disease-modifying therapy, and obvious palliative care needs.
The Educational Imperative
Hospitals are the site of training for most clinicians. Researchers have documented significant deficits in palliative care knowledge, skills, and attitudes among medical students, residents, and practicing physicians. Medical school and residency curricula, although improving, offer relatively little teaching in palliative care principles and practice.10,11
In 2000 the Liaison Committee on Medical Education mandated that medical school curricula include “important aspects of … end-of-life-care.” That same year the Accreditation Council for Graduate Medical Education encouraged internal medicine training programs to provide instruction in the principles of palliative care. Inpatient palliative care programs could provide much of this teaching through medical student and resident rotations, informal teaching during the consultation process, and through workshops and grand rounds.
The Financial Argument
Medical costs are rising exponentially due to multiple factors, including effective yet expensive new technologies and an expanding elderly population with more chronic conditions. Under the current Diagnosis Related Group (DRG) system, long, high-intensity hospital stays are causing a fiscal crisis for hospitals. The hospital and insurer of the future will have to work together to learn how to treat serious and complex illness efficiently and in the most cost-effective manner possible. Palliative care programs have the potential to ease this looming crisis through decreasing length of stay, both in the ICU and on the floors, and decreasing direct costs, including radiology, pharmacy, and laboratory costs. Researchers are beginning to document the positive fiscal impacts in rigorous studies.