Optimally palliative care is delivered through an interdisciplinary team consisting of physicians, nurses, chaplains, social workers, pharmacists, as well as other disciplines as patient/family needs warrant. Models of palliative care delivery include hospital-based inpatient consultation services, inpatient palliative care units, outpatient and home-based consultation services, and ambulatory clinics. Hospitalists are ideally positioned to start inpatient palliative care services and reap the professional and institutional benefits that palliative care offers. Tools to develop a program can be obtained through the Center to Advance Palliative Care (www.capc.org).
A Core Competency
The skills gained from developing expertise in palliative care are indispensable to hospitalists—even if they don’t formally work with a palliative care team. Palliative care itself is identified as a healthcare systems core competency of hospital medicine.2 In addition, other hospital medicine competencies overlap with those key to palliative care: pain management, care of the elderly patient and vulnerable populations, communication, hospitalist as consultant, team approach and multidisciplinary care, transitions of care, and medical ethics.3 For some of the most challenging, yet common, inpatient clinical scenarios, palliative care and hospital practice can become indistinguishable.
Inpatient Scenarios: How Can Palliative Care Help?
Scenario 1: A patient on chronic long-acting opiate therapy is admitted to the hospital with complaints of pain, nausea, and vomiting.
The appropriate assessment and management of pain is a patient’s right and an institution’s responsibility, yet it is often inadequate.4 Many barriers to effective pain management have been identified, including limited physician undergraduate and graduate training.4,5 A fundamental goal of palliative care is pain relief. In turn, expertise in the pathophysiology of pain and safe prescribing of opioid, non-opioid, and adjuvant analgesics is critical for palliative care physicians. Palliative care training and resources focus on principles of analgesic pharmacology, equianalgesia, changing routes of administration, control of continuous and breakthrough pain, opioid rotation, and adverse effects of analgesics. A comprehensive introduction to the fundamentals of pain management can be obtained via Education on Palliative and End of Life Care (www.epec.net.) Pain Management Module.
Non-pain symptoms can be as troubling for patients with advanced illness as pain. The formal assessment, reassessment, and management of common symptoms, including nausea, vomiting, dyspnea, constipation, fatigue, and delirium, are a primary domain of palliative medicine. Nausea and vomiting, for example, can become a demoralizing symptom complex. Stimuli to the vomiting center can arise from the cerebral cortex, vestibular apparatus, chemoreceptor zone, and gastrointestinal tract resulting in a broad etiologic differential diagnosis.
With a solid understanding of its pathogenesis and pharmacologic and non-pharmacologic therapeutic principles, nausea and vomiting can be treated in the vast majority of patients. Multiple agents addressing multiple mechanisms may be required. Even the nausea associated with complete bowel obstruction often can be successfully palliated, without the use of nasogastric tubes or surgery.6 The End of Life/Palliative Education Resource Center (www.eperc.mcw.edu) is one of many resources with tools to improve a hospitalist’s evaluation and treatment of non-pain physical symptoms.
Scenario 2: A patient with advanced heart failure and his family are overwhelmed by differing consultant opinions on the appropriateness of implantable cardioverter defibrillator (ICD) insertion.
Effective communication with patients is a core responsibility of both hospitalists and palliative care physicians. A complementary—and at times challenging—skill is the ability to promote communication and consensus about care among multiple specialist consultants. Ripamonti and colleagues write, “Almost invariably, the act of communication is an important part of therapy: Occasionally it is the only constituent. It usually requires greater thought and planning than a drug prescription, and unfortunately it is commonly administered in subtherapeutic doses.”6