The American Academy of Hospice and Palliative Medicine UNIPAC series is a resource for physicians to hone their general communication skills, as well as those more specific to palliative care, such as sharing news (often bad) with patients and families and engaging in therapeutic dialogue.8
Palliative care begins with establishing the goals of care with a patient.9 All physicians bring great value to patient care when they are skilled at negotiating goals of care. There are numerous possible goals of care, from prevention, to cure, to prolongation of life, to achieving a good death. Ideally, goals of care should be discussed with patients and families as early as possible in the course of a serious, life-threatening illness. Establishing realistic and attainable goals of care assumes increased importance in the setting of advanced disease, where treatments intended to prolong life may become more burdensome than beneficial.9
As the reader may have experienced, too often these discussions have not taken place or are held late in the trajectory of illness, such as when patients are hospitalized for severe progressive disease or are facing imminent death.10 In the scenario of potential ICD insertion, conversations with patients to clarify device-specific goals are best accomplished before they are placed and in the context of a broader discussion of the patient’s general medical condition and overall goals for care.11 This type of discussion ultimately improves the informed consent process for ICDs and other technologies. ICD recipients should be guided to periodically revisit their goals, particularly when their health status significantly changes.11 Unlike for initial ICD placement, there are no guidelines for disabling already implanted ICDs. The opportunity to discuss this issue with a patient before a crisis or before they lose decision-making capacity is frequently lost and occurs all too often at life’s end.12
Scenario 3: An elderly debilitated woman with advanced cervical cancer has been hospitalized six times in the past two months. She is cared for at home. Her family is tired but they are doing “the best they can.” She is brought to the emergency department again with weakness.
Effective implementation of care management strategies for patients with life-threatening and advanced disease requires assessment of their physical, social, emotional, and spiritual concerns.1 Similarly, family caregivers have their own—often unvoiced—biopsychosocial stressors.13 Physicians directing patient care must appreciate the significance of these multiple issues, even if they are not comfortable or are ill-equipped to handle them on their own. The power of the interdisciplinary palliative care model is that team members evaluate the patient from different perspectives and pool their expertise in addressing the complex needs of their patients and families.8
In some multidisciplinary models, the onus may lie on the physician to recognize the patient and family needs and mobilize the appropriate resources. Coordination of care at home for patients in the later stages of chronic illness may seem daunting during hospital stays. However, by employing measures utilized by palliative care teams, such as reviewing the goals of care, introducing community resources to help patients and families manage at home, providing anticipatory grief and bereavement support, and considering hospice referral, discharge planning and transitions in care can be much more sustainable.14 With these interventions, patients, families, physicians, and hospitals all benefit.
Conclusion
Hospital-based palliative care programs are growing exponentially.15 Hospitalists are in a unique position to continue their development. Even if the time or circumstances are not yet right for you to become a part of a formal palliative care program, there are daily opportunities to reap rewards from the knowledge, attitudes, and skills that palliative care training offers.