The Basics
Palliative care’s focus is managing patients’ symptoms, maximizing quality of life, and clarifying treatment goals—regardless of diagnosis or other treatments they might be receiving. It is not hospice care, which is defined by Medicare as treatment for patients with a terminal prognosis of six months or less (see “Hospice and Palliative: End-of-Life Care Siblings,” p. 21). Palliative care and hospice care utilize many of the same techniques, and are combined in the ABMS program for certifying subspecialist physicians.
The interdisciplinary consultation service, where a palliative care consultant rounds with a team that might include physicians, nurses, social workers, pharmacists, and chaplains, is the most common palliative-care model in the hospital setting, but other approaches include dedicated units and community-based programs.
The latest data from the American Hospital Association (AHA) and the Center to Advance Palliative Care (CAPC) count 1,486 operational palliative-care programs in U.S. acute-care hospitals, more than twice as many as a decade before.1 Currently, the demand for physicians certified in hospice and palliative medicine outstrips the supply, which poses challenges to those trying to hire as well as bona fide opportunities for qualified physicians hoping to pursue their dream jobs in the field, says Dr. Pantilat, a past president of SHM.
“A few years ago, it was cutting-edge for hospitals to just have a palliative care program,” Dr. Pantilat says, “but now the focus is on quality and the qualifications of the palliative care physicians and other professionals. Expectations for what palliative care will deliver will only go up.”
UCSF’s palliative care service “lives” within its HM division. Five of the six palliative care attending physicians are hospitalists. They divide weeklong assignments on the service into seven-day commitments at the hospital; each shift includes an on-call pager for night coverage.
A palliative-care shift can be just as emotionally demanding as an HM shift, although usually with fewer patients. One big difference: More time is needed for each palliative care consult, Dr. Pantilat says. A typical consult consists of an intense conversation with the patient and family to explore the patient’s prognosis, family values, and goals for treatment and pain relief.
Additionally, palliative care physicians routinely discuss the psychosocial and spiritual distress that the patient and family normally encounter.
Know When to Call for Help
Hospitalist involvement in palliative care varies by service, individual experience, and institution guidelines. Generally, though, it starts with an understanding of what the service provides and determining when is the right time to call a palliative-care consultant for help (see “Your Page Is Welcomed,” p. 22).
Hospitalists can obtain basic training and incorporate palliative-care principles and practices into the care of all hospitalized patients (see “Training Opportunities,” p. 22). If your hospital has a palliative-care service, hospitalists could join an advisory committee or provide backup coverage. If no such service exists, hospitalists could advocate with other physicians and hospital administrators to start one, Dr. Pantilat says.
Some hospitalists go deeper, developing subspecialty expertise and board certification in palliative medicine.
For HM groups, integration with a palliative-care service could mean taking on medical management of the service. If your group chooses to go this route, experts suggest you research how busy the service could be and gauge the interest of physicians in your group. Also check on the willingness of hospitalists in the group who are not interested in working on the palliative care service; they could help free up time for those who want to do it.
Dr. Bekanich
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