Who Should Palliative Medicine Be Asked To See?

Now that the value of palliative care has been demonstrated,^1,2 a pressing question is, for whom are the specialist resources best deployed. There is a general sense that palliative medicine is underutilized in hospitals as well as in the community, even as successful teams complain they can barely cope with the volumes of patients and families they now see, and the amount of money available decreases.

In an industrial model, such questions are answered rationally and dispassionately. One proxy has been the percent of deaths seen by the palliative care team. In this issue, one hospital found that 25% to 37% of such cases were seen—a likely marker of underutilization. ² Yet, if the expertise of palliative medicine is the relief of suffering associated with serious illness, the number of deaths in a hospital is likely to underestimate need; the denominator will be too small. Most people suffering with advanced disease survive to discharge—they are just readmitted frequently in an ever increasing tempo until a final “terminal” admission. In addition, one can imagine that, with application of terminal care pathways like the Liverpool Pathway, it might be that most deaths are well managed without specialist attention. It will be the people who are likely to die in the foreseeable future (months to years) that most need specialist expertise.

The Center to Advance Palliative Care has stepped into the breach with a set of triggers that, applied at admission, would be expected to capture more of those who need palliative care during the hospitalization. ³ Presumably, this would let fewer needs go unmet, prevent crises and hospitalizations for manageable problems, and improve quality of life. Also, still pursuing the logic of the industrial model, if there are lists, there will be fewer errors and more quality.

There is an important limit to industrial models in medicine as it is now practiced in most parts of the world, however. Chief among them is the model of “my doctor; my patient.” In every setting, there is an attending physician who is responsible for the overall care of the patient. For the consultant, the managing service has the prerogative of accepting, or rejecting the advice of the consultant. This is not unique to palliative medicine. The infectious disease specialists have vilified surgeons and medical oncologists, among many others, for decades for not following their advice about antibiotics.

In training physicians to be consultants in palliative medicine, the most challenging skill to teach is consultation etiquette. ⁴ Briefly summarized, the best consultant (meaning the one whose recommendations are likely to be accepted and is most likely to be used again) determines the question to be answered, addresses it, and doesn't reach beyond that remit unless further permission is given by the managing service. Palliative medicine trainees note that many, many issues go unaddressed, or are addressed “wrong” for that reason. Wizened palliative medicine attendings respond to such youthful positivism that, when such etiquette is routinely breached, palliative medicine is “shut out” of some areas of the hospital—like intensive care units, oncology units, geriatric units, general medical surgical units, and the emergency department. In other words, such behavior will lead the palliative care team to be lonely in its righteousness. That might explain why, in another report in this issue, when looking at the outcomes of patients seen by the consultation service, one hospital found they were less than stellar. ⁵ Upon discharge, patients noted lack of information about prognosis, how to take their pain medications, and who to call with questions. Yikes!

The industrialists would respond that such choices should be taken out of the hands of the managing service; that palliative care should take control. Palliative medicine should respond that communicating clearly, in speech and in writing, in language the patient and family understand, about their condition and the treatment plan, is a fundamental skill for all managing services. Palliative medicine can't be the only group who know how to talk about prognosis, pain medications, and who to call for help.

In this approaching era of “accountable care organizations” into which we are rapidly hurtling, pressure to improve is bound to increase. We will need to maintain resolve on what properly belongs to specialist palliative medicine and what belongs to everyone who cares for sick patients; secondary palliative care versus primary palliative care skills. ⁶ Palliative care can't ever become the “new” primary care for the seriously ill; there is no conceivable industrial model that would produce enough skilled physicians, nurses, pharmacists, social workers, counselors, or chaplains. Furthermore, it would deprive the profession of some of the most rewarding parts of a career in medicine. This new era will be a golden one for palliative medicine; we cannot be so overwhelmed by all the attention as to not insist that everyone learn to play their role.