When Will “Usual Care” in Advanced Illness Be “Palliative Care”?

Another study in this issue of Journal of Palliative Medicine has amplified the value of hospital-based palliative care consultation ¹ by illustrating the reduced costs of care and decreased utilization of intensive care for veterans who received palliative care consultation compared to similar veterans who received “usual care.” Two findings from this study have provoked me into wondering when sustained application of evidence-based best practices will be found universally. In other words, how long until palliative care is usual care for patients with advanced illnesses and at the end of life.

First provocative finding: 40% of usual-care patients died during the study interval without the benefits of palliative care consultation. Additionally, more veterans who received palliative care were dying from cancer than the veterans who died from other chronic illnesses with usual care. ¹ This result is alarmingly similar to the findings from nearly 25 years ago about which hospitalized patients received a DNR order. In the earliest days of describing gaps and opportunities about care at the end-of-life, patients with cancer had DNR orders written disproportionately more often than patients with similar prognoses such as those with advanced heart failure or cirrhosis. ² Yet, in 2010, we still find more patients with cancer receiving palliative care consultation than patients with other advanced, progressive illnesses.

How much evidence do we need to support palliative care as best practice? The earliest hospital-based palliative programs began describing their positive outcomes more than 20 years ago.^3,4 Persuasive studies called for changes more than 15 years ago.^5,6 The Robert Wood Johnson Foundation spent millions of dollars on initiatives and demonstration projects in the last two decades.^7–13 The Center to Advance Palliative Care (CAPC) has influenced the exponential growth of hospital-based palliative care programs. ¹⁴ Clinical and organizational leaders collaborated to produce standards to guide quality care. ¹⁵ The results from a number of studies, including these recent findings, ¹ have repeatedly demonstrated positive patient, family, and system outcomes of palliative care consultation.^16–20 There has been a substantial increase in the number of palliative medicine fellowships and palliative care-focused nurse practitioner tracks.

So, with all the work, effort, money, and evidence to promote quality care for patients with life-limiting illnesses, I am still provoked by the large number of patients who do not receive palliative care consultation. As a middle-aged person, I am fearful that I will not benefit from these services as my last days approach. Perhaps we don't need any more descriptions of the value of palliative care consultation; perhaps we need more evidence from interventions that change the proportion of those who get palliative care compared to those who don't.