Where Will Palliative Care Go Next?

Palliative care clinicians are in demand (but you probably already know). As the newest subspecialty in American medicine, and a growing interdisciplinary field around the world, we face a breathtaking growth in demand for our high-value services. Grounded in high-quality evidence from clinical trials, the American College of Clinical Oncology recommends concurrent palliative care for all patients with Stage IV nonsmall cell lung cancer at the time of diagnosis, and encourages a similar approach for all patients with advanced stage malignancies. ¹ Cardiologists who focus on the high mortality risk population with advanced systolic heart failure have also discovered palliative care. In health systems with tertiary care for this population, including left ventricular assist devices and transplantation, early co-management by palliative care experts is being expanded to meet needs in symptom management and to support complex decision making. ² Our medical and nursing workforce is growing, but will continue to fall short of projected needs. ³

As this issue of the Journal of Palliative Medicine makes clear, investigators are driving innovation in palliative care delivery. Building on the effective ENABLE (Educate, Nurture, Advise, Before Life Ends) intervention for patients with advanced cancer, Bakitas and colleagues report on their adaptation of this unique clinical approach for patients with advanced heart failure. ⁴ In the original clinical trial, this intervention—grounded in the chronic care model—deploys the skills of palliative care advanced practice nurses as distance coaches to educate, activate, and empower patients with advanced cancer and their caregivers. ⁵ The intervention resulted in improved quality of life and psychological symptoms. The ENABLE intervention extends palliative care expertise in important ways—across geographic areas to a diffuse rural population, and beyond the requirements of inperson interdisciplinary team care. As Dr. Bakitas reports here, this intervention is worthy of adaptation to new patient populations. Interventions like ENABLE help us to envision novel ways to add high-value care despite our workforce limits.

More patients with serious illness are transitioning to long-term care or home settings for their final phase of care, and yet a higher percentage of patients who remain in hospital are entering critical care settings—driving inpatient consultation demands while encouraging innovation in outpatient and home palliative care. ⁶ In fact, innovative palliative care programs are responding to this shift, and a growing body of evidence supports outpatient palliative care to improve satisfaction, symptom control, and quality of life while reducing intensity of health resource use.^7,8 This issue includes an interesting study of a novel outpatient palliative care clinic serving patients with advanced life-limiting illness, cancer survivors without active disease, and patients with chronic pain. Analyzing effectiveness of the form of expert pain management, the authors found that palliative care was most effective for patients' pain when a life-limiting diagnosis was present. In their discussion they raise the possibility that targeting this population may be the most effective use of palliative care teams. ⁹ Also in this issue, a study by Tangeman and colleagues reminds us of the limited reach of inpatient palliative care consultation without meaningful post-acute care. As other analyses have shown, inpatient palliative care consultation is effective to reduce the cost of care compared to propensity-matched control patients. However, these investigators examined rates of readmission after discharge and found that inpatient consultation combined with hospice enrollment was the key to reducing readmission in serious illness—a patient population with a higher rate of readmission in the absence of hospice. ¹⁰ This research finding suggests that transitional care planning may be an essential part of inpatient palliative care, and that inpatient teams and hospice teams may be more effective if they join forces to create a continuum of palliative care services.

Research helps us to “think outside the box” of our current practices. Our expanding evidence base is an essential tool to help us deploy palliative expertise most effectively and efficiently. If we only envision palliative care as traditional free-standing hospice agencies and interdisciplinary teams consulting inside hospitals, we will find ourselves standing helpless before the tsunami of demand. The good news—and it just keeps coming in these pages—is that we are a creative tribe still willing to reinvent and refocus our roles in order to add value to the care of seriously ill patients and their families.