Abstract
D
As I observe contemporary health care, I observe a pattern that reminds me of this game. A typical patient with five or more chronic illnesses goes to the primary care provider. That provider says, “I have 10 minutes to handle all your preventive health strategies and one problem every three months—keep moving”. Each of the five specialists says, “I have 10 minutes to handle the one problem that I handle; for the others, keep moving.” When the patient comes to the emergency department, or is admitted to the hospital, the hospitalist says, “I'm going to address the problem that got you in here well enough to get you out—for a comprehensive approach, keep moving.” Each health care provider in the circle is hoping that, when the predictable health care crash comes (i.e., the music stops), the patient will be in some other part of the circle, not theirs.
I can sum up the last 18 years of science published in the Journal of Palliative Medicine and elsewhere by asserting that palliative medicine has been proven to deliver on the value equation. By that I mean that palliative medicine has been proven to deliver higher quality at lower cost. The next task is not in the realm of the biological sciences, but in the social and political sciences. If palliative care is best, whose job is it to routinely provide it? Will we require routine palliative care quality measures? Whose job is it? By that I mean, Who has the accountability to assure that palliative care is delivered?
In this issue Chen and Thorsteindottir report on a community-based program for providing palliative care to elders. 1 Yet again, higher quality at lower cost are demonstrated. However, this is at the Mayo Clinic—a revered institution known for its domination of fee-for-service medicine. Yet it is demonstrating the effectiveness of population-based approaches that are required for the new reality—even in rural Minnesota. But it's a special team. Is palliative care only the job of a special team or program?
Some are asserting that the future rests with training/retraining the health care work force in ‘primary’ palliative care skills. Yamamoto and colleagues report on the effectiveness of such a ‘retooling’ in Japan. 2 Interestingly, the national government of Japan mandated that all hospitals in the country would offer palliative care. The physician community has scrambled to rise to the challenge.
What happens when palliative care is available to some and not to others? The report by O'Conner and colleagues tells the tale. 3 Some win, some lose. If we believe that everyone should have access to the best care, then this should strike us as wrong. To address the kind of ‘hit or miss’ qualities of contemporary specialist palliative care, I propose that enrollment in hospice care for a median of three to six weeks before death is the expected completion of high-quality care for someone who is expected to die from a known chronic progressive illness, like cancer. It is easily measured and reported by hospital and by doctor. The data is strong enough to assert this as a health care standard.
As we implement the changes for this new world where palliative care is routine, we mustn't forget the cost to those who practice. If specialist palliative care providers see the most difficult cases, leaving the routine to everyone else to practice primary palliative care, there will be a significant cost associated with repeated exposure to severe suffering. Tony Back and colleagues formulate a model of how we might push forward on this front, too. 4
What happens where musical chairs is played? Children grow up. They learn that collaboration and teamwork are also fun—not just individualistic win and lose. Will we learn that in the grown-up world of health care?