Abstract
Dear Editor:
Palliative medicine is a key component of health care reform. By reducing hospital readmissions, decreasing lengths of stay, and decreasing unnecessary diagnostic and therapeutic procedures, palliative medicine improves care quality and lowers costs. 1 As a result, in the last several years members of my palliative medicine team have been asked by hospital administrators to take a major role in several initiatives. These include, among others, the promotion of the Physician Orders for Life Sustaining Treatment (POLST) paradigm for patients discharged to skilled nursing facilities, the development of triggers to identify patients appropriate for palliative medicine consultation, and participating in hospital length-of-stay rounds. These are all worthy endeavors that can improve patient care. Similar endeavors have likely received extensive support elsewhere.
Such support, however, should not be taken for granted. It hinges on how clinicians perceive the organizational impetus behind the initiatives. Clinician identities are often drawn from their work purpose, i.e., providing excellent patient care. This is also the dominant ideology championed by hospital administrators. 2 Thus, clinicians' professional and organizational identities are aligned. However, this alignment could falter as hospital administrators push to achieve the cost savings that palliative medicine can provide.
Hospital administrators would do well to appreciate the major role ideology plays in defining clinicians' relationship with the larger organization. Research in organizational management and psychology has demonstrated that significant operational problems arise when employees perceive “a divergence between the beliefs, practices, and procedures of the institution versus [their] profession.” 3 Promoting the economic benefits of palliative medicine could promote distrust if clinicians perceive themselves to be working in an environment that devalues compassionate care for the sake of economic benefits. Such was the case with the failed Liverpool Care of the Dying Pathway (LCP). Designed to bring the best end-of-life care pathways from hospices to hospitals, the LCP was scrapped in part because clinicians perceived that hospital administrators were sacrificing patient care for financial gain, i.e., the “medical mission” became secondary to “freeing up hospital beds.” 4
Palliative medicine is integral to achieving the triple aims of improving patient experiences and outcomes while reducing costs. If you ask any palliative care clinician, there is an important causal pathway: palliative medicine reduces costs because it improves patient care. As administrators plan and communicate their reforms, they must remember that successful interventions hinge on their espoused ideology: providing excellent patient care. This must never be overshadowed by economic benefits.