Abstract
A
What are we to make of these results and how are they to be interpreted? For the authors, the results represent a “true shortfall in care” and “indicate ample opportunities to improve both the provision and timing of palliative care consults in VA and the timing of hospice care across both VA and Medicare for veterans dying with cancer.” Our interpretation of this study is rather different. Indeed, whereas there is room for improvement, these data are notable for the positive change in practice patterns that have occurred within the VA and the success in enhancing access to palliative care within this integrated healthcare system.
Why do we see the glass as more than half full? To begin, it is important to recognize the limitations of the authors' dataset. Whereas, as the authors note, it is now recommended that palliative care be initiated soon after the diagnosis of advanced cancer, it was only in February of 2012—the same year as this study's data—that the American Society of Clinical Oncology (ASCO) first made this recommendation in a provisional clinical opinion. 3 It is unlikely that the changes in practice patterns recommended by ASCO would have been implemented the year that they were issued. Analyses of more recent data (when available) will provide a better measure of response to new guidelines. Second, the overall number of veterans who received hospice services is, as the authors note, well above national averages—indeed 50% higher than the 2013 national average. Given the limitations of the hospice benefit (the 6 month prognostic window) and the difficulty of some to accept that they are dying and access hospice, it is unrealistic to believe that we will ever get to 100%. Similarly, although data regarding receipt of palliative care services are difficult to find, it is notable that our study of seriously ill veterans who died during 2004–2006 within the five hospitals of Veterans Integrated Service Network (VISN), 3 found that only 18% received palliative care. 4 The 51% figure reported in the present article represents a marked positive change over a 6 year period. Furthermore, almost 50% of those receiving palliative care received concurrent antineoplastic treatments. Hence, we view these data as remarkable improvements within a system that has an established system-wide policy to ensure that every patient has access to high-quality palliative care.
What then can we learn from the VA? Whereas it is difficult to draw causal conclusions from the data presented, the elevated rates of hospice enrollment in VA as compared with national averages suggest the importance of standardized access to both upstream palliative care in all VA medical centers (as a bridge to hospice) and the VA's decade-long policy of allowing hospice care concurrent with antineoplastic treatments. Similarly, the VA has invested heavily in clinician mid-career training in the core knowledge and skills of palliative care as well as system-wide quality measurement and improvement. The nation's more than 1700 hospital palliative care teams would do well to replicate these strategies. 5 The 30% of U.S. hospitals with more than 50 beds with no palliative care services at all can use the VA's roadmap to improve. 5
What can the VA do to build on its success? It is well known that waiting for clinicians to make the referral to palliative care means that many, if not most, patients who need palliative care support do not receive it or receive it later than they should. A number of hospitals have begun to use triggers for referral to palliative care, standardizing access, and timeliness of support for seriously ill patients and their families. The major barrier to scaling such an approach is the workforce deficit in palliative care. Already, many palliative care specialists are facing rising demand that they cannot meet, and are forced to triage their services to the most sick and complex, and often those closest to death. Since the quality impact of palliative care is dependent upon the right people receiving it in a timely manner,6,7 we must invest both in training more specialists and in scalable mid-career training for all clinicians who take care of seriously ill people and their families.
Increasing access to high-quality palliative care is a social transformation of profound importance to our health system, our nation, and to people living with serious illness and their families. The striking progress achieved in the VA illuminates the path forward for the rest of our health system. The goal now is to standardize timely access to quality palliative care for all who can benefit.
Dr. Morrison has a 1/8th appointment at the James J. Peters VA Medical Center, Bronx, NY. The contents of this editorial do not represent the views of the Department of Veterans Affairs or the United States Government.