Abstract
Dear Editor:
A recent issue of Journal of Palliative Medicine contains an article by Horton et al. 1 looking at the impact of hospital-based specialty palliative care on hospice and ICU length of stay across a large sample of hospitals. Like other studies have noted, hospitals with palliative care programs in this report were more likely to be larger, be urban, have oncology services, and be teaching hospitals. Comparing 295 hospitals with palliative care programs with 679 nonpalliative care hospitals, they found no difference in the two outcome measures. How can this be?
The authors note several potential reasons for this lack of impact, both technical to the methods employed in this retrospective propensity-matched research design and relatively low program staffing. The average palliative care program employed only 1.2 physicians and 1.1 advance practice nurses (average hospital size was 424 beds; J Horton, personal communication). The authors conclude, and I agree, that low staffing impedes the ability of teams to change hospital culture. They suggest that primary, aka generalist, palliative care might be an option for improving outcomes.
Let me suggest three additional reasons for the lack of demonstrated impact; reasons that may be uncomfortable for some. First, when visiting palliative care programs and listening to team members discuss cases, I am often disturbed by their lack of palliative care knowledge and skills, particularly in complex symptom management and complex communication encounters. Board certification and even fellowship training for providers are nice, but insufficient to guarantee that the workforce is adequate to the highly complex clinical tasks of specialty palliative care. Second, far too many teams are still working in a physician referral mode where the bulk of consultations for patients occurs at the brink of death. Thus, it is no surprise that the average hospital palliative care program would not see a change in hospice or ICU length of stay. Third, I find relatively few programs have worked proactively to develop relationships with referring clinicians and administration to move palliative care upstream. The cause of this failure is three-fold and self-reinforcing. First, as noted in the article, teams are often woefully understaffed, so that all their time is being used in caring for the near-death patients, thus limiting their ability to reach out and work on hospital culture change. Second, most palliative care providers have little to no knowledge or skills in leading culture change projects, as these require a completely different skill set from clinical duties. Third, hospital administration provides no incentive to palliative care teams to improve global care, as they view us as part of an “end-of-life service line.”
Do not get me wrong, I think palliative care teams have and continue to make an overwhelmingly positive impact on individual patients and families and are improving hospital culture toward the care of the seriously ill. But we must also be humble enough to recognize our shortcomings. We need to work to be both the best possible clinicians and strong patient advocates for changing the system of care by advocating for greater depth of specialty and generalist palliative care and the system changes needed to ensure that all patients in need have access to palliative care services.