Response to Research Brief Vol. 20(12):1313: Models of Palliative Care Team Composition

Dear Editor:

As palliative care nurses working in a variety of capacities, we were interested in the letter to the editor research brief published in the Journal of Palliative Medicine, 2017 (Vol. 20, 12:1313) entitled, Models of Palliative Care Team Composition: Nurse Practitioner-Only versus Interdisciplinary Teams that Include Specialist Physicians. The authors do raise the important issue of differing models of palliative care delivery in an inpatient setting. We do agree that the discussion of differing palliative care models is a particularly timely topic as there is a rapidly increasing demand for palliative care services and inadequate number of qualified practitioners.^1,2 At the same time, there is paucity of data to allow for a comparison of various palliative care delivery models in various settings to determine which provides the most cost-effective and efficient approach while also assuring quality of care.

The report and conclusions drawn raise a number of concerns particularly because a decision was made to change the care delivery model at the Advance Practice Nurse (APN) study site based on a single, small analysis where conclusions were not supported by data presented. The letter does not provide sufficient setting details between the comparision sites and how they differ in terms of patient population, illness types and severity, hospital philosophy, baseline length of stay, APN administrative support, and referral process. To provide useful, relevant clinical data, studies should control for setting type (academic vs community, urban vs suburban, etc.), facility size and numbers of beds, patient acuity, social demographics, and internal and external resources available to palliative care clinicians.

As written, there is also no discussion of the actual methodology, so it is unclear how the observations were accomplished and what controls might have been included in the analysis, such as age of patient, illness severity, ability to transfer to another setting, etc. It was difficult to ascertain how it was determined that the APN model resulted in “indirect” communication versus the “direct” communication reported in the team model. Given that these issues are not included, we were concerned that the conclusions drawn were premature to drive a change in team structure.

A comparison of practices utilizing different clinician types (APN, MD/DO) would require a very complex design and involve multiple institutions across many states. Many factors affect provision of APN practice, including state law, hospital bylaws, hospital culture, and administrative support. At a minimum, comparisons would include provision of equal palliative care resources, multiple sites, and measures that are obtained using valid, standardized, reproducible research methodology.

As noted above, we believe research of effective models of care is needed. Findings from well-designed, reproducible, and valid research would serve as a valuable determinate to delineate types of settings where different models are cost and resource efficient while still meeting the palliative care mission. Such studies should be conducted to identify appropriate factors that comprise successful palliative care programs. In an ideal world, we strongly support the value of an interdisciplinary team because it uses the strengths of the various professions to meet patient and family needs. At the same time, we realize that it may not be feasible for all team members to be part of a core palliative care program and believe that research is needed to explore and validate which innovative approaches may be effective to meet the increasing demand for palliative care.

Thank you for your consideration.