Abstract
Dear Editor:
How big should a clinical palliative care program be? It is generally assumed that all physicians and clinicians will practice primary palliative care. 1 Specialist palliative care teams will be needed for those patients and families whose needs exceed those with primary palliative care skills or to whom that role is delegated by referral because of preference or time constraints.
An 11-hospital health system with a 50% market share serving 40 counties with 3.5 million people living in central Ohio is building a single program of hospice and palliative care. There are 3600 physicians with medical staff privileges serving the system.
Operationally, the program sits in a single business unit with one president, the accountable executive, and paired with one physician executive. This is designed to ensure one standard of care for the system. One unit of specialist palliative care provision is defined as a team including a specialist physician, advanced practice nurse, social worker, chaplain, and pharmacist. Hospitals cannot form their own teams or go outside the system to purchase palliative care nor can they pick which disciplines they want while excluding others. The explicit aim is to see 10% of acute care admissions (not observation patients).
The Clinical Guidance Council is composed of physicians who set standards of practice for the system with an eye to reducing variability to improve quality and reduce cost. Subcommittees represent the specialties of medicine. To help refine the system plan for specialist palliative care services, the clinical guidance councils representing primary care, hospitalists, critical care, oncology, cardiology, neurology, and pulmonology were asked whose job it is to manage pain and other symptoms of the diseases they see (Table 1). The choice “specialist” means the specialty who is being asked. For example, for the oncologists, the “specialist” is an oncologist. They were also asked whose job it is to have a goals of care conversation to communicate the “whole picture” and elicit values and goals from patients and their families (Table 2). Collectively, >175 people contributed their opinions through a multiple choice, anonymous questionnaire.
At a routine meeting, members of each clinical guidance council (listed across the top of the table and comprised about 25 individuals in each group) were asked this question in an anonymous survey, “Whose job is it to assure that pain and other symptoms are managed?” The choices were (1) primary care, (2) hospitalist or resident, (3) specialist, and (4) palliative care team. These choices are listed on the left-hand side of the table.
At a routine meeting, members of each clinical guidance council (listed across the top of the table and comprised about 25 individuals in each group) were asked this question in an anonymous survey, “Whose job is it to communicate with patient and family about the overall clinical situation with a goal of eliciting values and determining overall goals of care?” The choices were (1) primary care, (2) hospitalist or resident, (3) specialist, and (4) palliative care team. These choices are listed on the left-hand side of the table.
We conclude that there is an impressive amount of variability. It is an old axiom that “when it's everyone's job, it's nobody's job” in terms of organizing process for consistent outcomes.
There is little variability in the finding that about one-quarter of physicians think it is the specialist palliative care team's job to do these things in the hospital. This suggests two important conclusions for planning purposes: (1) efforts to educate physicians in primary palliative care with the intent to change practice but who do not think it is their job are likely to fail and (2) specialist palliative care teams will need enough staff to see those patients for whom their doctors think it is not their job or do not have time or inclination. Thirty percent of hospitalized patients are found to need palliative care. 2 Specialist palliative care teams are generally staffed to see 5%–10% of admissions. In light of these data, that planning goal is likely too low.