Abstract
I was asked to speak to the hospitalists in one of our large hospitals about the role of “early” palliative care in heart failure. The system where I work, like many, is now participating in projects where we are rewarded for better managing chronic illnesses and preventing hospitalization and rehospitalization.
I started by asking them to go around the room and say one thing they appreciated about working with the specialist palliative care team. Far and away the most common comment was, “communication.” They so appreciate that they are called before the palliative care team sees the patient, then called back afterward. This has been called “consultation etiquette.” 1 They said they learned things, felt included, and valued. One said, “they always say ‘thanks for asking us to see your patient.’ I know they are busy, like we are, but it is still nice to hear it.” Others lamented that other specialist services do not communicate this way. They appreciate that the palliative care team marshals the patient and all the family members for the family meetings, including all the emotion, and gets everyone on board with a plan. They like the help with symptom control, but the communication abilities are 80% of the customer delight.
Most of the research articles in this issue are about communication. I have heard some comment that the goals of care talk with patient and family is the defining procedure of palliative care in the way that the angiogram defines interventional cardiology or colonoscopy defines gastroenterology. That puzzles some people. “Why would you spend all that money on a specialist team when anyone can talk…just teach/make the hospitalists do it.” How to do it, who does it, and what are the reliable outputs are of intense interest.
The article by Palladino et al. in this issue points out the core issue: emotion. Patients and families are willing to discuss difficult things that are associated with strong emotion. The rub comes when the health care professional is unable, unwilling, or uncomfortable in the presence of strong emotion. As I reflect on the patterns of rapid and extensive uptake of specialist palliative care and the growth of hospice care in our large health care system, I see the need to offload the emotion, particularly the anger, sadness, and tears, to those who have the time, talent, and interest to do so. The contemporary industrial models for reducing errors, improving quality and reducing cost by eliminating unwarranted clinical variation are gummed up by emotion. Yet, if emotion is not addressed, the wrong things happen in the areas of quality and affordability.
Interestingly, when I asked the hospitalists what the barriers are to get the palliative care team involved earlier in the course of illness, perhaps years before the patient is expected to die, the chief issue was their emotion. Not emotion related to the patient, but emotion related to their own uncertainty about what to ask the specialist palliative care team. They are happy to ask palliative care to see patients and families when they are certain what they want them to do (e.g., move them to comfort care, enroll in home hospice care, “get” the do-not-resuscitate order). But, when they are uncertain about what a goals of care conversation might look like many months or years ahead of the terminal phase, they worry that palliative care will think less of them or they do not feel as confident about themselves as physicians. In short, anxiety. They, like most physicians, are least anxious when they feel in control. Conversely, their anxiety rises when they are uncertain. That includes uncertainty about the reactions from the other specialists involved in the care—that they might be angry or sad or otherwise be emotional! I reassured them that, because the specialist palliative care team always telephones before the visit, it was a safe place to discuss the uncertainty so the palliative care team will “get it” before seeing the patient and family. That includes the need to pull in the other specialists before the team sees the patient and family. It turns out that specialist palliative care teams are as adept at dealing with referring physician emotions as those of patients and families. It is a core skill, in fact.
When I started down the path of this career >25 years ago, it never occurred to me how central this skill would be: individually, collectively, and corporately. But now, it is clear to me, its all about the emotion.