Abstract
At the end of the calendar year, it is always tempting to wonder whether there has been any progress. As I look at what is published in this issue, I think we can all see the progress that is being made in our field around the world. There is little controversy among experts that interdisciplinary teams delivering palliative care are an essential part of standard health care. To move this into standard health care, for real, with the same importance as vaccinations, or aseptic technique for surgical operations, or antibiotics, remains a frontier that is being pushed back on many fronts. What remains controversial is whether this should be accomplished by improved generalist competencies, with specialist teams, or some combination. It also remains controversial whether the outcomes should be health system quality measures with teeth, in the same way that mortality and function after surgery is followed.
This issue of Journal of Palliative Medicine includes a very intriguing retrospective review of coding for a population in Germany, 0.55% of all people need palliative care by Peter Engeser et al. Of those needing palliative care, 8% were served by specialist palliative care teams for a median of 40 days, who got better outcomes than the generalists. If we extrapolate to the population of Germany, a developed “rich” country with an aging population of 83 million people, that suggests 456,000 people need palliative care and 36,000 need specialist palliative care on any given day.
How does this correlate with the United States? The Hospice Medicare Benefit is available to all >65 years of age insured by the national plan. Of the 330 million inhabitants, ∼3 million people die each year. Only 10% die sudden deaths, the remainder die of serious illnesses. Of those >65 years of age with the national insurance scheme Medicare, ∼50% die with hospice care. However, there is extraordinary regional variability—and some health systems achieve 90% death with hospice care, mostly at home.
As I see it, the German data and the U.S. data are on the same order of magnitude. The next step is to make these outcomes into quality measurements that are important enough to impact funding and accreditation. In the United States, where the world of “big data” is beginning to compare all hospitals, death with hospice care and death in hospitals are rising to the top of the list of things that hospitals and health systems want to manage. This is good news for our field. We should be encouraging, and participating in, comparisons and some friendly competition to get it right.
Dr. Slama and colleagues' courageous report in this issue of Journal of Palliative Medicine is also interesting. When just a specialist physician sees advanced cancer patients along with standard cancer care, there were no differences between the intervention and control groups. His report is courageous in a number of respects. It is always a challenge to publish negative findings. It is also courageous to say what one thought was enough was in fact not enough. In other words, other team members are needed besides physicians to deliver effective palliative care. Which team members and in what proportions is another area remaining to be researched.
We are narrowing in on who needs our care, what disciplines are needed, whether generalist or specialist teams are needed, and where the care needs to be given to achieve best outcomes. This is progress, to be sure. In the health system where I work, the hospital-based consultation teams were “essential workers” as important as pulmonary critical care specialists during the COVID-19 surge and remain so during the current phase of stable number of infections and hospitalizations. When the physician leading the surge planning was asked what he needed if there were to be another surge, he said, “more palliative care” was the only thing he needed. Amazing. From where I sit, this looks more and more like we are part of standard health care, including its emergencies. That feels a lot like growing up and enjoying both the privileges and the pressures of adult life. I think we are ready.