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Educating hospital staff about palliative care
Hospitals increasingly recognize need for it
Palliative care once was a rare treatment option in the hospital setting, but in recent years it has grown in popularity to the point that most major hospitals and many small-to-mid-sized hospitals have palliative care programs available for patients, an expert says.
Hospital administrators and providers have come to realize that palliative care is not the same as hospice or end-of-life care. It's a way to provide patients with more comfortable care than they'd receive while in the hospital or nursing home, which is where many patients spend their last days. With palliative care, patients often transition more smoothly from the hospital to home care or nursing home care, often receiving better quality and more cost-effective care, according to the Center to Advance Palliative Care in New York, NY.
"It's a simultaneous care model that should be administered at the point of diagnosis of serious illness, cognitive impairment, or multiple illnesses," says Diane E. Meier, MD, director of the Center to Advance Palliative Care at Mt. Sinai School of Medicine in New York, NY.
"Palliative care is what we do to prolong life, improve the quality of life, mood, depression, family caregiver well-being, and reduce the likelihood of someone ending up in the hospital or intensive care unit (ICU)," she adds.
There are more than 1,500 hospitals in the United States with palliative care programs, and 80% of the largest hospitals have palliative care programs, Meier says.
"Palliative care serves the sickest 5% to 10% of patients, the group that tends to have long and costly hospital stays that don't benefit the patient and are paid by DRGs," she explains. "The longer these patients stay in the hospital, the less money the hospital makes, so hospitals lose money on these very sick patients."
Also, there are various ethical considerations: First, these very sick patients would have a better quality of life in a palliative care program, where it was presented at home or in another care setting; and, two, other patients who need the hospital beds occupied by the very sick patients are prevented from getting the care they need, Meier says.
"This small group of patients blocks up the intensive care unit (ICU) and emergency department and increases the rate of ED diversion which is a huge financial hit for hospitals," she adds. "They reduce efficient throughput, and that's why so many hospital CEOs have not only invested in palliative care programs, but have recruited leadership to lead these programs."
In these poor economic times, hospitals are under incredible financial stress, so anything they can do to provide better patient care while strengthening their financial reserves is important, she says.
Hospital ethics boards might address palliative care, looking at whether their own facilities properly identify and refer patients to these services, and they might help educate staff and providers about palliative care, Meier suggests.
"They might take the lead in educating physicians and the nurse community within the hospital about how palliative care is not end-of-life care," she says. "They should show data on the impact of palliative care on quality, survival, family well-being, and patients getting the kind of care they need in a setting they want, while avoiding risk."
Hospital stays are in themselves a risk factor for higher morbidity and mortality, she notes.
People who are very ill often are at the greatest risk of infection or having complications while in the hospital, Meier says.
"There's the risk of medical error and the risk of hospital-acquired infection," she adds. "So when you have serious and advanced chronic disease, an infection acquired in a hospital can be life-threatening."
Research has shown that hospice care itself can prolong life in congestive heart failure patients and among people with some types of cancer, Meier says.
Hospice care can positively impact patients' psychosocial well-being, social support, and mood/depression. Since palliative care provides some of the same pain relief and psychosocial support that hospice provides, it's likely this type of service also would have a positive emotional impact on patients.
"You can't separate the body and the mind," Meier says. "When people are incredibly stressed, anxious, and not sleeping, they die sooner."
These are all potential reasons for the beneficial outcomes of palliative care.
"I think it's important for ethics committees to not see palliative care as a means for people we've given up on," Meier says. "Palliative care helps people live longer, and ethics committees should be at the forefront of promoting early and widespread integration of fundamental palliative care principles."
Hospital ethics committees also might look at their health care institutions' policies and procedures to identify what's in place to promote the timely application of palliative care.
"Ethics boards should ensure the fundamental competencies of palliative care for front-line staff, including care managers, critical care doctors, oncologists, and other groups who take care of this 5% to 10% of the hospital population," Meier advises. "The staff should be encouraged to get additional training, skills, and expertise in palliative care."
Hospital staff can obtain checklists, policy templates, and other materials about palliative care from the website of the Center to Advance Palliative Care at www.capc.org.
There are referral checklist tools available for a free download, as well as a tool that offers suggested communication phrases in palliative care and guidance on how to respond to emotion.
"Ethics committees could see that hospitals have the checklist integrated into required care," she says.
At admission, nurses could find out whether patients have appointed surrogate decision-makers in the case of loss of capacity and ask whether the patient or family have any questions about what to expect regarding the illness, she adds.
"The screening list would be done by admitting nurses with a daily checklist done during work rounds by whoever is responsible for the patient," she says. "There would be continuous assessing for these issues."