Palliative care model fits biomed ethics principles

Side benefit: It brings cost savings

Some of the core principles of medical ethics are patient determination, doing good for patients, and doing justice. These also are some of the chief attributes of palliative care, experts say.

"I view palliative care as applied medical ethics," says Diane E. Meier, MD, director of the Center to Advance Palliative Care (CAPC) at Mount Sinai School of Medicine in New York City. "Palliative care is medical ethics operationalized at the bedside. My interest in palliative care grew out of my interest and work in medical ethics."

The modern U.S. health care system has become so fragmentized that patients are viewed in the system as a series of organs and diseases with a different specialist for each one, Meier says. "The patient as a person is no longer the focus of the health care system, so it's very difficult to honor the core principles of medical ethics when health care is approached in this very narrow, organ-disease-driven manner," she says.

The best way to influence this culture might be to show health care providers a different way of approaching the care of patients by beginning with trying to understand who the patient is and what they hope the medical profession can accomplish for them, Meier suggests.

"We can help patients and families develop a care plan and set of goals that are achievable with reasonable expectation of benefits and that are matched to what is most important to this patient and family," she adds. "This is what palliative care embodies, an approach in which patient self-determination is at the core."

The fact that palliative care saves hospitals and health care systems money is incidental to its goals. Meier says that palliative care advocates do not design or try to advance access to palliative care because of any concern about saving money. The drive behind palliative care is a desire to rekindle the originating impulses of the medical profession and making patient care center stage. "Cost savings was an unexpected consequence," Meier says.

Hospital systems do care about the cost savings. This unplanned benefit has been an important reason why there has been a recent and rapid growth of palliative care programs nationwide, experts say.

R. Sean Morrison, MD, director of the National Palliative Care Research Center and a Hermann Merkin professor of palliative care, a professor of geriatrics and medicine, and vice-chair for research, all at Mount Sinai School of Medicine, says, "There is a reluctance in health care right now to embark on any new program that is going to cost the system a lot more money, even if it's the right thing to do. Hospital budgets and health care budgets are stretched so tight there's no room in the system for something new, even if it improves quality. That's an unfortunate statement of where we are now."

Between 2000 and 2008, the number of palliative care programs in U.S. hospitals increased from 658 to 1,486, a 125.8% increase. This increase means 58.5% of hospitals with 50 or more beds now have a palliative care program, according to CAPC.

Prior to the 21st century, palliative care had very limited availability in the United States. It was an option delivered primarily through hospice care and was available to patients living at home.

With palliative care programs, there's a win-win on all counts because investigations including a study Meier and Morrison recently published show that palliative care can accomplish both quality and cost-savings.1

From a biomedical ethics perspective, the cost savings is immaterial, but from a pragmatic viewpoint, it matters. "Palliative care teams effectively improve quality of life, reduce symptoms, and improve satisfaction with the health care system," Morrison says. "They can do this and at the same time be fiscally responsible."

From an ethical perspective it's important to draw distinctions between what palliative care accomplishes and what it is intended to do, says Haavi Morreim, JD, PhD, a professor in the Department of Internal Medicine, College of Medicine, University of Tennessee Health Science Center in Memphis.

"The focus of good quality palliative care is to enhance the quality of life of the patient," Morreim says. "And if the patient is mortally ill, then its purpose is to enhance the quality of the dying process."

Saving money is not the goal, but it is a noticed side effect of good quality palliative care, she adds. "Another side effect is there have been some studies that show people live longer on palliative care," Morreim says.

Palliative care help to put ethics committee education and goals into action in the areas of conversations of inappropriate treatments and end of life issues, notes Robert M. Arnold, MD, Leo H. Kreep chair in patient care and chief of the section of palliative care and medical ethics at the University of Pittsburgh (PA). The palliative care model is very helpful to ethics committees because they provide clinicians who can focus on patients, elicit patients' goals and values, and then provide the best possible care to people who have life-threatening illnesses, he adds. "As mediators, palliative care teams have good communications skills and can operationalize many ethical concepts in helping patients," Arnold says. "You have to have basic competencies in medical ethics to do a good job in palliative care."

The goal of palliative care is to elucidate the patient's goals and make sure the treatment a patient receives matches those goals. These goals also overlap with what ethics committees want to see happen in the clinical arena, he says. "Many palliative care committees have multidisciplinary teams, and the ethics committee can say, 'Can we get involved to help you work together, provide education, communication, informal consults?'" Arnold suggests. "Many palliative care teams have multidisciplinary teams meeting once a month, and ethics committee members can go to these meetings."

Hospital ethics committees could view their health systems' palliative care programs as a role model for how health care providers can adhere to biomedical ethics principles, Meier says. "Pontificating on those values is not a good way of teaching," she adds. "You need to show people how to implement and apply those values at the bedside, and that's what palliative care teams do; these are their central principles of work."

Palliative care teams might seek out members of hospital ethics committees to work with them and coordinate educational efforts. In certain types of cases, palliative care teams and ethics committees might collaborate. "A lot of what hospital ethics teams have done overlaps with palliative care," Morrison says. "They are consulted when there are unclear goals of care and conflicts arise; they are called in to mediate that conflict."

Ethics committees and palliative care teams can work well together because there is much less reason for conflict when providers help patients and families articulate their goals of care, he adds.

Morreim notes that one idea palliative care advocates and ethics committees have been working on involves encouraging providers involved in the care of long-term intensive care unit patients to have standard team and family meetings.

"As soon as it looks like the patient will be in intensive care for more than a few days, this person will encourage early communication and a sit-down meeting with the family and main people providing the care," Morreim says. "This is not for the purposes of making drastic decisions, but is to make sure everybody is on the same page."

Reference

1. Morrison RS, Penrod JD, Cassel B, et al. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med 2008;168:1783-1790.