Palliative care hardwired into hospital system

Care consultations part of all aspects of hospital care

Palliative care isn't just for hospice patients — it is also used to manage the symptoms of those with chronic or advanced illnesses. One hospital system in Michigan has brought palliative care into all aspects of hospital care for all patients. The efforts of St. John Providence Health System to develop a screening tool for palliative care needs has earned it a spot as one of the recipients of the American Hospital Association's Circle of Life Award — Celebrating Innovation in Palliative and End-of-Life Care.

The health system has integrated palliative care into all aspects of care. "This was a leadership-driven initiative," says Elizabeth DiStefano, RN, BSN, coordinator of palliative care services for St. John Providence Health System, Warren, MI. "I didn't have to spend time trying to talk anyone into it. Anything they can do for us, executive leadership is really supportive of the program. That's really unique — oftentimes people have problems with their leadership, but this was something we needed to provide to the patients," she says.

St. John first introduced palliative care consultations in its hospitals in 2005, but there was no standard in place to identify prospective patients. To solve this issue, St. John partnered with Duke University's Institute on Care at the End of Life to improve the screening process for palliative care needs and develop criteria that all physicians in the system could follow.

Palliative care triggers

"We partnered with Duke to increase access to quality palliative care with increase in attention to spiritual needs,' DiStefano says. "We had five objectives: to screen for palliative care needs, to fully integrate spiritual care with palliative care, educate all associates on basic palliative care, engage the faith community, and institute a culture change for these efforts."

From the collaboration came a trigger tool that medical staff could use to screen patients for palliative care that was pilot-tested in the ICU of St. John Hospital and Medical Center in Detroit, the system's largest hospital. "It was a larger tool that we did. It became cumbersome and lengthy, so we use the top nine triggers from our tool," DiStefano says. "Now, all patients are screened for palliative care needs upon admission, and after five days if they are still in the hospital."

Palliative care triggers include:

  • code status changed to DNR;
  • conflict about stopping/starting life-prolonging treatment;
  • goals of care or code status discussion needed and/or surrogate or proxy distressed about decision-making;
  • uncontrolled symptoms that interfere with quality of life;
  • marked decrease in functional status/ADLs in last 60 days;
  • considering PEG tube placement;
  • admitted from extended-care facility with ADL dependence or chronic care needs.

The palliative care process involves more than just physicians — according to DiStefano, St. John's palliative teams comprise a nurse practitioner, social worker and chaplain for a multidisciplinary approach for the patient and his or her family. "We don't just care for the patient — we care for the whole family," she says. "We look at the dynamics, and we look at their needs and if they need spiritual care. The multidisciplinary approach is helpful to the families as well. They have the time to spend with the team to work out the care and what kind of care they want to receive. The team can have those difficult discussions with the family. If they want to see a spiritual care provider daily, they can have daily rounds with chaplains and clinicians."

"I would say that it's an extra layer of support for the patients," DiStefano continues. "Doctors find it very helpful because it saves them time and they don't have to do difficult family meetings. They have found it to be very valuable. We called it value-added care — the value that has been added is an extra team member in there."

However, DiStefano says, attending physicians were initially reluctant to order palliative care consultations. "When we rolled it out, there were issues that were going on," DiStefano says. "Staff education has been very helpful, and the culture has changed over time. Speaking with doctors about it one on one has been helpful, and having the support of the medical executive team has been key."

Response has been 'overwhelming'

In fact, the system has had "mass education from housekeeping staff to the CEOs" on palliative care, according to DiStefano. "We have annual training days and ask staff members to become champions and train four or five other associates," she says.

Response from the community on the program has been "overwhelming," DiStefano says. "I wrote an article about the program for a newspaper for seniors — a little old lady [patient] brought the paper with her to the doctor and said she wanted that kind of care. We have phone calls from the community all the time in support of the program. When people make comments like 'Where have you been?' ... it's good feedback from the community."

"We are always willing to share information with other health systems — we want to improve the field of palliative care," DiStefano explains. "We want others to learn from our lessons and what we've done. We want to help other programs improve."

[For more information, contact Elizabeth DiStefano at]