Palliative care hardwired into hospital system

Care consultations part of all aspects of care

Palliative care isn't just for hospice patients; it also is 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 in Warren, MI, 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. "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.

Suggested Data Points for Palliative Care

  • Patient demographics: age, gender, race/ethnicity
  • Consultation diagnosis
  • Referring service and/or referring MD
  • Admission date
  • Discharge date
  • Consultation date
  • Disposition: inpatient death vs. discharge
  • Consultation volume
  • Disease distribution: cancer vs. non-cancer
  • Location of consult
  • Age distribution
  • Consults by referring service or physician
  • Length of stay
  • Length of stay outliers: admission-consultation > 30 days or consultation-death > 30 days
  • Origin of admission: direct to palliative care (hospice or non-hospice), ED, ICU, ward
  • Type of inpatient unit: fixed bed unit (average daily census, average % occupancy) or swing bed unit (average daily census).

Source: Center to Advance Palliative Care, New York, NY

Palliative care triggers

"We partnered with Duke to increase access to quality palliative care with an 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/activities of daily living (ADL) in last 60 days;
  • considering PEG tube placement;
  • admitted from extended care facility with ADL dependence or chronic care needs.

Process is a joint effort

The palliative care process involves more than just physicians. According to DiStefano, St. John's palliative teams include 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.

It can be an extra layer of support for the patients. "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," says DiStefano. It is called value-added care, which is an extra team member.

However, DiStefano says, attending physicians initially were 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."

The 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. "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, DiStefano says. The program constantly gets support from the community in the form of phone calls. "When people make comments like 'Where have you been?' ... it's good feedback from the community," DiStefano says.

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


For more information, contact:

  • Elizabeth DiStefano RN, BSN, Coordinator of Palliative Care Services, St. John Providence Health System, Warren, MI. E-mail: