How and when to call palliative care

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Category : Attending Rounds

Did I tell you that I was a big fan of palliative care? Palliative care started around 15 years ago at the VA where I worked. We saw the service evolve. We saw how the palliative care approach improved the quality of both life and death.

Many physicians have not yet accepted or at least understood palliative care. Many physicians use some palliative care principles and believe palliative care is superfluous. My experience is quite different. In the two hospitals where I have worked with palliative care, our patients receive a team approach to quality of life. The palliative care team designs a program for the patient and the family.

Few physicians develop the skills of discussing advance directives and goals of care that our palliative care teams have developed. Few physicians have the time for the family meetings that often help achieve patient centered goals.

Too often we see palliative care called to late. Palliative care does not equal hospice. Sometimes that involve hospice, but that is a separate and important approach.

Many physicians think of palliative care for cancer patients, but we’ve seen great results with severe systolic heart failure, COPD, cirrhosis and CKD stage 4 or 5. We help our patients and their families when we involve palliative care earlier rather than later.

I have developed a standard way to introduce the concept to patients. The students and residents find this introduction useful.

When we suggest a palliative care consult, we make a distinction between treating the disease and treating the person. We often explain that we have no major options for the disease process but that does not mean we cannot make each day as positive as possible. We explain that the palliative care physician and team will focus on addressing their symptoms and them as a person who has a disease or several diseases. This introduction makes the palliative care team’s job much easier. They need a positive introduction.

Patients fear abandonment. Patients dislike discomfort in many dimensions. Palliative care addresses these issue, helps the patient and family develop clear plans for improving every day and eventually approaching a dignified ending.

Hooray for the palliative care movement!

Comments (11)

[…] How and when to call palliative care […]

Will be backlinking as Related Content to “How do you want to die – The End of Life CAN be comfortable and enlivening.”

Unfortunately, it has not been a particularly popular post with my readers (EFD/TBI/ADD etc). I was hoping it could serve as an Intro to a Series on the way various cultures handle death, grieving & honoring, but it seems that no one in my crowd has any interest in reading about such things. Pity.

I hope you will pop over & take a look (if so, leave me a comment so I know you were there). Links back always appreciated, of course.
xx,
mgh
(Madelyn Griffith-Haynie – ADDandSoMuchMore dot com)
– ADD Coach Training Field founder; ADD Coaching co-founder –
“It takes a village to educate a world!”

It is interesting to note that the few randomized trials show that palliative care produces a variety of good outcomes, and even has a positive effect on survival. On the other hand, it is hard to find that much of the circus attending the high tech deaths of today do any good. There is no good reason not to advocate for palliative care early in disease evolution.

“Few physicians develop the skills of discussing advance directives and goals of care that our palliative care teams have developed.” Dr. RW has written about this before. These are all skills that all good physicians/NP/PA should have! We are basically outsourcing these things to them because we don’t have training or time. Addressing these important aspects of patient care is not a separate field of medicine. We shouldn’t need consultants to help us focus on the patient and his/her symptoms rather than the disease; that is our job as the primary team. I think there’s a role for palliative care when: 1) particularly difficult goals of care discussion 2) particularly difficult/refractory pain/symptoms or 3) seen as outpatient by palliative care.
-JA

Old Doc:
“There is no good reason not to advocate for palliative care early in disease evolution”.
Yes, there is -within reason.
I am as much in favor of palliative care as anyone; 25 plus years in ICU, I signed as many death certificates as anybody.
But I am starting to notice an aggressive palliative care. People who are not necessarily terminal are getting palliative care which includes failure to do appropriate diagnostic tests, failure to give medicines and on occasion unnecessarily hastening death.
In addition, it has become a business
Let’s not blindly fall all over ourselves heaping praise on palliative care without taking a critical eye.
It is a good concept.It is often good in practice. But it should be evaluated on its actual merits in every case just like another branch of medicine.

Cory:
We are in agreement. That is why I referenced randomized clinical trials. There are too few of them, but the ones that are out there favor palliative care. I have trouble finding any trials favoring things like hyperalimentation in people with Alzheimer’s or intubation of 80 year old COPD patients with fever and positive blood cultures.

Excellent palliative care does not exclude continuing testing and treatment of disease. Palliative care that discourages appropriate testing and disease treatment is not excellent palliative care.

Dr. C:
I’m with you.
But your concern, as a professional leader and big supporter, should be Gresham’s Law: Will bad palliative care drive out good?

I certainly hope not. I have had the great fortune to work with excellent palliative care. The leaders seem highly motivated, so I am optimistic

Thank you for this. As a primary care physician I see a lot of cases where futile care is being provided to terminally ill patients. Palliative care is the right approach for many.

Have just had a month of Palliative Care Team evaluating my 87 year old mother. There was a Social Worker, a Physical Therapist, an RN and a Medical Doctor. Also assigned was a person to give my Mother a weekly shower.
Due to the many falls, shakiness, and living alone, we as her daughters and main caregivers, found thru the PT that for safety we needed: move furniture to clear paths for constant walker use. We were told to obtain a lift chair. We put in more bars in the bathroom near toilet and shower. Mom was given movement and strengthening exercise program. Much has improved, even though slow signs. We have learned much as caregivers and brought an agency in to help also. We have had a positive experience from this team.

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