Meeting the Palliative Care Needs of Hospitalized Patients

Good palliative care covers a broad spectrum, from life promotion to death acceptance.

"The best possible medical care may mean an immediate focus on symptoms and quality of life, and offering a full spectrum of services," said Dr. Porter Storey, an associate professor of medicine in the geriatric section at Baylor College of Medicine and medical director of St. Luke’s Episcopal Hospital’s palliative care service.

At the first 2002 meeting of the community-wide Pain & Palliative Care Grand Rounds Jan. 31, 61 attendees gathered to listen to Dr. Storey comment on the importance of meeting the palliative care needs of hospitalized patients. Dr. Storey is a local expert on pain and palliative medicine, having served 18 years as vice president of patient care at The Hospice at the Texas Medical Center.

"You might ask, ‘Why should we provide palliative care in hospitals?’" he said. "People come to hospitals to make transitions in their care. Because patient care plans are developed in hospitals, palliative care programs can make an important contribution to the care of terminal patients."

The World Health Organization defines palliative care as active, total care of patients whose disease is not responsive to curative treatment.

Dr. Storey said the discipline of hospice and palliative medicine is a relatively new medical specialty, and board certification is now available. Currently, about 850 physicians across the country have achieved certification.

"It is not yet recognized by the American Board of Medical Specialties, but this is the way all new specialties begin," Dr. Storey said.

How does palliative medicine fit into hospice care?

Hospice is a program in which palliative care is delivered. It is a team approach involving medical care and pain management. Care can be provided in a patient’s home or a home-like setting.

Dr. Storey said teamwork is absolutely essential. Through medication, the team should be able to ease the discomfort of the patients, and through education, give families and caregivers peace of mind.

The skills of the physicians, nurses, chaplains, physical therapists, and dieticians are essential, he said. Although time is imperative, networking is essential to ensure that patients get the best possible care, and to help patients and their families through a distressing time.

"In other countries, hospice care and palliative care are synonymous. In this country we have Medicare and insurance programs that dictate what type of care can be provided," Dr. Storey said. "They mandate that if you sign up for hospice care, you can’t have access to a hospital, or the kind of treatment available in hospitals, like CT scans and radiation therapy, because the hospice becomes financially responsible for all the treatment related to the terminal illness. Insurance programs give them only about $100 a day, which makes it tough to provide medication, nursing and social work care."

Dr. Storey cited a model of palliative care that encompasses a spectrum of needs. The spectrum is made up of several phases including standard acute care, active care, comfort care, and urgent care.

"It is important for hospitals to use palliative programs for this full spectrum of life promotion and death acceptance, and ensure a full benefit of care," Dr. Storey said.

There is a profound emotional tension that comes at either end of the spectrum, he said. Hospital teams must realize that there will be a lot more tension at the beginning of a patient’s palliative care than near the end, because at the beginning there are many decisions to make about patient treatment and benefits. Emotional tension toward the end tends to subside as a patient becomes more comfortable, but may increase at the middle phases of a patient’s life, as another realm of the spectrum is crossed.

The best way to ease this tension is by offering a full spectrum of services, making patients and their families feel at ease.

The financial strain on hospitals doesn’t always make the full spectrum possible, Dr. Story said.

"It would be ideal to have a location for inpatient services, outpatient services, and a home care team," he said. "We don’t want to cause an overlap of existing services, but we don’t want any holes in the health care delivery system either."

Hospital-based palliative care teams can best serve patients by knitting together existing services. This way, patients are sure to get the services they need.

Dr. Storey said shortening the length of hospital stays could fund palliative care teams.

"The team at Mt. Sinai in New York was able to demonstrate this," he said. "On their consults, they were able to shorten the lengths of stay by an average of a little over one day, and that was enough to generate the millions of dollars needed to totally support a multiperson team."

Teamwork is expensive, he cautioned. The cost of advanced practice nurses, social workers and chaplains is not easily passed on to insurers, yet these positions are an essential part of the team. Finding sources that will help support these team members who can’t directly bill is a major part of a hospital’s palliative care needs, Dr. Storey said.

Success seems to be achieved when patients are able to focus on doing things they like, rather than on when the next dose of medication is due.

"Nothing pleased me more as a hospice medical director than to call a patient about a follow-up visit, and to be told, ‘Could I come the day after tomorrow? I am going fishing with my grandson.’ This is successful palliative care," Dr. Storey said.

The bottom line is that continuity of care through different spectrums is complicated.

Dr. Storey said working with continuity of care, so that people get what they perceive is a seamless network of care without blocking competition of competing services, is a difficult challenge, he said.

"I think that’s our challenge for the future."

Dr. Storey closed the discussion with what he called the essential message of palliative care: You matter. "You matter to the last moment of your life. We will do all we can, not only to help you die peacefully, but to live until you die."

Pain & Palliative Care Grand Rounds are open to medical professionals, patients, or anyone interested in pain and palliative medicine. Future meetings will be held March 27, May 23, July 25, Sept. 26 and Nov. 21. All meetings are held at the Edwin J. Hornberger Conference Center, 2151 West Holcombe Blvd. from noon to 1:30 p.m. For additional information, contact Lori Nelson in the Texas Medical Center Executive Offices, 1133 John Freeman Blvd., Suite 406, Houston, Texas 77030, (713) 791-8880, or lnelson@texmedctr.tmc.edu.

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©2006 Texas Medical Center

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