Palliative Consult

The Hospitalist. 2006 May;2006(05):

May 1, 2006 | The Hospitalist

For instance, it may appear to a palliative care consultant that a certain patient should not undergo chemotherapy, but in fact the patient or the family may demand it.

Stephanie Grossman, MD, assistant professor of medicine and co-director of the Palliative Care Program for Emory University Hospital and Emory Crawford Long Hospital in Atlanta, says the majority of consults she does are with oncology patients. She has found that attending Monday morning sign-out meetings with Emory oncologists has not only increased referrals to the palliative care service, but has added to her understanding of oncologists’ decision-making processes.

“When I go to weekly meetings, I hear the full spectrum of what they are doing. I see how oncologists work and how they decide about treatments,” she says. “It’s been a really good experience because I never would have seen this from the hospitalist viewpoint.”

Emory’s palliative care program was launched in November 2005 and has grown so quickly that they already need additional staff.

Consult Etiquette for Palliative Care Services

Consultation etiquette defines the relationship between the primary physician and the consultant. “Having a clear primary relationship with one physician who’s the quarterback is clearly in the best interest of the patient,” emphasizes Dr. Meier of the Center to Advance Palliative Care. Those who honor the following unwritten rules will establish a more collegial relationship with the referring physicians and be more likely to be called on a regular basis.

Respond quickly to a request for a consultation.
Call the referring physician (or service) to confirm you have received the request and to clarify what the person wants you to do.
See the patient, but do not give advice to the patient. Be clear that you are there to help the patient’s main physician provide care. Spend time and attention to what the referring physician asked you to address. Do not say anything to the patient that would create a division between the patient and his or her primary physician.
Call the referring source after you have seen the patient—and before you write anything in the chart. If you see a need to furnish more services, ask the referring source for permission before you proceed.
Write a note in the medical record summarizing why you were asked to see the patient, your pertinent findings, your recommendations (that you have already negotiated with the attending physician), and your plans. Finish the note graciously thanking them for asking you to see their patient. Start or finish your note with phrasing such as, “Thank you so much for asking me to participate in the care of this interesting patient.”—GH

Source: Charles F. von Gunten, MD, PhD, medical director, Palliative Care Consultation Service, UCSD

The Primary Client

The “key message” for a hospitalist when asked to do a palliative care consult is to remember that the client of a consultation service is the referring physician, points out geriatrician Diane E. Meier, MD, director of the Center to Advance Palliative Care and the director of the Hertzberg Palliative Care Institute at Mount Sinai School of Medicine in New York City. “As a geriatrician, if I call in an infectious disease consultant, I’m calling that physician to help me make decisions about my patient—not for that person to take over the care of my patient or to undermine my relationship to that patient. This is basic consultation etiquette, but physicians are often not taught in medical school or residency the difference between a primary care responsibility and a consultation responsibility.”