A Resting Place
The basic clinical skills needed to perform palliative medicine include:
- Titrating opioid analgesics;
- Using adjuvant pain medications;
- Managing nonpain-related symptoms, including nausea, vomiting, constipation, dyspnea, seizures, and anorexia;
- Managing delirium, anxiety, and depression;
- Communicating sensitive information;
- Working with cultural issues and differences; and
- Bereavement support for families.
“Every hospitalist should know how to elicit a patient’s goals of care and incorporate them into routine treatment, be fluid and comfortable discussing advance-care planning, and possess basic skills in pain management,” says Jeanie Youngwerth, MD, hospitalist and director of the palliative-care service at the University of Colorado Denver. “Unfortunately, we’re not there yet as a field, given current residency training in internal medicine. Our center has a hospitalist residency training track, and those residents all get dedicated, palliative care experience.”
The main distinction between the two is that hospice care was recognized by Medicare as a covered benefit starting in 1983, allowing terminally ill patients to die in relative peace and comfort, without unwanted aggressive medical treatments, often in their own homes. Under Medicare coverage, hospice has grown into a $12 billion industry serving an estimated 1.4 million patients per year.
To qualify for hospice coverage under Medicare (along with Medicaid and many private health plans), a patient must be certified by two physicians as having a terminal illness with a prognosis of six months or less to live, assuming the disease follows its expected course.
Palliative care, as practiced in many hospitals, shares with hospice the commitment to supporting patients and their families emotionally and spiritually and helping them make treatment decisions that reflect their hopes and values. But palliative care does not require a terminal diagnosis or prognosis. Many palliative-care guidelines do not even mention the word “terminal.”
Medicare does not have a palliative care benefit, although consults provided by palliative care physicians and advanced practice nurses can be billed the same as for other specialists.—LB
Knowing when to refer a patient to a palliative-care specialist is another important skill, Dr. Youngwerth explains. The CARING criteria, developed by Dr. Youngwerth’s colleagues at UC Denver, are a simple set of prognostic markers that identify patients with limited life expectancy at the time of hospital admission. The CARING criteria are a set of prognostic criteria that incorporate cancer diagnosis, repeated hospital admissions, ICU stays with multi-organ failure, residence in a nursing home, and meeting non-cancer hospice guidelines developed by the National Hospice Organization, which collectively correlate with the need for a palliative-care consultation (see Table 1, above).2
A simpler way to initially assess a patient’s need for palliative care is to ask yourself: Would you be surprised if you found out this patient had died within a year? “If physicians don’t think the patient is going to be alive in a year, then they should incorporate palliative care into the care plan,” Dr. Youngwerth says. “The next question is: Should I do it myself, or refer for a palliative-care consultation?”
Dr. Bekanich, who starting this month will head a new palliative care program at the University of Miami that features a 10-bed inpatient unit, encourages hospitalists to avoid focusing only on terminally ill patients when considering a palliative consult. Any seriously ill patient with unmet needs could benefit from a referral, he says.
“Lots of hospitalists are good at controlling nausea and vomiting, but if the symptoms are refractory or have uncommon presentations, I would like to get on board as the palliative care consultant,” Dr. Bekanich says. “I have also tried to emphasize to my group the importance of timely family meetings.
