Tim Cousounis with a thought provoking post reporting on the Palliative Care Summit held this past week at the School of Population Health at the Thomas Jefferson University. I think his post well captures the mood of the hospice and palliative care field these days–lots of excitement mixed with bewilderment and uncertainty. Tim puts it this way:
Compelling cases were made during the summit…on why hospice/palliative care is/are(?) the solution to many of the health care industry’s woes. Meanwhile, just next door other industry thought leaders were offering compelling cases on why “medical homes” or “expanded chronic care models” or “mobile technology” were desireable solutions for transformation of the health care system
Cousounis notes some frustration that the ‘time has been now’ for hospice and palliative care for quite some time but that the fragmentation of the system and turf wars have made it hard for the science and approach of palliative care to spread more widely than it has.
Certainly one barrier is confusion over what hospice and palliative care actually are. In simplistic terms, palliative care focuses on improving quality of life and helping patients clarify their goals, regardless of prognosis. Hospice is a subset of palliative care that focuses on persons who are believed to have a life expectancy of 6 months or less, and provides interdisciplinary care designed to address symptoms, maximize quality of life, and address the wholistic needs of both patient and family.
Because of cost problems in the health care system, the desire for a panacea is strong. Hospice and Palliative Care do not provide that and I have written with my colleague Amy Abernethy that end of life cost savings are in many ways the ‘fools gold of health reform.’ That is because you don’t know when the last year of life starts until it ends, so it makes it very hard to determine when you should start trying to save money, making savings from ‘wasted care at the end of life’ hard to achieve. Others worry that the most high profile study on palliative care in years (a RCT of early palliative care in patients with stage IV lung cancer) set a standard (extend life; improve quality of life; reduce costs) that may be hard (impossible?) to consistently replicate across diseases and settings now that the public is paying attention.
As someone who focuses quite a bit on research energy on end of life issues and who also spends lots of time thinking about health reform, I think the most important contribution of hospice and palliative medicine to overall system reform may not be answers, but questions.
- Will it improve quality of life?
- Will it extend life?
- How much does it cost?
These are common questions in the fields of hospice and palliative medicine, but they are uncommon questions in our culture with regard to health care, and in most parts of our health care system. If we ever get control of health care costs, regardless of what policy mechanism is involved, asking these questions in a prospective manner will have to become more common.