• Prime Time for Palliative Care?

    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.

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    • Having just watched two close friends go through heroic/futile end of life chemotherapy which enriched the medical industry but had a negative effect on quality of life and a questionable effect on length of life, I would have to say that this area is ripe for palliative care to improve the quality of life and reduce the cost (could avoid financial ruin for both of these folks families).

    • I have never viewed hospice and palliative care primarily as a means of saving money in our health care system. But it does seem to me that if we (here in the US) had a healthier belief system about death and dying we could not only help patients maintain their dignity throughout the process, but also save at least some money.

      Though I realize anecdote is not evidence, my own experience with a relative was that the medical system wanted her to undergo yet another round of either chemotherapy or radiation, which could have given her maybe (MAYBE) a few more months to live. Her prior experiences with chemotherapy were unbearable. So she opted not to undergo further treatment and, with the help of hospice, was able to die with some modicum of dignity (and relatively pain free),

    • When the hospice benefit was added to Medicare in 1982-83 holding cost at least constant was an explicit part of the argument. So, the hospice has had that expectation ever since. There is really not much else in health care (are some public health examples) that we expect to improve quality and reduce costs. Of course part of why some papers have been able to show cost savings is how expensive the ‘normal care’ option happens to be. I believe a focus on quality of life will yield some cost savings. Certainly we need to figure out a way to stop care that doesn’t extend life or improve QOL.
      Don

    • Some interesting data:

      http://www.overcomingbias.com/2007/11/hospice-beats-h.html
      http://www.nhpco.org/files/public/JPSM/march-2007-article.pdf

      I read somewhere that hospice costs as much as other care but I cannot find the reference and I could be wrong.

    • Thank you for your efforts in the field of palliative care. Working at a county hospital, I see innumerable examples of where palliative care (specifically hospice care) would be the most appropriate approach in the care of patients, mitigating unnecessary patient and family suffering and cutting down on costs incurred in futile health care. Although we have started a palliative care program at our institution, it is underutilized for many reasons, the most concerning of which seem to be physician nervousness about not “doing everything” for their patients (however misguided that might be) and ignorance regarding the utility of palliative care in medicine. I plan on continuing to write a number of stories (www.theamericandoctor.net) whereby palliative care is sacrificed not only for the sometimes unrealistic concept of “saving” a patient., but also by irrational concern about legal liability. This must be changed, and as a physician, I appreciate your ongoing efforts.