Executive Summary
Earlier palliative care consultation during hospital admission is associated with lower costs, according to a recent study which adds to a growing body of research on the benefits of early palliative care intervention. Other study findings include:
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Patients often associate the term “palliative care” with end of life.
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Even physicians misunderstand the difference between palliative care and hospice.
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Bioethicists can define the term “palliative care” whenever it is used.
Earlier palliative care consultation during hospital admission is associated with lower costs for patients admitted with an advanced cancer diagnosis, according to a recent study.1
“The earlier in the hospital stay the patient gets factual information about their illness and treatment options, the sooner the care delivered actually matches patient priorities,” says Diane E. Meier, MD, one of the study’s authors and director of the Center to Advance Palliative Care in New York City.
Researchers investigated costs in 969 adult patients with an advanced cancer diagnosis who were admitted to five U.S. hospitals from 2007 to 2011. Of this group, 256 patients were seen by a palliative care consultation team; 713 received usual care only. Palliative care consultation within two days of hospitalization reduced hospital costs by 24%. If the consultation occurred a few days later, cost savings were only 14%.
“The earlier that palliative care was consulted, the larger the savings — even adjusting for how long people live. Saving 24% of the total hospital bill is hardly trivial,” says Thomas J. Smith, MD, one of the study’s authors and director of palliative medicine at Johns Hopkins Medical Institutions in Baltimore.
The results contribute to the growing evidence base on the importance of timing in palliative care, says lead author Peter May, PhD, a research fellow at Trinity College Dublin’s Centre for Health Policy & Management in Ireland.
“We have been surprised by quite how important timing turns out to be from a methodological standpoint in accurately estimating an intervention’s cost effects,” he says.
While providers would not hesitate to call a cardiologist for a heart failure patient, they often don’t view hospice and palliative medicine as the same sort of specialty help. “We hope that this will give oncologists and hospitals more reason to say, ‘She’s really sick and her family is having a hard time adjusting. Let’s get some experts in to help us manage this,’” says Smith.
May expects to see an increase in earlier referrals, as the benefits of palliative care are better understood.
Most of the time, early palliative care “translates into the desire for care that will improve function and quality of life, as opposed to endless rounds of subspecialty consultations, imaging studies, and blood tests in the hospital,” says Meier.
Associated with end of life
“No, you don’t need that yet. It’s much too early for you.” If patients ask about palliative care, they’re sometimes discouraged by well-meaning physicians who mistakenly associate it solely with end-of-life care, experts say.
“Even among medical professionals, the stigma exists. How can we expect patients and families to understand the relevance and importance of early palliative care if they are getting mixed messages from providers?” asks Camilla Zimmermann, MD, PhD, head of the Palliative Care Program at University Health Network in Toronto, Ontario.
One obstacle is physicians’ lack of understanding of the difference between palliative care and hospice. “Older physicians — in my age group — trained before palliative care existed in hospitals. Many of us are stuck in old ways of thinking,” says Meier. More recently trained physicians tend to be more comfortable working in partnership with palliative care professionals.
Confusing palliative care with end-of-life care is a primary obstacle to earlier referrals. “Although that was the original meaning of palliative care many moons ago, it’s now changed,” says Zimmermann. “People have to recognize that palliative care is relevant right from the beginning of the disease.”
Zimmermann says physicians shouldn’t shy away from using the term “palliative care.” “The more we normalize it, the more people will realize that it’s something everybody needs if they are diagnosed with serious illness,” she says.
Bioethicists can make a point of explaining the term. “If you mention palliative care, people freeze up,” Zimmermann says. “It’s not something that can be mentioned on its own without reassuring people.”
Physicians might say, for instance, “By palliative care, I don’t mean the end of life. What I mean is pain management and symptom management and care for you and your family, in terms of coping with the illness and getting the support that you need.” “Everyone wants palliative care if you phrase it that way. It’s just that they don’t want to die right now,” says Zimmermann.
Standardization is needed
Some have argued that it’s simply not possible to offer palliative care to all patients diagnosed with a life-threatening illness. “There is the idea of, ‘Who is going to provide all this palliative care?’” says Zimmermann. “I don’t think palliative care needs to be provided only by palliative care physicians.”
Instead, nurses and physicians in the primary care setting can take on this role with appropriate training. “Every physician should know how to provide pain and symptom management and arrange home care,” says Zimmermann.
In order for referrals to happen earlier in a hospital stay, the process of identification of patients who can benefit from palliative care needs to be standardized, says Meier. “At present, it remains dependent on the whims of the attending physician,” she explains. “Referral depends on individual doctor biases and the luck of the draw.”
Some systems are using checklists or trigger tools to identify all patients who might benefit from palliative care. “I hope we will see more of this, as a result of our findings on the benefits of early palliative care,” says Meier.
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May P, Garrido MM, Cassel JB, et al. Prospective cohort study of hospital palliative care teams for inpatients with advanced cancer: Earlier consultation is associated with larger cost-saving effect. Published online before print June 8, 2015, doi:10.1200/JCO.2014.60.2334
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Peter May, PhD, Research Fellow, Centre for Health Policy & Management, Trinity College Dublin, Ireland. Email: [email protected].
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Diane E. Meier, MD, Director, Center to Advance Palliative Care, New York, NY. Phone: (212) 201-2673. Email: [email protected].
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Thomas J. Smith, MD, Director of Palliative Medicine, Johns Hopkins Medical Institutions, Baltimore. Phone: (410) 955-2091. Fax: (410) 955-2098. Email: [email protected].
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Camilla Zimmermann, MD, PhD, Head, Palliative Care Program, University Health Network, Toronto, Canada. Phone: (416) 946-4501 ext. 3477. Fax: (416) 946-2866. Email: [email protected].
