Palliative care 101: Know where to start first
Programming, educational support vital elements
Even with broad philosophical support among caregivers for providing better end-of-life care, many hospitals are finding they need help firmly establishing a palliative care program at their institution. The answer, many are finding, is to establish a dedicated team of health care professionals — physicians, nurses, other health care providers, chaplains, and social workers — solely dedicated to studying and implementing palliative care ideas and protocols at the facility.
"Most physicians and nurses in the field of palliative care medicine believe that palliative care should be a core component of the approach to treatment of any patient with any serious illness, regardless of their prognosis and regardless of the plan of care and disease modifying or curative treatments," says Diane Meier, PhD, co-director of the New York City-based Center to Advance Palliative Care.
"It’s a way of thinking about the patients’ and families’ needs that should be automatic and universal. But, in order to promote that kind of shift in practice for nurses and physicians and other health professionals, there needs to be a cohort of people with additional rigorous training in palliative care who can serve as faculty educators."
Develop a business plan
To that end, the center, a project of the Princeton, NJ-based Robert Wood Johnson Foundation at the Mt. Sinai School of Medicine, is sponsoring several educational seminars for health care professionals about establishing palliative care programs at their institutions. In addition, they are gathering case studies of established programs on their web site (www.capc.org) for others to follow.
For example, how do you draw up a business plan for a palliative care program that will convince hospital administrators to support the effort? How do you code for reimbursement for palliative care consultations? Should you have a designated inpatient palliative care unit? What is the best way to manage hospital-hospice collaborations? These are some of the questions that the center tries to answer.
"We no longer have to make the case for palliative care, or to do the job of convincing," says Meier. "But, we need to give people the tools to go back to their institution and hit the ground running."
The U.S. Department of Veterans Affairs (VA), one of the nation’s largest providers of medical education through its health care system’s hospitals, also is dedicating new resources to improving the provision of palliative care to seriously and chronically ill patients. The VA recently announced the formation of its Interprofessional Fellowship Program in Palliative Care, which will fund four one-year fellowships in palliative care at each of the six demonstration sites throughout its system.
"At each of the sites there will be up to four fellowship trainees, and at least one — but no more than two of these — will be physicians, but the other two will be nonphysician trainees, people in nursing, pharmacy, psychology, or even chaplaincy," explains Stephanie H. Pincus, MD, chief of the office of academic affiliations at the VA, the office that oversees the agency’s medical education programs. "We want these people to learn about palliative care fully in a way that they are interacting with each other; we can spread the knowledge to more than just physicians."
Different VA sites will compete to host each of the six fellowship programs, and one of the sites also will be charged with coordinating a curriculum, she adds. "A unique feature is that each of the sites will also be required to develop an educational dissemination project, and the purpose of that is to enhance the education of all health care professionals in the area and to spread the quality of care to patients at additional sites."
It is important to emphasize that the program’s purpose is to not only improve the care of patients nearing the end-of-life, Pincus adds. "We are talking about comprehensive management of the patient’s physical, psychological, social, spiritual, and existential needs as well," she explains. "It is really anybody with a serious or life-threatening medical condition for which we really want to have a patient-centered approach."
Deciding to promote dedicated programs is not without controversy, Meier notes. There is some debate in the field about whether designating "palliative care" as a specific area of expertise, or medical specialty or subspecialty, is a good idea.
"There is a risk that the concept of palliative care will be seen as sending the patient to someone else,’ which we don’t want to convey," she admits. "There is a tension between acknowledging that every provider needs to know this stuff and be good at it, at least a minimum level depending on what they do. But, if you don’t have this well-trained, acknowledged, employed group of people who say, My main job is palliative care’ who consider themselves educators and researchers, the educational effort that is going to be required here isn’t going to happen."
A key resource for hospitals interested in palliative care will be local hospice organizations, adds Meier. Facilities can develop consulting, contractual, and even cooperative efforts with local hospices to improve patient care of terminally and chronically ill patients. "There hasn’t been medical school and residency education about palliative care and there are only 19 fellowships in palliative care across the country," she says. "So, how do you get manpower into the hospitals with people with the skills necessary to lead palliative care programs?"
The knowledge base is in the hospice community, she says. "I would say, Know your community, collaborate with the best, and bring that nursing, social work, and medical expertise into your hospital.’"
Source
• Diane Meier, Center to Advance Palliative Care, Box 1070, One Gustave L. Levy Place, New York, NY 10029-6574.
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