The arguments behind building a comprehensive palliative care program are both simple and surprising. Symptom relief is good for seriously ill patients and their families, and therefore the right thing to do, says Steve Pantilat, M.D., director of the Palliative Care Service at the University of California, San Francisco.
Also, relieving pain decreases costs spent on more invasive or high-tech care that doesn't always make a patient better and often leaves them feeling worse.
"Our focus is on what the patient's wishes are and on quality of life rather than on interventions to prolong life," says Pantilat, a general internist and hospitalist who also sees patients in consultation on palliative care.
"It takes time and knowledge, but it doesn't have to be expensive," he says. "We've found it is an appropriate use of resources. For example, we may use more pain medications but fewer X-rays and blood draws."
Pantilat says palliative care is an umbrella term applied to a range of treatments provided by an interdisciplinary team. It centers on the relief of symptoms such as pain, fatigue, anxiety and nausea. It also involves discussing values and goals of prognosis and supporting patients and their families emotionally, psychologically and spiritually during any stage of care, not just at the end of life.
According to the New York-based Center to Advance Palliative Care, the palliative approach decreases length of hospital and ICU stays and eases patient transitions between care settings, resulting in increased patient and family satisfaction and compliance with hospital care-quality standards.
Yet only 800 of the nation's 5,000 hospitals have palliative care programs.
Part of the problem is lack of training, says Tom Smith, M.D., professor and chair of hematology, oncology and palliative care and co-director for cancer control at the Massey Cancer Center of Virginia Commonwealth University Health System in Richmond, Va.
"We don't know how to do this as well as we do treating heart attacks, for instance," Smith says. "It may not be quite as simple as just one problem. It is a teachable skill, though, to recognize depression, pain, shortness of breath and other symptoms, and to fix those according to a relatively simple algorithm."
Since opening the 11-bed palliative care unit at Massey in 2000, staffers have been able to relieve symptoms 90% to 95% of the time, Smith says. They also provide consultative services throughout the hospital.
Smith says new research shows the cost of taking care of patients on the unit is reduced by 25% to 50% compared with the rest of the hospital. Doctors and nurses are trained to use explicit, internally designed guidelines modeled after the commercially available symptom-control curriculum of the American Society of Clinical Oncologists.
The unit is not a big revenue generator, Smith says,
But he estimates it will save the system almost $1 million by transferring people from high-cost units to a lower-cost setting and by rigorously examining the care given.
"It's a very homelike unit where people can be transferred to die, if that's what's going to happen," he says. "But nearly half of our patients are admitted for symptom control and are discharged in better shape than when they came in."
Palliative care presents physicians with new opportunities to expand their practices and generate another source of income while participating in interesting and rewarding work, Pantilat says.
"It is billed like any other consultative service," he says. "Medicare and private insurance have not been an issue for us. These are professional services provided in consultation with an attending physician."
Until recently, there have been many reasons people haven't embraced palliative care, Pantilat says: a focus on youth, denial of death, addiction and legal concerns about prescribing opioids for pain--concerns he contends are largely unfounded within the wide area of practice for management of pain.
"All these issues conspire to make palliative care less available than it might be or than it should be," Pantilat says. "But we are also making great strides in this area. It is consistent with what patients want. The question is, how do we integrate it into care so it's not 'either/or' but 'and?"'