Palliative Care - 1996 and 2010

More than 13 years ago, Philadephia Inquirer reporter Michael Vitez wrote a series about end-of-life care which won a Pulitzer Prize - see here for the first installment of that five-part series.

Some excerpts from that piece:

"Medicine has gotten so good at keeping people alive that Americans increasingly must decide how and when they will die. They must choose if death will come in a hospital room with beeping machines and blinking monitors or if it will come at home, with hospice workers blunting the fear and pain that so often accompany the final hours."
"The intensive-care unit offers a hope for recovery, but the price can be a miserable death. Deciding when to surrender can be a torture all its own."
"Advocates for change believe doctors are too optimistic, too sparing in what they tell patients. They say that families would be more willing to accept death earlier if doctors were more honest, more realistic. Reformers want to make sure that patients get the care they need, but not unnecessary or unwanted treatment. The key to humane and cost-effective intensive care is to treat those who will benefit, but not squander precious resources and impose futile treatments on those who will not. But often it is impossible to know who will live and who won't."

In today's Philadelphia Inquirer appears an article by Michael Vitez (read here), as part one of an occasional series on the dilemmas facing today's hospitals. The subject is how hospitals are addressing end-of-care issues, and in his article Mr. Vitez follows the work of the palliative care team, led by palliative medicine physician Dr. Diane Dietzen, at Abington Memorial Hospital, a large, suburban Philadelphia hospital. An insightful article, one that lays out in very personal stories the challenges faced by families and providers alike. In Mr. Vitez' words: "My goal is to spend a year at Abington, writing stories that show how one hospital deals with the biggest issues in health care today and also the changes that are coming fast and furious - regardless of what Congress and the President do - to hospitals and health care.
This first story looks at how the palliative care movement is medicine's response to the dismal way people have died. I try to show, up close, how the team works, the agony that families feel, the immense costs involved. "

Has much changed around end-of-life care in those 13 years? Surely, a patient in an ICU with a poor prognosis is more likely today than 1996 to be consulted by a palliative medicine physician such as Dr. Dietzen. But how much more likely, and if a consult is requested, is the timing appropriate? Just as surely, large variations in late-life care continue to persist among hospitals and communities, still raising questions about the appropriate role for acute hospital care in the management of patients with advanced illnesses.

As one of the doctors in the 1997 article stated ," America wants to offer the most advanced technology and treatments to everyone, yet keep health-care costs down."
How to balance those desires, the doctor added, "is a discussion nobody wants to have." Thirteen years later, when one considers the discussions taking place in the name of health reform, one must wonder how far have we advanced.

Grand Junction - an Exemplar Palliative Care Community

President Obama held a town hall recently in Grand Junction, Colorado. To healthcare reformers, Grand Junction, CO., is one of the areas of innovation -- a place that provides high-quality healthcare at a fraction of the costs in most other communities. And, according to some experts, Grand Junction chalks up some impressive statistics. Only 12% of Medicare patients required readmission 30 days after a hospital visit, as opposed to the nationwide rate of 20%. Children on Medicaid in the HMO are four times as likely as other Colorado Medicaid children to receive all immunization treatment -- and adults on Medicaid were up to 10 times as likely to get comprehensive diabetes care. How does Grand Junction stack up for its palliative care practices? The Community Palliative Performance Profile, compiled by DAI Palliative Care Group, graded Grand Junction as an A-plus (an exemplar community). Why did Grand Junction earn this superlative? For starters, less reliance in the final months of life upon intensive care (less than half of national average) and one of lowest percentages of deaths occurring in a hospital (20.7%). And hospice enrollment nearly 30% greater than the national average. Is it mere coincidence? We think not, as a profile of one of the senior palliative care physicians in Grand Junction will show in future posts.

Redeploying Physician Services at End-of-Life

A recent post (read here) suggesting that the "redeployment" of physician services for end-of-life care is one way to address the health care cost issue at once threatens the income potential of many physicians.

In a statement before the April 2009 US Senate Finance Committee Roundtable on Delivery System Reform, Allan Korn, M.D. ,Senior Vice President and Chief Medical Officer of Blue Cross and Blue Shield Association, called for the creation of "clinical pathways to help physicians provide compassionate and cost-effective end-of-life care." Among patients who died of cancer, Dr. Korn noted, a major contributor to cost and quality-of-life issues is the widespread use of chemotherapy in the last three months of life. Studies show that 15 to 20 percent of patients with incurable, end-stage cancer receive chemotherapy within 14 days of their death, a time when chemotherapy has no benefit. He went on to recommend funding a pilot starting in 2009 to identify the extent of overuse errors in treatment of cancer patients, for example by measuring non-palliative chemotherapy use in the last two weeks of life, and to establish best use of palliative care.

The American Hospital Association identified longer-term cost-containment strategies that will be pursued, as evidence, tools and nationally-endorsed measures emerge. One such strategy advanced by the AHA is to "Promote Efficient Resource Utilization" – more specifically, to promote palliative and hospice care through the use of advanced directives and best practices.

Indeed, palliative care should be better distributed throughout our communities. But palliative care is not an add-on. Rather, its value lies in its offering an alternative, or a substitute for another type of physician care/service already being provided to patients with advanced ilnesses. Lots of revenue/income is at stake. Is it any wonder why critics of health reform are associating palliative care with rationing?

August Edition of Palliative Care Grand Rounds

Palliative care has been much talked about in the context of health care reform. The August edition of Palliative Care Grand Rounds (here) , hosted by Risa Denenberg, offers readers an excellent round-up of the commentaries from the blogosphere.

Palliative Care Grand Rounds Vol 1, Issue 6

Welcome to the sixth edition of Palliative Care Grand Rounds, a monthly (appearing the first Wednesday of each month) summary of interesting, thought-provoking, timely, relevant, humane, and exceptionally well-written postings from the blogosphere.

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Health reform has been at or near the top of the news this past month, so it's hardly surprising that health reform and palliative care has found its way into the blogosphere. Usually within the context of rationing and futile care.

The blog Practical Bioethics addresses this issue in a well-reasoned way on a regular basis. In one of last month's posts, Dr. John Landos comments on one particularly useful way to think of the debates about rationing. Nearly 30 years ago, early in my career as a health care executive, one of the must-read publications for us was an insightful piece on rationing by the noted health economist Uwe Reinhardt. The title is as clever as it is fitting: Table Manners at the Health Care Feast.

What should a doctor recommend for a 90 year old man with pancreatic cancer and liver metastases? Palliative care? An Ohio surgeon thought so. Read the experience of Buckeye Surgeon in his blog . KevinMD picks up on this notion of futile care in his post.

Maggie Mahar offers an edifying piece around who should be responsible for defining futile care. In this post, she presents the case that " we also need to “pay more” for certain vital services such as primary care, chronic disease management, and palliative care. "

Are financial incentives for providers properly aligned with good palliative care? A New England Journal of Medicine article offers up a report on this matter, and Drew Rosielle, MD captures its highlights in his post. In a similar vein, Pallimed picks up on the hospice cap issue, as well as a recent press release from the National Alliance for Hospice Access. Access to the hospice benefit is a vital issue for patients, clinicians, executives, and policymakers, and has stirred up conflicting position statements and controversial points of view. To this blogger, the key question has been submerged. How should health care providers best organize to better assure open access for those with advanced illness, is what we ought to figure out.

Rationing versus futile care. Reading the blogosphere, and particularly comments to postings, leaves one with the impression that advanced illness management is either one or the other.

Prompted by President Obama's interview reply on the subject of the American approach to the end of life, David Tribble, MD, blogs about the "absurdity" of spending scarce resources on therapies known to be ineffective, but which Dr. Tribble adds, "we employ simply because we cannot stand not to."

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Alex Smith, MD, posts in the blog Geripal of the challenges of incorporating geriatric and palliative care into the Emergency Department. Dr. Smith asks "How can we integrate the vast experience and strengths of palliative and geriatric medicine in a setting such as the emergency department to meet the needs of older adults with serious illness, and contain costs?" No easy answers, to be sure, but a question every ED director and hospital executive should be asking. We know the HPM MDs and geriatricians have been asking questions like this for the past 15 years.

In his Medical Futility blog, Thaddeus Mason Pope comments on the disappointing, but unsurprising, survey results that Advance Directives are followed SOME of the time. Should we be doing more to make POLST documents a national standard?


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For patients and families seeking answers about palliative care, there are a handful of worthy blogs. In one, Dr. Pedro Calves relates an encounter with a patient who found the "pal" in palliative care. In another, written from the perspective of a patient under the care of hospice, the blogger/hospice patient comments on her health plan's reversal of an earlier denial and her change of hospice providers. When the author first started this blog, it was mainly to keep the people in her life up to date on how she was doing; now, it seems that she has picked up readers outside her immediate circle of family and friends. Angela Morrow brought this blog to my attention in last month's Palliative Care Grand Rounds.

Dr. Drew Roselle posts that most patients with advanced illnesses prefer to have hospice discussions, yet a recently published study found that only half of patients in this study had such discussions, and in a separate yet related post that understanding of CPR outcomes and code status is poor among hospitalized patients.

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Mort Kondracke is the Executive Editor of Roll Call, the newspaper of Capitol Hill. While technically not a blog (it's actually a column), Mr. Kondracke pays tribute to his mother's example of living - and also a "public policy" tribute to the manner of her death, in HOSPICE care. As health reform moves through Congress, a voice like that of Mr. Kondracke can be very powerful.

Veteran journalist Larry Beresford, who has written extensively about palliative care, discusses the emotional barriers to hospice access for people with terminal illnesses in a thought-provoking piece . Referring to several recent research studies, Mr. Beresford notes that
"this kind of research can help us understand some of the nuances of such encounters at the end of life, but I wonder if they take us closer to solving hospice's Flying Dutchman status in our society."


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Jessica Knapp writes in her blog The Good Death that she gives a two thumbs-up to the film, Departures, which, without much fanfare, won this year's Academy Award for Best Foreign Film. Then again, how many foreign films (award-winning and not) are greeted with great fanfare?
Glad that Ms. Knapp brought it to our readers' attention.

For a peek into the week of a hospice nurse, see Dethmama Chronicles. And Pallimed directs us to a week in the life of a palliative consult service, via Twitter.

Christian Sinclair, MD, co-editor of Pallimed and one of the prime movers behind Palliative Care Grand Rounds, announced a social media marketing venture and a sabattical from Pallimed. But not before he posted a useful summary of legislative and regulatory issues concerning palliative care.

On the arts/technology side, Amy Clarkson, MD reports on the complimentary blog of Pallimed about The Digital Afterlife, the legacy lockers and digital memorials brought to us by digital technology.


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Thanks to all who sent me suggestions for this month's Grand Rounds! And if you're interested, here's where you can find issues 1 , 2, 3, 4, and 5.

PCGR now has subscription options; you can follow by email or RSS feed. An aggregated feed of credible, rotating health and medicine blog carnivals is also available.

Next PCGR will be out August 5 and will be hosted by Risa Denenberg http://risaden.blogspot.com/- forward suggestions or links to risaden@gmail.com .

Showcasing Advanced Palliative Care Communities

To detractors of health reform, universal health care is code for rationing, or "less care". And for those detractors, palliative care is associated with less care. Reform opponents use the argument of rationing because they know that there is little political will to provide "less care".
Yet this argument falls short on two counts. Less care ,or rationing, takes place in the current system, for those who are uninsured, or underinsured. And less care does not have to mean substandard care, as data from the Dartmouth Medical Atlas has shown. Interestingly, those opposing health reform are the same who oppose comparative effectiveness studies, and their deployment to guide clinical practice.
The promises to contain costs advanced recently by the coalition of hospitals, physicians, and pharmaceutical manaufacturers, among others, are surely commendable. But one has to wonder what can these providers and organizations do that hasn't already been tried? Their promises were surely short on details.
When it's time to fill in the specifics, it will be time to take a close look at Advanced Palliative Care Communities (APCCs) see here and here , and how palliative medicine physicians in those communities practice their specialty to produce better outcomes at lower costs.

Palliative Care and the Stimulus Bill

Those interested in how palliative care makes out in health reform (and stimulus bill) discussions should keep an eye on a small (relatively, at $1.1 billion) item in the House version related to effectiveness comparison research.

The $1.1 billion in research funding would be doled out primarily to the National Institutes of Health. President Obama supported research into comparative effectiveness during his campaign. He could launch a new federal Comparative Effectiveness Institute along the lines of the British National Institute for Health and Clinical Excellence (NICE). Surely, palliative care would be viewed favorably in this context, would it not?

Meanwhile, the drug and medical-device industries are mobilizing to gut this provision in the stimulus bill, portraying it as the first step to government rationing. Interesting, because discussions around "best" end-of-life care inevitably get around to "rationing", as if palliative care were merely a stripped-down version of full-fledged medical care.

Reminds me of the "effectiveness research" done in the mid-90s, when the government's Agency for Health Research Quality suggested that there were too many unnecessary back surgeries. Of course, certain industry groups attacked the conclusion, and Congress at the time slashed the agency's budget and stripped its authority to make Medicare-payment recommendations.

Successful Palliative Medicine Practice Business Models -Are There Any?

I regret that my posts have been irregular of late. I don’t wish to be circumspect, so please know that my recent silence around health reform is not born of indifference, but a result of my participation in a group studying issues around health reform and whose participants have been asked not to reveal its deliberations until its work has been submitted. So while I haven’t been forthcoming about my thoughts around health reform and its impact on palliative medicine, I’m confident that what hypotheses I might offer hereon will be better informed. And while predicting the outcomes of highly charged and politicized issues such as those surrounding the nation’s health care system is surely not my intent, if I can help frame the key issues for those of us seeking to advance the profession and field of palliative medicine, then perhaps we can better prepare for the sweeping changes that will engulf us.

Back to the question I’ve contemplated a great deal over the past couple of months – will health reform accelerate or stall the progress of palliative medicine? It seems to me that the answer depends upon whether one believes that there exists today a business model that pretty much guarantees a livelihood to a physician practicing palliative medicine full-time. In other words, the practice can sustain itself through patient revenues without having to rely upon subsidies from a hospital or other sponsoring organization (if a hospital , for example, wishes to support a practice because it recognizes the value of a palliative medicine practitioner, by all means such support should be accepted). But there is a big difference between HAVING to GO back to a sponsor to request additional subsidies to relieve the growing pains of a palliative medicine practice, and operating a practice whose value (financially and clinically) is so widely acknowledged that the practice is actually “sought after” by other providers. And while palliative medicine physicians are surely in demand, just as surely palliative medicine practices are not. Therein lies the great disconnect.

As we have learned, it is very difficult to disengage the success (or lack of ) of a palliative medicine practice from its related program. More later on why practices are not in great demand. For now, just ask yourself, how many physicians have you recently heard mention that they planned to start an independent practice in palliative medicine?

Will Health Reform be Kind to Palliative Care?

Were I a betting person, I'd wager a princely sum on our getting within the next year a major reform of the health care system. Why am I so confident? Because the auto makers financial crisis will highlight the nation's health care cost issue. The "car czar" will make sure of it. And while the implications and ramificiations of "reform" will undoubtedly be wide-ranging, I've given to wonder what reform will mean for palliative care in general, and palliative medicine practices specifically. Mounting signs suggest that reform will be, indirectly, unkind to palliative care. In upcoming posts, I'll offer my take this subject. In the meantime, I invite yours.