Palliative care – treatment in which the focus is on managing patients’ symptoms rather than curing illnesses — holds promise for both achieving patients’ goals and reducing end-of-life medical costs, according to healthcare experts.
New approaches to this type of care were discussed yesterday at a forum that drew palliative specialists from southern New Jersey and Pennsylvania to Rowan University’s Cooper Medical School. They discussed how palliative care is expanding beyond specialists to other doctors, as well as nurses who provide care to patients at their homes.
Cooper University Health Care President and CEO Adrienne Kirby said palliative care exemplifies the team-oriented approach needed to balance healthcare quality and cost.
“I believe that the financial argument for palliative care is building and I think it’s building faster than maybe some of us realize,” Kirby said.
Teams of healthcare providers, including doctors, nurses, chaplains and mental-health providers, generally provide palliative care. They focus on providing the quality of life desired by patients who have painful conditions that cannot be cured.
Palliative care generally starts with providers meeting with patients and their families to talk about the patients’ goals and treatment options.
While palliative care was first provided as end-of-life care at hospices, it can be used to reduce the amount of pain caused by any condition.
Dr. David Casarett, the keynote speaker at the event, described a federally funded project at the University of Pennsylvania Health System to provide palliative care through nurses who visit patients at their homes. The federal Centers for Medicare and Medicaid Services (CMS) awarded the system a Health Care Innovation Award through funding from the 2010 Affordable Care Act.
The goal of the project is to increase coordination of care to manage patients’ symptoms while also meeting their emotional and spiritual needs. In addition to the nurses, the care teams include doctors and – if needed – social workers and chaplains.
Casarett cited the case of a patient named John, who had advanced colon cancer and had been hospitalized four times in six months for pain and nausea.
“His story is emblematic to me of all the ways that we fall down,” said Casarett, emphasizing that patients should receive care for symptoms at home or at outpatient clinics to prevent unnecessary calls to 911 that lead to costly and needless hospitalizations
Federal rules for Medicare frequently limit palliative care to patients in hospice, which is only open to patients who have a prognosis of less than six months to live.
Casarett said doctors have a poor track record in making these prognoses accurately, limiting the number of patients who receive care they can benefit from. That’s why he’s excited about the federally funded project, which is open to a wider group of patients.
The early results are promising, with hospitalization costs cut in half for the patients involved in the study. This could lead to the program being expanded to New Jersey and nationally.
“We’re very, very excited about this data and we’re hoping that CMS will be as well,” Casarett said. In the case of John, he required no hospitalizations in the four months after he began receiving palliative home care.
Dr. Mark Angelo, Cooper University Health Care’s palliative care chief, said Cooper has been able to teach doctors how to talk about palliative care with patients and their families. In addition, palliative-care specialists join intensive care doctors as they make their rounds with patients.
Angelo said that it’s wrong to think that, as a doctor, it’s depressing to provide end-of-life care.
“I think I have the best job in this place,” Angelo said. “I get to provide comfort – when I leave the room, somebody feels better. Families have breathed a sigh of relief – we have talked about what (the patient’s) goals are, and they’ve let the family in on a piece of their life.”
New Jersey Health Commissioner Mary E. O’Dowd said she has made improving end-of-life care in the state one of the department’s top priorities during her tenure. She said it’s a way to reduce healthcare spending and overuse of specialists while also improving patients’ quality of life.
“People don’t know enough about what their options are,” O’Dowd said. She said she hopes that conversations between patients, their families and their healthcare providers about palliative options become “a normal part of care.”
She has been promoting an approach calledPractitioner Orders for Life-Sustaining Treatment, or POLST.
The POLST form carries more weight than traditional advanced directives in determining what treatments patients will receive because it is an order from a patient’s doctor that other healthcare providers must follow.
“Creating that form was very important and, in fact, I think set New Jersey up as a national model for how to have a conversation about end-of-life care,” O’Dowd said, adding that a key point is that the POLST form starts with a question about the patient’s goals rather than questions about specific medical procedures. “A conversation flows easily through the rest of that form in terms of defining the medical treatment,=” O’Dowd said.
Some hospitals have eagerly adopted the POLST form. O’Dowd said the University Medical Center of Princeton at Plainsboro has had 2,000 patients register POLST instructions. She added that state health officials plan to work with long-term care facilities like nursing homes to increase POLST participation.