Having the Palliative Care Talk

By Haydn Bush	December 14, 2011
What's the best way to broach palliative care with patients and their families?

In my research for an upcoming article in the print edition of H&HN on the growth of palliative care services in hospital emergency departments and intensive care units, I've been particularly intrigued by two questions ? how hospitals identify patients who may benefit from palliative care, and how they broach the matter with patients once they've identified them. Given the relatively recent emergence of palliative care in EDs, ICUs and other acute care settings, there aren't a whole lot of best practices out there to date, which means that early adopters are experimenting with a variety of different approaches.

Recently, I spoke with Russell Portenoy, M.D., chair of the Department of Pain Medicine and Palliative Care at Beth Israel Medical Center in New York. Portenoy, who helped launch the department 15 years ago, says the hospital now consults with 800 patients a year about palliative care. Patients who meet a specific set of criteria, including advanced illness and a weeklong stint in the ICU, are automatically referred for a palliative care consultation.

Over time, Portenoy has watched the conversations evolve from a traditional emphasis on controlling pain to a discussions on a broader range of palliative care services and a larger potential patient population. But communicating those services to patients and their families is still difficult, Portenoy says.

"The general public knows the word, but they equate it with imminent dying," Portenoy says. "They don't have a sense it's a set of services."

But while the general public may not yet be aware of what palliative care entails, a growing number of initiatives are designed to bridge that communication gap. Yesterday, I spoke with Margaret Cornell Vigorito, R.N., senior program administrator for Quality Partners of Rhode Island, about a statewide initiative to develop a bundle of best practices around palliative care services in ICUs. The program, part of a broader ICU quality improvement collaborative in the state, was launched in 2010 and includes all of Rhode Island's 11 acute care hospitals and 23 ICUs.

However, the bundle developed there does not include an assessment tool for identifying prospective patients. Instead, clinicians discuss the program with all incoming ICU patients, with the exception of patients who are in the ICU less than 24 hours, end up there following an elective service, are boarding in the ICU because of a lack of room elsewhere or are there for a psychiatric evaluation. Everyone else, Vigorito says, is consulted for the services. Since the program began, roughly 53 percent of ICU patients have had a palliative care consultation.

"We decided that based on the fact everyone in the ICU is at risk," Vigorito says. "It's more of an opt-out versus an opt-in."

That method also eases the burden of broaching the subject with patients and their families, Vigorito says, since the conversation is integrated seamlessly with the rest of their care and not seen as a service oriented only toward terminally patients. During the consultation, patients and their families are consulted about their wishes and preferences for their treatment courses within the first three days, and information about resuscitation orders and other directives are not only discussed but documented in a given hospital's electronic medical record.

"This is to ensure the entire health care team knows what the decisions are," Vigorito says.

Email your thoughts on identifying, and talking to, patients about palliative care to hbush@healthforum.com.

Haydn Bush is senior online editor for Hospitals & Health Networks magazine.

The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association.

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