American College of Physicians: Internal Medicine — Doctors for Adults ®


Treatment vs. harm: How to care for seriously ill patients

Ditching the 'either/or' model can help reduce patient suffering, ease hospitalists' palliative care role

From the June ACP Observer, copyright 2006 by the American College of Physicians.

By Deborah Gesensway

The 67-year-old patient with metastatic lung cancer to the brain, liver and bone is dependent on the ventilator and sedated. His doctor and family want to offer him chemotherapy. Can this patient also qualify for hospice care under Medicare?

Diane E. Meier, FACP, says palliative services are good for both patient care and for hospitals' bottom line.

Under current Medicare guidelines regulating access to hospice care, the answer is “no.” Under government criteria, patients are only eligible for hospice if they are diagnosed as “dying,” but are ineligible if they are receiving curative or life-prolonging treatments.

“Whether you and I disagree about the benefits vs. harm of disease-modifying therapy, we should be able to agree that this patient is in desperate need of palliative care, regardless of whether he is going to get more chemo,” said Diane E. Meier, FACP, professor of geriatrics and medical ethics at Mt. Sinai School of Medicine in New York and director of the Lilian and Benjamin Hertzberg Palliative Care Institute. “It should be a both/and decision, not an either/or decision.”

Speaking at Annual Session, Dr. Meier discussed efforts now underway in U.S. hospitals to build palliative care programs. Many of those efforts are being led by hospitalists involved in palliative care consult services. They want to change the dichotomous model of curative vs. palliative care to one that stresses “simultaneous care,” employing aspects of both palliative and life-prolonging treatment that are most likely to benefit the patient.

“The either/or model has nothing to do with patient and family needs," she said, "but has everything to do with the [Medicare] payment system.”

She urged internists to teach residents and colleagues never to use these words: “There’s nothing more we can do.” That sentence, she said, “conveys a real abandonment of the patient by the medical profession." As patients get sicker, she added, internists need to do more, not less, to help patients and families go through one of the most difficult stages of life. The payoff is more humane care for patients, she said—and a healthier bottom line for hospitals.

Two key skills

Physicians who want to improve medical care of the seriously ill should hone key skills they may never have been taught in medical school or residency. Those include:

  • Symptom management. Unfortunately, doctors and the procedures they order are responsible for some of the suffering of dying patients.

    Dr. Meier said she and colleagues did a study a few years ago in which patients reported that certain commonly performed procedures cause severe pain or discomfort. Those included central line and peripheral IV insertions, blood gases, mechanical ventilators, nasogastric tubes, restraints, and Foley catheters.

    “They are part of the ritual of being in the hospital,” she said. “It may be justifiable to cause physical distress if a procedure is likely to help a patient. But if it’s just routine ritual behavior—such as daily blood draws—then remember that there’s a cost in terms of suffering.”

    In addition, she said, everybody knows—even if they don’t talk about it—that the reason do-not-resuscitate orders are rarely written until just before death is because “they are often overinterpreted in a triage model as 'do not treat.' In the middle of the night, these patients often are not treated.”

    That is significant because about half of all Americans now die in the hospital. Moreover, nearly the same proportion—about one-quarter of all patients—die in the intensive care unit as die at home.

  • Helping families. Hospitalists, who often work with palliative care consult services, can play an important role in helping families and primary care physicians set appropriate goals as the patient’s illness progresses.

Good business

Palliative care services are good for business as well as for patient care. According to Dr. Meier, the growth in palliative care programs has gone hand-in-hand with the rise of hospitalists—who often lead palliative care teams—and both programs are improving hospitals’ bottom line.

Hospitalist-led services save hospitals money because hospitalists know how the system works—and can effectively negotiate it on behalf of patients.

Physicians staffing such services also have time to talk to patients and families “so they can get out of that gridlock of, 'He’s not getting better like we hoped he would, so let’s call another consult.' ”

And as consultants, palliative medicine and hospitalist physicians need to avoid disrupting patients' relationship with their primary attending physician and treat the primary care doctor as a valued client.

“What we don’t want to do is compound the patients' and families' losses by adding loss of their trusted primary physician,” she said. The job of the consulting palliative care physician—and the hospitalist—“is to build and support that primary doctor-patient relationship.”

If a physician asks her, for instance, to “just manage the pain, but don’t talk about prognosis,” that’s what she will do. “If the patient asks, ‘Am I going to die?’ I say, ‘Your physician asked us to come and help him with the care of your pain. Let me go back and talk to him, and one of us will get back to you.’ "

Deborah Gesensway is a freelance health care writer in Toronto.

The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.


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