Hospitalists And Palliative Care: A Natural Alliance

Main Category: Palliative Care / Hospice Care
Also Included In: Primary Care / General Practice;  Caregivers / Homecare;  Cancer / Oncology
Article Date: 29 Jun 2006 - 0:00 PDT

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The Hospitalist Role

More than almost any other medical specialty, hospitalists play an active role in improving the hospital environment as a whole by participating in quality initiatives, protocol development and other leadership activities. In many hospitals they are the de-facto providers of pain and symptom management for seriously ill patients, and they frequently interact with the ER and ICU, as well.

This focus for hospital medicine suggests a natural affinity with palliative care. In fact, the professional organization for hospitalists, the Society for Hospital Medicine (SHM), recognizes palliative care as a core competency for hospitalists.1 SHM's past president, Dr. Stephen Pantilat, director of the palliative care service at the University of California-San Francisco Medical Center, has been an important national advocate for the hospitalist's role in advancing palliative care in the hospital.

The Growing Field

"Hospitalists are becoming predominant medical providers of hospital care," Pantilat noted in a CAPC-sponsored national audio conference on May 18. Forty percent of U.S. hospitals now employ hospitalists to manage in-hospital patient care; many others are planning to do so. There are approximately 12,000 working hospitalists in the United States and the number could grow to 30,000 by 2010. "Hospitalists are providing care for many hospitalized patients who need palliative care," including the half of all Americans who die in hospitals, he said.

Hospitalists, in growing numbers, recognize the importance of palliative care to their work, but many feel they have not received adequate training in palliative care. Pantilat added that data from the Robert Wood Johnson-funded California Hospital Initiative in Palliative Services (CHIPS) project care suggest that the presence of hospitalists in a hospital is positively correlated with success in establishing a palliative care service, regardless of whether the hospitalists were actively involved in the program's development.

Hospitalists are uniquely qualified and positioned to lead efforts to improve access to palliative care in the hospital setting, with natural alignments in care goals and parallel competencies, Dr. Howard Epstein, a hospitalist at Regions Hospital in St. Paul, Minn., said in a presentation at the National Hospice and Palliative Care Organization's Clinical Team Conference in San Diego, Calif., in April.

Epstein led a two-year planning process to launch the palliative care consulting service at Regions in 2005 and now participates with six other members of the hospitalist service in providing palliative care at the hospital. They also assume medical management of patients from an affiliated hospice program who are placed in the hospital for inpatient hospice care.

Creating the Alliance

How can palliative care advocates take advantage of this natural affinity? Epstein said they can start by recognizing the parallels between hospital medicine and palliative care, such as:

-- The need to document improved clinical, customer satisfaction and financial outcomes for the hospital in justifying each service's existence;

-- The need to educate other physicians about the value and appropriate utilization of each service;

-- Their shared focus on helping patients transition to other levels of care including, when appropriate, referral to hospice; and

-- Recognition of the importance of the interdisciplinary team.

Palliative care advocates are advised to learn the role hospitalists play in their institutions, identify and recruit potential palliative care champions from within the hospitalist service, and suggest roles that those champions can play in the development and provision of palliative care.

The most basic role is for the hospitalist to recognize which hospitalized patients could benefit from palliative care consultations and refer them to the palliative care service. With education and convenient printed referral guides from the palliative care service, hospitalists could become major referrers to palliative care.

Hospitalists who recognize a personal interest in palliative care can obtain additional training from CAPC, the American Academy of Hospice and Palliative Medicine or similar groups. The palliative care tools, concepts and perspectives they learn could then be incorporated into their daily practice. They can also participate in quality improvement initiatives such as writing protocols for ventilator weaning or pain management.

If there is no palliative care service at the hospital, hospitalists can advocate for establishing one, participate in a planning or organizing committee, and then remain active on the palliative care interdisciplinary team or medical advisory committee. Some may take on direct clinical responsibilities as attending physicians on the palliative care service. An advanced step is for the hospitalist to become board-certified in hospice and palliative medicine and take a leadership role in palliative care for the hospital.

However, experienced practitioners caution against the danger of trying to add palliative care responsibilities to existing full-time commitments as a hospitalist. "Zero FTEs is not viable in the long run" for a palliative care physician, Dr. Susan Block of Harvard Medical School noted in a recent article in The Hospitalist, a magazine published by SHM.2 Many hospital medicine services are busy and struggling to hire enough staff to keep up with demand, while a day working on the hospitalist service can be intense, Pantilat added.

A more viable alternative might be for several members of a hospitalist group practice to incorporate palliative care rotations into their schedules, or to have a reduced hospitalist caseload on days when they are covering the palliative care service. Other creative scheduling approaches may need to be explored. Hospitalists could also provide medical back-up to a full-time nurse practitioner who carries most of the caseload for the palliative care service, or round with the palliative care service one hour a day.

For hospitalists who find that they enjoy and are good at family meetings, medical goal planning or pain management, palliative care can offer opportunities for diversity and enhanced satisfaction in their jobs, for working with a high-functioning interdisciplinary team, and perhaps for an additional revenue stream of billing for medical consultations.

Hospitalists can either lead, participate in or refer to palliative care, Pantilat concluded. The natural link between hospital medicine and palliative care can be a win-win proposition for the hospitalist, the hospital, the palliative care service and the patient and family.

By Larry Beresford, Contributing Editor, Center to Advance Palliative Care

The Center to Advance Palliative Care (CAPC) is a national initiative supported by The Robert Wood Johnson Foundation, with direction and technical assistance provided by the Mount Sinai School of Medicine (NY). CAPC provides health care professionals with the tools and training necessary to start and sustain successful palliative care programs.

1 Click here to see article in hospitalmedicine.org.
2 Beresford L. Palliative care services offer new horizons for hospitalists. The Hospitalist, July/August 2005, p. 10-15.

http://www.capc.org

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