Although most hospitals report having a palliative care program, an Institute of Medicine (IOM) report highlighted the many ways U.S. hospitals can do better in caring for patients with advanced illness.
Palliative care is catching on as a service line.
As of 2013, 90% of hospitals with 300 or more beds reported having a palliative care program, as did two-thirds of hospitals with at least 50 beds, according to a study published in the Journal of Palliative Medicine in 2016.
Despite making deep inroads into health systems nationwide, however, palliative care programs often have room for improvement.
A 2014 report from the Institute of Medicine, titled Dying in America, called for sweeping changes to strengthen both palliative and end-of-life care nationally.
Obstacles identified in the study include disparities between the services needed by patients and families and the services they can obtain, barriers in access to care, and "inadequate numbers of palliative care specialists and too little palliative care knowledge among other clinicians who care for individuals with serious advanced illness."
Five guidelines may help take down those barriers.
1. Understand Advanced Illness
The leading misconception about palliative care—among the public and within the healthcare industry—is that it's synonymous with hospice or end-of-life care.
Although hospice and end-of-life programs often include palliative care, this service is not just for the dying. With this understanding comes an imperative for patients to receive palliative care earlier in their disease trajectory.
This requires a cultural shift that starts with physicians, according to Mohana Karlekar, MD, medical director of palliative care at Vanderbilt University Medical Center.
"When a physician is taking care of a patient and things aren't going well, often he or she will have this angst, and often will avoid these conversations until the last minute," she says.
2. Invest in Midcareer Training
As noted by the IOM, a top challenge in providing access to high-quality palliative care is an inadequate workforce pipeline, says R. Sean Morrison, MD, director of the Hertzberg Palliative Care Institute at Mount Sinai Hospital in New York City and director of the National Palliative Care Research Center.
"Because we're a relatively new specialty and because of caps in residency and fellowship training programs, there are just not enough specialists to meet the needs of every person with a serious illness in this country," Morrison says.
To manage this shortcoming, Morrison's first recommendation is to use palliative care specialists judiciously, enabling specialists to take care of the most complex cases, lead community-based teams and programs, and conduct research to advance the field.
The other piece of the equation, he says, is to rapidly expand training in core palliative care skills to nonspecialists, thus facilitating a team-based approach to taking care of patients' social, spiritual, and medical needs.
Also known as "midcareer training," the concept of improving all clinicians' skills in communication, pain management, and symptom control is critically important, adds Diane Meier, MD, FACP, FAAHPM, a professor of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai in New York City and director of the Center to Advance Palliative Care, also in NYC.
3: Screen for Need
After building a competent palliative care team, health systems' next priority should be creation of a consistent and standardized approach for identifying patients and families who would benefit from palliative care, Meier says.
In particular, hospitals should routinely ask patients about poorly controlled symptoms such as pain or shortness of breath, inquire about caregiver exhaustion, and note red flags such as repeat hospitalizations, she says.
"Anybody who meets one or more of those criteria would benefit from a comprehensive palliative care assessment and appropriate interventions. But right now, we don't screen for those issues, and if you as a patient get palliative care in a hospital, it's because you're lucky. If your treating physician doesn't think about making the referral, you almost certainly will not access the care," says Meier.
4. Spread Out
One of the more unique qualities about Vanderbilt's palliative care program is that it stems from the hospital's division of general medicine, which is under the department of medicine. "We are not connected in any formal way to any specific specialty, so the breadth of the different types of patients that we get is different than most programs," Karlekar says.
Oncology referrals account for approximately 15% and heart failure referrals account for approximately 12% of all palliative care referrals at Vanderbilt, with surgical, trauma, burn, stroke, and other serious conditions making up the rest, she says.
"We're embedded in heart failure, so we see people before they get transplants," she adds. "We see a lot of liver patients as well. It's earlier in the trajectory, and it's a much wider population specialty base."
Vanderbilt has run a dedicated inpatient palliative care unit since 2012. There, "we are the primary team taking care of those patients, some of which come in to have their symptoms managed, some of which will not leave the hospital because they're too unstable to get to hospice," Karlekar says.
"In some cases, there's some uncertainty about how they're going to do. Maybe they'll go to rehab, but we're not sure," she says.
What's more, the program that began as an inpatient consultative service also provides extensive outpatient services.
5. Monitor Service Line Metrics
The metrics that correlate with palliative care success are also more diverse than for other service lines.
According to experts, benchmarks most important to watch include patient satisfaction, avoidable hospitalizations, time from admission to palliative care service delivery, penetration rate (the percentage of annual admissions to your hospital that are served by your palliative care team), and 30-day readmissions and hospital mortality.
Debra Shute is the Senior Physicians Editor for HealthLeaders Media.