The challenge of creating a palliative care program

The orders came indirectly from the government.

Reduce hospital re-admissions. Cut costs.

So, the hospital contacted the local hospice-palliative care center and asked for help. Of course, overwhelmed with work and understaffed, the project was handed off to me.

My task sounded simple. Create a palliative care program at the nursing home. But as I gathered for the first meeting with the administrator, social worker, and clinical staff, I knew there would be resistance.

And, in fact, I had my own feelings of reticence. Although I had learned much over the years, I was not trained in palliative medicine. As I gazed around the room, I realized that neither were any of my colleagues.

***

I looked Nancy squarely in the eye as I explained my vision. Our beginnings would be simple and humble. Admissions would flag appropriate patients based on predefined criteria. Then social work would approach each patient and family within seventy hours and have “the talk.”

When Nancy heard her profession mentioned her ears perked up and her face twisted in confusion.

What do you mean, “the talk”?

Ready for her question, I pulled out a POLST (physician orders for life sustaining treatment) form and passed it around the room. The two page document was a series of basic questions.

Do you want to be resuscitated if your heart stops?
Do you want to be hospitalized if your condition worsens?
If you are unable to eat on your own, would you want a feeding tube?
Can IV fluids or antibiotics be given?

Attached, on the back, was a series of questions I had created myself.

Do you have a religious affiliation?
Would you like to be visited by clergy or a therapist?
If you knew you were dying, would you rather pass at home, in a hospital, or in the nursing home?
What are your health care wishes for the next six months?
What is more important to you: quality or quantity of life?

***

I looked around the room as the participants read the form. Nancy was becoming more anxious.

Isn’t this the doctor’s responsibility?

I answered her with a tinge of melancholy.

Yes, it is the doctor’s job. But it’s also the nurse’s, social worker’s, and therapist’s job also. It’s all of our jobs.

***

We met each week. Nancy presented new patients, and then the nurses and I would discuss clinical issues and pain control. The difficult cases were referred to the associated palliative care doctor from the local center.

During the first few sessions, I continuously hammered Nancy on the POLST form. For each patient, I wanted to know the answer to all of the questions. At first she rolled her eyes, but as time went on she got the hang of it.

A transformation occurred during our fourth meeting. We had ten people in the program. As Nancy presented each patient, I could sense a difference in the tone of her voice. She was now approaching the project with a new sense of zest and zeal.

At the end of the meeting, I asked her what was going on.

Well, you know Mr. Smith? He passed yesterday.

Mr. Smith had end stage dementia. He was in the process of dying for months, but his physician had not bothered to talk to the family about end of life care.

His daughters and I completed the POLST form a few weeks ago. So when he started to die, we were all on the same page. He passed quietly in bed without ambulances, IVs, or CPR.

I could see the change in her posture. She got it. She now saw how powerful these conversations could be. I smiled and congratulated her on how well she was doing such an important job. She looked down embarrassed.

It’s not like I saved his life.

Our eyes met.

No, you did something most doctors have forgotten how to do.

You saved his death.

Jordan Grumet is an internal medicine physician who blogs at In My Humble Opinion.

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