When should a physician obtain a palliative care consult?

I had a most surprising visit with a patient last week; she came to say goodbye, because she was dying. The surprise was that while she does have a terminal illness, she is not actively dying; I would put her prognosis at four to eight months.  She was bidding me adieu, because I had referred her to hospice.

There is confusion about the role of the primary doctor, when a patient signs onto home hospice.  Many families, patients and physicians believe that this ends the relationship with the original doctor, whether they are a family doc, internist, oncologist or other specialist.  Not infrequently, social workers or even hospice intake nurses, give the impression the hospice will take over for the remainder of the patient’s life, and that the patient will not return to the referring doctor.

This is incorrect for several reasons.  First, it is in violation of Medicare hospice rules, which specify that if the doctor and patient wish, the referring physician will remain the primary caregiver throughout the time on hospice.   While the original physician can sign off the case, if that seems ideal in an individual case, that is not the intent of the law.  If the primary doc does signoff, then a hospice physician or director becomes the managing physician

Most of the time, the doctor who understands the patient best and has the closest relationship, is the referring doctor.  This physician can give the most personal medical and emotional support, and for the patient the trust they have for the original doctor is invaluable.  Therefore, for a patient on hospice, while they gain tremendous assistance from the hospice team, which includes nurses, pharmacists, clergy, social work, and palliative care physician specialist; they keep their referring doctor.  They can see this doctor as often as is required and that doctor is paid by insurance or Medicare for their service.

This topic does raise an interesting question; should all doctors be trained to supervise hospice care?  Should they be able to handle basic medications to prevent suffering and should they have some comfort in counseling and support at the end-of-life.  Alternatively, should every patient, at the proper time, transfer their care to experts in hospice and palliative medicine (HPM)?

It is my belief that patients should consult the subspecialty of HPM only in unusual cases.  While there are specialists in infection or in heart disease, it does not require a super-specialist to treat an earache or give a water pill for blood pressure control.  However, sometimes subspecialists are needed, say in a patient with resistant staph or requiring a cardiac catheterization.

I believe the same concept works for end-of-life care.  The majority of physicians, especially working with a hospice, can give excellent palliative care, most of the time.  Occasionally, a patient will have pain that is out of control or another challenging problem and they should be referred to HPM experts.  For most patients, who want to stay close to the doctor that knows them the best, that understands them the most, end-of-life care should be as basic as penicillin, chest x-ray or ace wrap.

Oh, and that hospice patient who came to say, “Goodbye?”  She is coming back to see me in three weeks … after a trip to Disney World, with her grandson.

James C. Salwitz is an oncologist who blogs at Sunrise Rounds.

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