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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  • http://www.practitionersolutions.com Niamh van Meines

    I’m surprised that this hospice experience is occurring. Clearly, the hospice has not educated it’s staff on how to manage patients or educate patients on the attending role and the hospice medical director role. Any hospice that might tell a patient to say goodbye to their primary care physician are making a big mistake.
    There is no easy answer to your questions about care management. Healthcare recommendations for the future are that collaborative structures in care management are essential, however, hospice care is a great example of where this collaborative effort meets common challenges.
    The idea of a collaborative effort for optimal care of a terminally ill patient is a wonderful one. The reality is something entirely different. Take for example the attending physician who needs to see the patient, for whatever reason, every time the patient has a medical issue to be evaluated. This presents an unmanageable challenge to a patient in the terminal stages of disease. Deferring to the hospice to manage the patients care in this instance is a good plan.
    Or what about the physician who orders an abundance of tests to protect against leaving themselves open to legal challenges when the patient has a known terminal illness that must be managed & the level of intervention needed or patient choices in goals of care have not been determined or discussed? The hospice would most definitely do a better job of finding a conservative, patient centered solution in managing the patient’s issues. What about the physician who really has no expertise in pain and symptom management? Their patient does not benefit from the palliative care and quality of life focus of hospice care. And what about the discussions about decline in clinical status, death, dying, advance care planning etc? Many healthcare practitioners would rather run away from some of those intense discussions.
    And finally, what about the provider who does not visit the patient at home & does not know what is needed to make sure this patient with a terminal disease stays home as comfortably as possible while their disease runs it’s course and they approach end of life. Surely, doing it alone is not a good plan.
    As you stated, hospice is of great benefit but only if done with the patient at the center of the plan & supported by all the practitioners who can add value and meaning to the patients declining health and dying experience.
    Thanks for your thoughtful post!

  • Radha Denmark

    Having worked in hospice for many years as an RN, I point out lack of physician accessibility as the primary issue that leads me to disagree that the PCP is the logical one to lead end-of-life treatment. Our hospice medical director was always immediately available to me by cell phone. She would make a house call same-day if needed. Prescriptions to alleviate symptoms of pain or distress were available to be picked up and delivered within an hour to the patient. The interdisciplinary team of physician, nurses, social workers and nursing aides would sit together in a room once a week, for three hours, and discuss our patient panel, their progress and needs. All of the hospice team visits the patients regularly, providing them with supplies, comfort and advice. This is not reproducible by a single, well-intentioned PCP.

  • Cory Ingram, M.D.

    Palliative care is becoming the standard of care for seriously ill patients and their families due to improved outcomes and increased longevity. See Temel et al and Shannon et al, where PC improved QOL and in the temel study longevity. The ASCO position paper on concurrent PC supports this as well. There are many studies that demonstrate that non-palliative care clinicians typically inadequately treat the symptoms of seriously ill people. Additionally, traditional models of medical care don’t provide a dedicated approach to the lived experience of seriously ill people.

    Serious illness is different these days, than in years past, due to medical advances resulting in people being more ill when they die. The best approach to both seriously ill people and dying people is a team approach of all specialties that are needed. Often PC and Hospice clinicians are the most skilled and due to their involvement early in the illness they know the patient and family very well. Additionally, many will have a practice model that allows them to be actively involved with patients and families as they transition between different care settings and care goals throughout the trajectory of an illness.