Palliative care has become the last bastion of health care sanity

I couldn’t really blame the social worker.  He was just doing his job.  The skilled nursing facility (SNF) connected to the hospital was full of flailing patients.  So he thought he would ask for a palliative care consult (after getting an okay from the primary team).  It was his third request of the day.  He spoke slowly as he tried to untangle the twisted path the patient had taken.

“Dr. X was managing poor old failure to thrive before he came to the hospital.  But then Dr. Y, the hospitalist, admitted him and treated the urinary tract infection.  Dr. Z was covering Dr. W on the cardiology side.  And of course Dr. S, the oncologist, was giving chemo before he landed here.”

My head started to swirl as I waived him away and ambled back to the nursing station.  This was another complex patient with multiple doctors and few answers.  I reviewed the chart and then went to the room and began my exam.  He was an elderly, confused, chronically ill gentleman with labored breathing.  He was unable to communicate effectively.

I left the room and called the daughter.  She hadn’t spoken to any of the doctors in awhile.  She was hoping to meet later in the day to talk.  I hung up and paged the nurse practitioner who covered the hospitalist patients in the SNF.  Even a move down the hallway ended in a hand off to yet another provider.

It was just as I expected.  Doctor X didn’t come to the hospital.  Dr Y had finished his week as hospitalist and was now off for the next seven days.  Dr. Z and Dr. W signed off the case since the cardiomyopathy wasn’t responding to maximal therapy.  And Dr. S, the oncologist, said that the metastatic prostate cancer was the least of the patient’s problems.

So it would be me, the newly consulted palliative care specialist, who would sit down and talk to the patient’s family about end of life and futility.  I would start a little morphine, tweak a few medicines, and stop the Ativan due to delirium.

I have to admit that it all left a sour taste in my mouth.  This is just one example of many.  Yes, this is what we are good at, but it also kind of makes me wonder.

Has palliative care become the last bastion of sanity in the dumping ground of today’s disjointed and broken healthcare system?

Jordan Grumet is an internal medicine physician and founder, CrisisMD.  He blogs at In My Humble Opinion.

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  • Suzi Q 38

    So sad. i saw this behavior with my husband, whose father was dying of kidney failure and old age at the time.
    He would barely see him!
    It was tough to get him in to see his own dad.
    I realized that some people just do not want to face that a loved one is dying. They don’t want to be part of it or see it in any way.
    I had to come to an understanding of this, and realize that it happened to me with my own father, too.
    It is called “denial.”

    Thank you for what you have to do.

  • ninguem

    “…..Has palliative care become the last bastion of sanity in the dumping ground of today’s disjointed and broken healthcare system?…..”

    Since primary care has been destroyed, probably yes.

  • Judy Hamilton

    Hospice is the better way to care for patients with multiple conditions and doctors. They are too sick to keep going to appointments in order to just get their meds, too sick for constant bloodwork, etc. Doctors cause such anxiety and stress and pain to both patient and caregivers by not getting it together so that there is just one stop doctoring which is what FINALLY happens in Hospice. No need to verify UTIs just call and got script, no need for another office visit to change heart med or BP med, just a call to Hospice Dr. BUT WHY does it have to get to this stage of serious illness before we can accept that this could be done with a caring collaborative team and effort of specialists with one overseer doctor and or nurse specialist? It makes no sense at all the other way and we are killing people off by the process and causing what doctors say is their prime directive, “first, do no harm.”

    • Patricia

      I wonder if it has to do with reimbursement practices with insurance companies? Sounds like doing the ‘humane’ part of the work does not get paid for but doing exams and tests to diagnose or treat does. I am guessing, not accusing. Because if that is the problem then somehow that is where advocates need to focus (??)

  • Jospeh Caraway

    I am a nurse practitioner with an internal medicine group that provides care in SNFs. I see this very scenario every day…investing countless hours (poorly reimbursed, by the way) educating and preparing families for the eminent demise of their loved one. Given that these family members often do not know me…or understand my role…it takes even more time to gain their trust. The system began fragmenting years ago as so few “family docs” followed their patients to “nursing homes”. The biggest question that I am asked by families…”Why didn’t the doctors at the hospital tell us this?” …when I explain the circumstances.
    I am fortunate to be with a group who respects and treats me as a colleague. I have nurtured a professional relationship with many of the specialists and hospitalists in my area, which is helpful as I relate to the patients and families whom they have referred. However, it is time that all understand that sometimes our profession “does things TO people instead of FOR them”…and that compassionate end of life care is a viable, humane and cost effective option.

    • meyati

      I wish that I could meet somebody like you in my system. Friday, I’m going into my head oncologist to basically do what my nurse navigator should have done. Get my medical history. You probably would be prejudiced, because the nurses and social workers say that I need lots of counseling. Part of that is that I still like to joke and smile. I’m allergic to acetaphetamine, so they call me a dope addict trying to get codeine sulfate. I’m allergic to bandaids and neosporin, etc. My temp is 96. Von Willebrand runs in my family. Lab techs say that I’m really bleeding too much, and they’ve asked if I have a blood disorder. I was bitten by my dog. I was at the ER in 10 minutes. I told them that I was a cancer patient, and I finished radiation in Feb. The ER didn’t follow cancer protocol. Within 50 hours, I was hospitalized with IV antibiotics. I had pus mounds coming out of every puncture. My temp was at 98.0. I kept calling and calling to get help. I didn’t want to return to where I was treated badly. They laughed about my PCP listing allergies in red. I didn’t want to go sit with sick people for hours in Urgent Care. I called and called and called my PCP. My first oncologist wanted to do rad surgery, but didn’t order any lab work. I asked the nurse navigator about lab work-she said, “He didn’t order any.” and walked off. I tried to communicate to her through Emails, and she said that she’d talk to somebody, but never got back to me. I’m asking the Quality of Life Counselor to sit in with me, while we deal with these issues. I have a team of good doctors that seem to respect my desire to walk my hounds and work in my yard at dawn, do woodwork, paint, eat and laugh with my family for as long as possible. diagnoses: aggressive, atypical BCC stage 2T, on nose and lip. Part of my nose, lip, and the space in between have been removed. For some reason, I took well to radiation-gained weight and face is normal color. That also creates a problem in getting appropriate medical care-like dog bite protocol 4 cancer and radiation patients being followed.

  • Susan Czarnecki

    Palliative Care was called in early in my care, when I began Chemotherapy, it was offered. I am so glad I took that opportunity ! I am so thankful for the knowledge and CARING that came with them. After a Liver resection, I was confused and hemodynamically unstable in the ICU. The ICU staff refused to call Palliative Care in because I was not “terminal”, my husband did. They met my husband @ 7:00 a.m and stayed with us until 8:00 PM ! And came everyday, twice a day !Their Pharmacist calculated what my doses for pain meds and all my drugs should be with 80% of my Liver removed. They found 1/4mg of Ativan stopped the vomiting, took off the Scopalimine patch, and titrated my Epidural MS and I was a new pain free person within 24 hrs. I see them monthly and if I had to rearrange or give up a provider, it would not be them. Both, my husband and I are very appreciative of their care. By the way, they did a 2 day inservice educating the ICU team of the new role Palliative Care is taking, coming in sooner and a more cohesive management of all issues not just pain or “end of life”. I am sure they have played a huge part in my still managing my illness 5 years later.

  • katerinahurd

    Do you think that the company of doctors (WXYZNS) who compartmentalize the diseased body of the elder did their job just like a social worker? Do you think that the performance of their skills did not contribute to bettering the life of the elder and thus deny the biological process of death that make them distant from their patient?

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