During morning rounds on my sub-internship, we always spoke softly about TG. There was never any good news. The 56-year-old writer’s lifelong battle with substance abuse was coming to an end – her heart, liver, and kidney were slowly failing. But TG’s devoted husband was in denial. And behind the scenes, we were struggling, too. The patient needed pain control, symptom management, and psychiatric support among other things. At this stage, who was responsible for providing these and talking to the family? When would it be appropriate to consult palliative care? We had already called the service twice that week for less challenging cases. There was no clear division, and our confusion was further complicating the situation.
To address these concerns and others, Dr. Timothy Quill and Dr. Amy Abernethy envision a new model of palliative care in a recent perspective article published in the New England Journal of Medicine. They propose dividing palliative care skills into those that all clinicians should incorporate into their practice (“primary palliative care”) versus those that take advantage of the expertise of palliative care physicians (“specialty palliative care”). Their model would increase overall access to palliative care services and strengthen existing patient-doctor relationships. The authors explain how the shortage of palliative care physicians is impetus to revise the contemporary approach to end-of-life care. Current demand already exceeds the field’s capacity, and this mismatch will worsen significantly with demographic changes.
Every physician, most notably those who regularly care for very sick patients such as generalists and myriad specialists, should be trained to deliver the basic end-of-life services that constitute primary palliative care. Primary palliative care skills include the following: basic pain and symptom management; treatment of general depression and anxiety; and ability to facilitate discussion about prognosis, goals of treatment, suffering, and code status. These skills should be taught and reinforced at every level of training and across medical fields. The authors also encourage each specialty to define an essential set of primary palliative care skills for its members, and, as a starting point, share these with practicing clinicians through workshops. In the case of TG, applying the new framework would suggest that our team had yet to exhaust the skills of primary palliative care.
As a result, we did not yet require what Quill and Abernathy describe as specialty palliative care: the advanced skills and knowledge possessed by those trained in the field. The services of specialty palliative care range from management of refractory pain and complex depression to assistance with conflict resolution. By making a clear distinction between primary and specialty palliative care, the new model would allow physicians from all fields to maximize their contribution to a patient’s care near the end-of-life. Palliative care would only be consulted when true expertise is needed, and primary care physicians would remain the quarterbacks of their patients’ care. If applied widely, the refined approach would make the specialized skills of palliative care doctors available to more patients, while simultaneously improving the confidence and competency of all doctors caring for sick patients. Adopting this more sustainable model would benefit everyone: patients like TG, their families, and the individuals taking care of them.
Deep J. Shah is a medical student.