Study calls for more and better hospital palliative care

Interest in such centers continues to grow, but at least one expert believes it may not be growing fast enough.

By Andis Robeznieks, amednews staff. Dec. 3, 2001.

More U.S. hospitals are providing palliative care programs, but the number and the quality of these programs have to improve, says Cynthia X. Pan, MD, and her colleagues at the Hertzberg Palliative Care Institute at Mount Sinai School of Medicine in New York City.

"In the United States, the majority of deaths occur in the hospital, but the dying process there is at best unsatisfactory and more likely inadequate for both patients and caregivers," Dr. Pan states in a report on hospital-based palliative care programs published in early November in the Journal of Palliative Medicine.

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In 1998, the American Hospital Assn. began including questions on palliative care in its annual survey. Dr. Pan and her research team studied the results of these questions and then sent out their own questionnaire to the 2,015 institutions that reported having programs for palliative care or pain management.

According to Dr. Pan's report, 719 (15%) of the hospitals surveyed reported having some sort of end-of-life care services in 1998, and 1,751 (36%) offered pain management services.

By 1999, these numbers grew to 961 (20%) for palliative care and 2,030 (41%) for pain management.

"It's a rapidly evolving field," Dr. Pan said. "As we were surveying, new programs were starting all the time. People asked, 'Can we turn in the survey later, we're planning on opening a center next month?' "

According to the study, the most palliative care programs were located in Midwestern states (115 or 34%), followed by the South (92, 27%), the Northeast (80, 24%), and the West (50, 15%). Outside of the Midwest, Dr. Pan said cities where palliative care programs were readily available included New York, Boston, San Diego and San Francisco.

New thinking needed

Many programs relied on charitable contributions for financing. Dr. Pan said this needs to change.

"It's important for the hospitals to buy into it -- not just with moral support, but also financially," she said.

In addition to financial needs, Dr. Pan said palliative care needs to be integrated into hospital systems, because a lack of integration has led to "organ-based" treatment where the focus is on the patient's heart, kidneys or some other failing body part.

"The patient as a person is not being paid attention to," she said. "It would be a real coup if we could get them to start thinking that way."

It's also important that physicians and medical students learn the best way to communicate treatment options and goals with patients and their families.

"We try to emphasize to medical students that it's very important what we say to the family and how we say it," Dr. Pan said. "People will remember for years how the news was delivered."

Residents have been particularly receptive.

"Residents are knee-deep into it, and they recognize the need for these skills," Dr. Pan said. "Residents are there at night when family members come in, and it's up to them to deliver bad news."

Rather than creating separate palliative care programs or departments, Dr. Pan said other options include:

Forming task forces within a hospital to write palliative care protocols on end-of-life care and medical decisions that can be used in individual departments.
Mini teams, where each floor would have people (usually a nurse and a social worker) trained to troubleshoot and advise others on palliative care.

There are 21/2-day programs where participants learn information and skills needed for palliative care, and also receive training so they can go back to their home institutions and teach the program content to their co-workers, Dr. Pan said.

Although the report was just published Nov. 3, the study already has had an impact.

Dr. Pan said its results already had been used to develop new palliative care programs, and -- as a result of the study -- the AHA is revising its annual survey to include questions on palliative care, pain management and hospice programs.

"The eventual goal is that every American will receive appropriate end-of-life care that is integrated and not just organ-system based," Dr. Pan said.