In traditional discussions of palliative care, patients are often given a choice: Do you want the aggressive care with the most powerful targeted therapies or do you just want to be comfortable?
Charles von Gunten, MD, PhD, provost for the Institute for Palliative Medicine at San Diego Hospice and is a professor of Clinical Medicine at University of California, San Diego, argues that it should never be the patient’s responsibility to choose. “Let there be no more talk of ‘do you want to be aggressive? Or comfy?” he said at the 2010 Supportive Oncology Conference in Chicago.
We have come a long way in palliative care in the past 10 years, from the time when clinicians could hardly say the word, von Gunten says.
Consider these statistics recently reported in the JAMA: 98% of National Cancer Institute-designated cancer centers said they have specialist palliative care, though at 92% of those centers that means one physician, often part time; and 78% of community care centers say they have specialist palliative care, though at 74% of those centers that means one physician.
But the journey in some ways has just begun. Von Gunten gave these tenets of integrating palliative care with cancer treatment, in accordance with American Society of Clinical Oncology (ASCO) guidelines:
--All cancer-control policies must include palliative care.
--Palliative care must be available from diagnosis.
--Essential drugs (such as morphine) must be available and accessible.
--Quality improvement is essential in palliative care.
He also noted a deficit in the way oncologists are trained. In a 1998 ASCO membership survey, oncologists were asked about their sources of information for palliative care. Ninety percent said they learned by trial and error; 73% said they learned from colleagues and role models (who presumably learned by trial and error); 38% said they learned from a traumatic experience.
Palliative care is interdisciplinary care focused on alleviating suffering and improving quality of life. It can be combined with other treatments or it can be the total focus of care. Over the past 20 years there has been steady data of the effectiveness of palliative care. It lowers costs, primarily because of lower hospitalizations, and people live longer with this care.
Structuring a palliative care team depends on your staff strengths. Von Gunten breaks oncologists into two groups: those who are very focused on the emotional lives of their patients and oncologists who are more focused on the biology and less comfortable with emotional interaction with patients. The system hospitals set up should reflect the needs of the organization after an honest assessment of what kind of oncologists they have.
Barriers to implementing these teams, particularly at smaller hospitals, often circle back to cost. But von Gunten notes that attention to palliative care may save you the cost of losing oncologists and nurses frustrated with lack of attention to palliative care.
“If one oncologist leaves you, it costs about $250,000 - $300,000 to bring a new one in; a nurse leaves, that’s about $100,000 to bring someone in—it’s an enormous cost savings to replace them. One thing that drives people wild is that palliative care issues are not being addressed,” von Gunten says.
Also, it’s important to remember the services are all billable, he said. “Make sure the billing department knows why this is so important, what you’ve been able to accomplish. A significant revenue stream can come in for this. It doesn’t have to be done though subsidization.”
Grateful patient revenue — future gifts from satisfied patients-- should also be included in a cost analysis, he said. At the heart of palliative care, von Gunten says, is a word not used in medicine very much: mercy.
“This is the compelling moral reason why palliative care needs to be a part of standard cancer care. We hear a lot about hope but not enough about mercy. Palliative care can’t be an accident,” von Gunten says. “We need to be building a system where this is routine. We have teams. We know that teams work—we have the science. We need the will to put it into comprehensive cancer care.”