Updated on: November 29, -0001

Putting the “PA” in Palliative Care

By Michael A. Salvatore MD FACP CHCQM
Original story posted on: December 21, 2016

“It removes the suffering of the sick, lessens the violence of their diseases, and it does not attempt to cure those who are mastered by their diseases, realizing that in such cases medicine is powerless.” 

Sound familiar? Perhaps something you recently read or heard about regarding the role of palliative care in managing disease? 

The spirit of this quote is indeed current, but the date is not. This is from Hippocrates’ The Art, written circa 410 BC!

We all know that best practices in Medicine can take years to seep into common practice. It has taken centuries for palliative care to begin gaining momentum, and it has not soaked all the way through the practice of medicine yet.

My interest in palliative care developed out of my 30-year career in intensive care. The ICU prevents many premature deaths in any hospital, but it can also delay the inevitable deaths of those “mastered by their diseases.” By the end of my career I had developed an intense interest and experience in having end-of-life discussions: extubations to quietly end a life rivalled by intubations to desperately save one.  

Palliative care has become vital in treating the complicated diseases of our increasingly aged patients, as their care has become segregated between the hospital and the community. Changes in disease complexity, patient demographics, and practice patterns have made palliative care imperative to humanely manage patients and their families.

However the imperatives go beyond patients and their illnesses; they directly come from the heart of our profession – the medical ethics to which we all strive to adhere. 

  1. Benefiance: While we all strive only to do good, we must recognize that care that cannot achieve a good is harmful to the patient and family.
  2. Non-Malfesiance: We all seek to “first do no harm,” but keeping a patient alive without a chance of restoring their life is just prolonging their suffering.
  3. Justice: Distributive justice mandates that we do not waste resources and social justice demands we use these resources fairly. Hospital beds and resources are to be used to maximize good and prevent harm.
  4. Autonomy: We are obligated to tell patients and families the clinical truth about each illness as medical certainty informs us – these facts can be hard things to accept.

When I transitioned from an ICU doctor to a PA one, we created a palliative care team, primarily to facilitate end-of-life discussions about code status, hospice, or comfort care. These are difficult discussions, but they produce tangible and intangible results. When we acknowledge “that in such cases, medicine is powerless” it releases medicine’s power to comfort. Reducing pointless suffering has a profound impact on patients, families, staff, and even utilization. While there is no DRG or ICD-10 code for suffering, it is everywhere there are patients. 

The impact in our hospital is that futile care has become less common, and many patients realize what they yearn for most is to go home, even just to die. A palliative awareness has markedly increased, as reflected by hospice referrals along with family satisfaction scores. Finally, length of stay (LOS) and readmissions have declined. But the ultimate goal for all providers should be to reduce palliative care in the hospital by increasing it in community practices – and, critically, skilled nursing facilities (SNFs). 

Job requirements for palliative care are modest: ears, a mouth, and a heart. Palliative care is all about finding out what patients and families know about the disease and what they expect, and then telling them the truth about both. Unrealistic expectations among some families are rampant for a variety of reasons:

  1. Never told by their physicians
  2. Never heard when they were told
  3. Hope triumphing over experience
  4. Denial triumphing over everything

Palliative care discussions not only benefit the patient, the family, the staff, and the institution, but they have many benefits for the PAs who initiate them:

  1. You can relieve suffering, which is good for your soul.
  2. It prevents withdrawal symptoms after a life in clinical medicine by keeping the human condition in your administrative world.
  3. You actually achieve something, which is antidote to the frustration of dealing with the Centers for Medicare & Medicaid Services (CMS) and insurers.
  4. You can be a clinical missionary to your administration, and you can humanize patient statistics.
  5. It gives your staff hope that the pain and suffering they witness daily can be ameliorated.

There are palliative care professionals and specialists everywhere, and count yourself blessed if they are working among your patients. But if they are not, or if your patients need help, then consider putting your ears, your mouth, and your heart together to form a palliative care team in your hospital.

I didn’t train under Hippocrates, but one of my early attendings would always chide us, “the sick do not inconvenience the well.”

Palliative care is not an inconvenience, and you will be well served if you give it a try.