Palliative care has
become a growing medical specialty in the United Sates with a large amount of
evidence showing that palliative care teams enhance the quality of health care
for persons living with serious illness and for their families while also
reducing medical expenditures (1). A recent review in the New England Journal
of Medicine discussed the differences between palliative care and hospice in
the United States (2). Palliative care is the interdisciplinary care (medicine,
nursing, social work, and other specialties) that focuses on improving quality
of life for persons of any age who are living with a serious illness and for
their families (2). According to the NEJM review “palliative care should be
initiated at the time of diagnosis and is provided concordantly with all other
disease-directed or curative treatments”.
In contrast, hospice
is the formal system of interdisciplinary care that provides palliative care
services to the dying in the last months of life. One of the issues that complicates hospice and palliative care in the United States is the varying levels of
insurance coverage as well as what we define as necessary medical improvements of life quality. “In the United States, unlike most other countries,
hospice is a relatively separate system of care for the terminally ill. Eligibility
criteria are defined by insurance benefits and federal programs, and
Medicare-certified hospices are subject to strict regulatory requirements” (2).
Currently in order to qualify for hospice, a patient must have a doctor’s
prognosis of survival of 6 months of less and are willing to forgo curative
treatments. I have volunteered with hospice departments in hospitals, and seen
patients go on and off hospice care because insurance coverage drops them or
deems it unsubstantiated. It is valid that more studies
should be done showing the efficacy of palliative care and its affects of
overall quality of life, this will help insurance companies as well as medical
providers to recognize the vital part of healthcare palliative care and hospice
provide. The question is what does our healthcare system aim to provide to
patients? If the answer is to increase quality of life, the discussion of end
of life care is a very pertinent and difficult aspect of healthcare that needs
to be addressed.
Ideally many of the
components of palliative care can and be should be provided by primary treating
clinicians, “much in the way that uncomplicated hypertension or diabetes is
managed by primary care physicians rather than by cardiologists or
endocrinologists” (2). But the reality
of the matter is that most doctors/providers/extenders have limited or no
formal training in these areas. Especially considering there already is a
shortage of primary care physicians it is unrealistic to think primary care
will be able to handle the large increase of patients who fall into the
category of benefiting from hospice care. According to the NEJM review
“approximately 1.8 million U.S. residents live in nursing homes, and this
number is expected to double by 2030, palliative care needs of this population
are vast” (2).
Healthcare in this
country has the goal of improving quality of life for patients, and doing so
does not mean simply finding a cure or procedure or treatment for a symptom. Many
randomized, controlled trials and case studies of palliative care interventions
have shown “reductions in patients’ symptoms and health care utilization and
improvements in quality of life and family satisfaction across a wide spectrum
of populations, including patients with advanced cancer, neurologic disease, or
lung disease and older adults with multiple coexisting conditions and frailty”
(2). So why are patients having trouble
accessing palliative or hospice care? “The number of palliative care
specialists falls far short of what is necessary to serve the population in
need” A 2010 study found 6000 to 18,000 additional physicians are needed to
meet the current demand in the inpatient setting alone (3).
Another alarming
aspect of palliative care in the U.S. is
regional, socioeconomic, and racial ethnic group determinants influence access
to palliative care (2). According to the NEJM review, “ persons of minority
races and ethnic groups access palliative care and hospice services far less
frequently than do whites” (2). This statistic is especially concerning
considering there groups have “higher rates of inadequately treated pain,
preference-discordant medical treatments, and low satisfaction with care and
provider communication” (4).
The term hospice and
palliative care seem like negative and bad things when introduced to patients
mainly due to wrong perceptions and politically charged debates by insurance
companies. Perceptions among doctors that palliative care is only appropriate
at end of life, and that is it synonymous with hospice, leads to patients
negative reaction toward palliative discussions, and the loss of all hope phenomena
if palliative care referral is discussed (2). According to this articles
review, a recent survey showed that “90% of adults in the U.S. had either no
knowledge or limited knowledge of palliative care, and when read the definition
stated that they would want palliative care for themselves of their family
members and that it should be universally available” (2).
Moving forward more
data and research needs to be conducted showing how palliative care teams
enhance the quality of health care for persons living with serious illness and
for their families which also reducing medical expenditures. This article showed
a very interesting aspect of healthcare in this country that has been seemingly
ignored by many professionals in medicine as well as by patients and patient's families.
3. Lupu D; American Academy of Hospice and Palliative Medicine Workforce Task Force. . Estimate of current hospice and palliative medicine physician workforce shortage. J Pain Symptom Manage 2010;40:899-911
4. Johnson KS. Racial and ethnic disparities in palliative care. J Palliat Med 2013;16:1329-1334
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