Wednesday, February 20, 2008
Pediatrics, the journal of the AAP, occasionally features palliative care issues, so when my wife's copy arrives I usually take a quick look at the table of contents. In the February issue they feature an article on the Barriers to Palliative Care for Children as perceived by health care providers. Davies et al polled all staff members (698) at UCSF Children's Hospital, and reviewed the results from the 117 nurses and 81 physicians who replied. Of the remaining 42 respondents they were from other disciplines and there were not enough to make significant comments as a group. The majority worked in NICU and PICU where you would expect they would see at least a few pediatric deaths per year, and only 9% of the respondents said they had cared for zero patients who died in the previous year. About 25% of the physicians had experience with more than 10 pediatric deaths in the past year, which makes the 'rarity' of pediatric deaths seem not so rare, at least in the hospital setting.
The bulk of the article is dedicated to reviewing the frequency of multiple barriers identified by the staff. #1 - Uncertain prognosis - was not too surprising, and ties in closely with the #2 reason - Family not ready to acknowledge incurable condition. These two reasons are intimately related and are joined by the skill to adequately communicate medical information, probabilities and uncertainties, and the ability (for staff and patient/family) to hold out for hope but accept the probability of decline. Given the plasticity of children to rebound from devastating illness and trauma, and the myriad of rare congenital conditions it is understandable to see why prognosis is difficult to outline for any one patient. Just because it is difficult doesn't mean we as a field should not try to make a larger commitment to finding what prognostic factors bode for good and poor outcomes across various disease entities. And if it comes down to the clinician's prediction of survival, we need to know the accuracy, precision and biases for pediatric predictions just as much as we need to study medical predictions in adults. These two reasons also make it much easier to advocate for early concurrent palliative care involvement. But I know from talking to pediatric palliative care colleagues is they suffer from 'We're not ready for you yet, because they aren't dying." similar to adult palliative care teams.
The authors explain this well:
"We think that clinicians need to realize that uncertainty is not something to be avoided but rather is an inherent dimension of care. An uncertain prognosis should serve as a signal to initiate palliative care, rather than to avoid it, even when it is not yet appropriate to begin EOL care."One large difference between adult & pediatric palliative care barriers highlighted is pediatric staff do not identify addiction fears, hastening death or legal action as significant or frequent obstacles. Some of these results seem discordant, for example: less concern with hastening death does not seem to fit with a large concern with an uncertain prognosis. Both have to do with the predicted timeline, and if you are uncertain where on that timeline death will occur, then by extension you may be concerned that your actions may hasten death. I do commend the researchers on using the neutral and descriptive term of 'hasten death' as opposed to the oft-confused terms euthanasia and physician assisted suicide, which we have covered here at Pallimed before.
Overall the study was well done, and had a good response rate, although it was only at one institution so hospital culture issues may exist as biases in this study.
Davies, B., Sehring, S.A., Partridge, J.C., Cooper, B.A., Hughes, A., Philp, J.C., Amidi-Nouri, A., Kramer, R.F. (2008). Barriers to Palliative Care for Children: Perceptions of Pediatric Health Care Providers.. Pediatrics, 121(2), 282-288. DOI: doi:10.1542/peds.2006-3153
As fellows start looking for future jobs, it is important to understand what physician salaries are like out there. These few links provide some basic information across different specialties (not palliative care) and as you can see the variation is wide. There is currently a MGMA survey for Palliative Care physicians (via AAHPM). I went through some of the initial steps, but as you get further into the survey it looks like your billing/administration department needs to be able to answer some questions. It is a bit more complex then how much did you make, and how much does it cost to employ you. I may put some of the areas for questions in the comments section if people are interested.
Regardless most people will tell you that you probably should not be going into palliative medicine if you are expecting to make loads of money. It is a 'thinking' and talking' medical specialty after all, but there are many other tangible rewards in the work that you can do. (links from A Physician on Job Search and Practice via KevinMD)