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When socializing with fellow young physicians, most of whom are not in palliative medicine, I am reminded, in Hospice and Palliative Medicine, I have the unique opportunity to share time and attention with my patients. We reflect on “the old days” of medicine, where physicians had long standing relationships with their patients which allowed them to more easily direct medical decision-making which was appropriate for the individual patient. I often tell others I chose this field because it is the closest thing to that particular kind of medicine, where we can still do ‘the right thing’ for patients, most of the time. That although many parts of hospice are very rigid (eg. 6 month prognosis, palliative goals only) we still have significant freedom to adjust the plan of care to meet the needs of our individual patients.

My friends envy the extended visits I have with patients where I learn about their family and friends and, by doing so, also learn about their goals and fears. The time I am permitted to invest in my patients allows me to find out who the person is and then work to match the medicine to their needs. My colleagues often talk about the opposite - how their job is to make the people fit the medicine. We've marveled over this golden part of medicine where, at least as they die, hospice provides patients what they really need to live well.

Most of us practicing in this field recognize this could not continue indefinitely. With increasing complexity of hospice patients, an aging population and less options for debilitated patients with poor social supports, it was inevitable that the growing cost of hospice would catch someone’s eye and become a target for cutbacks. We've seen necessary layoffs and closings of hospices across the country. Last month this became a personal reality when the hospice I work for was shaken by a downsizing where we lost 19 valued colleagues. We consolidated our two hospice units into one with a loss of four beds. This was made necessary by the increased scrutiny and decreased payments we have received for the care we provide. We now pick apart each component of the GIP stay to be sure patients meet criteria. We second-guess enrollment of patients whose prognoses are in question even when their symptom burden clearly demands hospice support. Our ability to ‘do the right thing, because it is the right thing to do’ has gotten more limited as we rely more heavily on benevolence funds to provide care for patients for whom insurance does not cover the bill. Increasingly, the feeling that I, too, force my patients to fit into the mold of medicine is creeping up on me.

On the day our agency announced the consolidation, I was caring for a young woman in our inpatient center. During her stay she had been very verbal about her appreciation for the way the hospice team cared for her and worked together to provide comprehensive care. She felt a level of respect and humanity she had not felt anywhere else in her long experience with medicine both personally and professionally. When she read about the changes in the news paper the next day and sensed the grief we were all feeling she was appalled  hospice would cut back like other areas of medicine. She made it a point to tell us,

“No matter whether you get lumped in with the rest of medicine, you are still special. What you do here is still special. That needs to be recognized.”

I’ve chosen to believe her. Because if I didn’t, it would be hard to continue to do what we do, knowing we now have one hand tied behind our backs. What we do is special. The people in this field are special. As financial resources continue to change, the field will be forced to change as well. What will not change is that there will always be caring nurses, physicians, counselors, and friends who recognize the value of meeting patients where they are and maximizing their lives as they live with serious illness. Seemingly, hospice and palliative medicine is unique in the way we still place value on time and attention to the person. We cannot lose this focus. The way we deliver the care may change. The setting in which we deliver the care may change. I am hopeful the commitment to care will not.

So where do we go with all of our compassion and commitment? I’m grateful to inspired leaders who lead us in the right direction where we can apply these skills. Grateful for the thoughts of leaders in the field like David Casarett, MD, MA who proposes an alternate method of delivering palliative care at home which does not force patients to give up curative treatments or have a prognosis of 6 months in order to get the care they need. And the work of CAPC and Diane Meier MD FACP who argue for expansion of palliative medicine instead of the limitation of it. And organizations like NHPCO’s Hospice Action Network who advocate for policies to ensure the best care for patients and families facing the end of life. Their recent activity at Capitol Hill aims to help maintain the quality care we deliver.

Because the care we deliver is still special. And the needs of our patients don’t always fit into a mold. Let’s not forget that.

Photo Credit: Heart Shaped Hands by nippe011

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After Hill Day is over, NHPCO will be hosting their 26th Management and Leadership Conference at the nearby Gaylord National Conference Center.  Just in time for the end of the Cherry Blossom Festival! I have never been to the MLC before but have been to the Clinical Team Conference a few years ago.  This session looks to be much more about the administrative issues as opposed to the medical-clincal aspects of the AAHPM and NHPCO CTC conference.  I am only able to go for the Friday sessions, but after looking over the sessions this past week I see many more topics that I would be interested in.  Reading through many of them I am reminded of the absence of a voice in the blogosphere since Hospice Guy at Hospice Blog left in 2009.  We don't have anyone really covering the day to day administrative issues of running a hospice.  (If you are out there Hospice Guy - email me, I have been wanting to talk to you and you have not answered your emails for the past two years!)


If any one is attending MLC and would like to tell us what you learned, we are open to hearing from you. Feel free to write a guest post.  I will report back this weekend on interesting things I picked up from the conference.

If you any Pallimed readers are attending feel free to email me at christian@pallimed.org and hopefully we can meet up. Another opportunity to get together would be the Social Media session on Friday from 11a-Noon at which I am co-presenting with Jon Radulovic (NHPCO) and Melissa Delacalzada (@mdelacalzada) (San Diego Hospice) I will be bringing the Palimed 'P' stickers and flyers for you to take home for you to continue our reader supported awareness initiatives.  We are not having a formal Pallimed get-together but who knows what the future may bring!

What do you all like about the various major meetings? Are there any others you would add to this list?

• NHPCO MLC
• NHPCO CTC
• AAHPM/HPNA Annual Assembly
• CAPC 
• International Congress on Palliative Care (Montreal)

Should we cover these meetings in more depth? Or less? Do you want to volunteer to cover any of them?

Photo credit: Flickr user Geoff Livingston

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In what has been an on-again off-again story of 5+ years that was beginning to seem like an unattainable holy grail, the Joint Commission has finally issued a press release stating in Fall 2011 they will be recognizing hospitals with exceptional palliative care programs with an emphasis on:

• A formal, organized palliative care program led by an interdisciplinary team whose members possess the requisite expertise in palliative care,
• Leadership endorsement and support of the program’s goals for providing care, treatment and services,
• A special focus on patient and family engagement,
• Processes which support the coordination of care and communication among all care settings and providers, and
• The use of evidence-based national guidelines or expert consensus to guide patient care.

This is really important for many reasons.  Many hospitals may claim to have palliative care teams but the members of the team, internal support and integration into hospital culture can vary widely as many who have worked with palliative care programs have seen.  No doubt we have seen large increase in the percentage of hospitals with palliative care with support from organizations like the Center to Advance Palliative Care, but The Joint Commission is the 600lb gorilla and more importantly is a non-palliative care organization to help support quality palliative care programs.

I do like the emphasis on the whole hospital program and not just the team. This may set some higher standards than all teams will be able to accomplish, but then I think that makes all of us strive to do better.  Or we can be like Lake Wobegon where everyone is above average.  I just wonder what percentage of teams will be able to achieve this certification for the hospital as a whole.  This cutoff point will be interesting to watch.

When The Joint Commission comes to your hospital, your palliative care team can get excited because now you may be the people that help the hospital achieve more recognition.  The suits in the C-Suite might find a new interest in what your program is doing and hopefully (fingers crossed) you might get the resources and staffing to achieve it!

One slight irony is the Advanced Certification for Palliative Care is housed in The Joint Commissions "Disease-Specific Programs."  Palliative care is about people, I guess we have to keep on educating.

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If you have not heard by now Gentiva Health Services (Stock Ticker: GTIV), a large home health care company has acquired Odyssey Hospice (ODSY) for a straight up cash deal worth nearly $1 Billion dollars. That's right one b-b-b-b-billion.  But oddly I have not heard very many people in hospice talking about this super-size merger. (Late edit: Larry Beresford covers it here)   I have lots of questions so I thought I would throw them to you.