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Quality Improvements in Palliative Care at Good Samaritan Medical Center
MD News sat down with Marcy Carty, M.D., to discuss palliative care.
Q: As a practitioner, what is your definition of palliative care?
A: Palliative care focuses on relieving and preventing the suffering (psychological, physical, spiritual or any combination of these) of patients with life-limiting illnesses. We focus on improving quality of life for both patients and their families/friends and enhancing communication about their goals and wishes regarding the use of medical technology should their diseases prove refractory to medical therapies. Palliative care is distinct from hospice care as we treat patients at all disease stages, including patients undergoing treatment with curative intent. From the start, palliative medicine utilized a multidisciplinary approach to patient care, which was radically different than most other areas of health care.
Q: What is your background, and how did you embark on this journey of becoming a palliative care practitioner?
A: Currently, I am the Vice President of Medical Affairs at Good Samaritan Medical Center in Brockton. Prior to that, I was the director of clinical operations at Brigham & Women’s Hospital in Boston where I oversaw inpatient documentation improvements, Joint Commission accreditation, and patient safety/quality and medical records initiatives. I was also the Milbank Palliative Medicine Fellow and a senior consultant to the Center for Clinical Excellence. I was drawn to palliative care because of its ability to help patients in a compassionate way that utilizes the whole spectrum of medicine.
Q: How is the concept of palliative care changing, and what is driving that change?
A: Palliative care has matured over the past two decades. Many physicians are learning about the value consults can bring to them and their patients, leading to significant increases in consult volume, larger numbers of inpatient programs and, finally, growth of some ambulatory/outpatient programs. Patients with cancer and those with other life-limiting diseases, such as chronic obstructive pulmonary disease, chronic kidney disease and dementia, are seen. We are often called to help families in the ICU who are being asked to make decisions about prolonging artificial life support measures for patients with far-advanced diseases, or to help others with an expected prognosis of months to years identify a proxy and make these choices in advance, creating what is called an ‘advance directive.’ In the near term, we will see Massachusetts aggressively implement the Medical Orders for Life-Sustaining Treatment, which will allow patients and their physicians to document their choices and for these decisions to become orders that can be acted on outside the hospital.
Q: What are the key ingredients to creating the best care team for patients who receive palliative care?
A: An exceptional palliative care program requires a high-functioning, interdisciplinary team. Each team member must truly respect and value each other’s expertise and opinions. At its core, the team includes physicians (including the patient’s primary physician and specialist physicians), nurses or nurse practitioners, and social workers. Teams also often include pastoral care, pharmacists, anesthesia/interventional pain specialists, advanced practice professionals, psychiatry, massage therapists, nutritionists and members of the rehabilitation services team. Members of the interdisciplinary team must have special skills and experience in communication, symptom management, psychosocial and spiritual assessment, hospice care, transitions in care, and discharge planning. They should also have institutional respect and be able to generate confidence quickly to ensure the program is successful.
Q: Why are you such a strong advocate of this approach to care delivery?
A: In my previous position as a hospitalist attending physician in a tertiary medical center, I saw many patients with life-limiting illnesses bounce between the hospital, nursing care facility and home settings. These patients experienced significant physical symptoms and psychological issues that remained unaddressed. Given the nature of hospitalist medicine and academic medical centers, these patients often were admitted to different physicians over the course of the year, leaving the patients with fragmented care plans and no one who could assess and treat symptoms over time. More importantly, the admissions often represented times of medical crisis for the patients and their families; times not well-suited to identifying and translating patient goals and values into a treatment plan.
During my palliative care training at Dana Farber, I was able to see the immense positive impact our inpatient and then, as we implemented it, outpatient programs, had on these patients and their families. Because we were able to meet them before they reached a crisis and could assess their goals and values at that time, we were able to help guide decision-making when difficult decisions were needed. Patients and their families trusted us, and we were better able to assess and improve symptom management because we had a baseline understanding of the patient, who they were outside of their illness and what was important to them.
Q: What role will a community hospital like Good Samaritan Medical Center play in shaping the future of palliative care in the next five to 10 years?
A: Our patient population is aging. Factors such as the increase in the prevalence of chronic diseases and the improvement in the five-year survival for many types of cancers will create a demand from significantly more patients with palliative care needs. As a community hospital where patients can be close to home and loved ones, Good Samaritan is well-positioned to support and grow palliative care programs to both provide these services directly to patients and their families, and, more importantly, to educate clinicians throughout the community on how to provide some basic palliative care services on their own.
Q: Please describe the benefits of palliative care for both patients and their loved ones.
A: A recent, well-publicized study by Jennifer Temel, M.D., et al. at Massachusetts General Hospital found that of 151 patients with metastatic nonsmall-cell lung cancer, patients assigned to early palliative care had a better quality of life (based on the FACT-L scale), less depressive symptoms and most surprisingly, despite less aggressive end-of-life care (chemotherapy), median survival was almost three months longer than for patients receiving standard care (11.6 months vs. 8.9 months, P=0.02). Research aside, as a palliative care practitioner, I see the following as key benefits of our specialty:
- Treating pain and other symptoms to optimize daily quality of life
- Actively listening and facilitating conversations over the course of time with patients and their families to ensure we all understand and agree on health states the patients would find untenable, current goals of care and what’s important for patients and their families to accomplish
- Improving understanding of what to expect in the future, providing practical recommendations and caregiver support
- As needed, coordinating care amongst numerous specialists
- Helping patients and their families navigate end-of-life decisions, make necessary plans and ensure needed advance care planning documents are completed
- Providing bereavement support to a patients’ families after their deaths
Q: With an aging population of baby boomers, what has to happen now in the field of medicine to ensure proper palliative care measures will be in place to handle the demands on health care in the coming years?
A: Many residency directors have realized the importance of training their physicians in basic palliative care skills such as pain management and patient communication. Even some surgical training programs, such as gynecologic oncology, have started to require palliative care blocks for their fellows. In addition to basic skills, there are now more than 80 palliative care fellowships with more than 210 fellows graduating each year. Most of these programs are for physicians with internal medicine, family medicine and pediatric backgrounds; however, programs for graduates of many other clinical programs — such as physical medicine and rehabilitation, psychiatry, neurology, anesthesiology, and surgery — have also been created.
According to the American Hospital Association Annual Hospital Survey, as of 2008, there were almost 1,500 palliative care programs in the United States, and many of these programs have since expanded their patient populations and expanded to outpatient areas. Even with all these graduates and a wide array of physician assistants and nurse practitioners working in the field, I believe we will be very short staffed in palliative care in the upcoming decade.
Q: What wisdom from past practices of palliative care will become part of the fabric of palliative care of the future?
A: My hope is that palliative care will become part of the initial care plan of every patient diagnosed with a potentially life-limiting illness. As palliative care is introduced to the clinical infrastructure, patients will have improved quality of life. This will occur because clinicians treating the patient will have a more intimate and sophisticated understanding of the patient’s goals and values. Palliative care experts can provide guidance and options for patients’ treatment choices to ultimately reduce their symptom burdens. In the end, we will give our patients and their families the tools and information they need to make decisions and enable them to better satisfy their own goals of care.
- Temel JS et al. Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer New England Journal of Medicine 2010;363:733-42.
MD News Future of Health Care 2011, Greater Boston