Palliative Care and Consulting Palliative Care

AJ Winer

What is palliative care?

Palliative care is a specialty focused on supporting the best quality of life for pts facing serious illness. 

Palliative care aims to relieve suffering for pts of all stages of disease, whether the aim of treatment is cure, life prolongation, or maximizing quality of life. 

While palliative care does specialize in hospice care, the two have distinct approaches to pt care as described below.

How is palliative care different than hospice care?

  • Stage of Illness
    • Whereas hospice provides care and support to a patient with a prognosis of 6 months or less, palliative care helps pts at any stage of disease and is not limited by prognosis.
  • Treatment Intent
    • Hospice care focuses on symptom control, quality of life, and transitioning with end-of-life care for patients with terminal illness. In contrast, palliative care is a supplement to current treatments; it can help patients who are receiving curative or life-prolonging treatment.
  • Treatment team
    • For hospice care, a hospice physician and associated care team provide a patient's medical treatment. Palliative care, on the other hand, is provided in conjunction with a patient's primary physician and specialists.

In what ways can palliative care help?

  • Symptoms
    • Palliative care can assist patients with serious illness who have severe, uncontrolled, or complex symptoms (pain, dyspnea, nausea, constipation).
  • Communication
    • Palliative care can help communicate big picture discussions.
  • Disposition
    • Palliative care can help with setting up hospice care or following up in outpatient palliative care clinic. Palliative care can also help transfer a patient to the palliative care unit (PCU).

When are appropriate times to consult palliative inpatient (vs outpatient referral)?

Not all patients with end-stage illness (i.e. new metastatic cancer diagnosis) require inpatient palliative care consultation. If a patient is likely to discharge from the hospital, and their symptoms are adequately controlled, an outpatient consult may be most appropriate. 

Not all patients discharging with hospice care require palliative care consultation. Below are examples of encounters that may warrant consideration of an inpatient consult:

  • Patient with complex symptoms that are Inadequately controlled (ex: patient on suboxone in pain crisis, patient who has malignant SBO with uncontrolled nausea)
  • Complex psychosocial and/or family dynamics (Insufficient family support or complex family dynamics that may Impact a patient's care)
  • Hospice care with complex needs (patient with NG tube to suction, above scenarios)

How do I introduce palliative care to a patient?

When considering Involving palliative care to a patient, It Is Important to recognize that not all patients/families are aware of palliative care. Of those who have heard of It, some patients may initially have a negative Impression due to false misconceptions (i.e. inaccurately equating palliative care with hospice care, believing I will interfere with current therapy. When introducing palliative care, it can be helpful to ask a patient If they have heard of It and what their understanding is.

  • Example: Ms. Smith, 78yoF with severe COPD (compliant with therapy) presents from SNF for a 3rd exacerbation in 6 months. She weaned from BIPAP and her oxygen requirement and work of breathing have stabilized. She is full code. Your team discussed code status, but she Is conflicted about "not doing everything" and wants to remain full code. She is frustrated by her recurrent hospitalizations and wants to maximize time outside the hospital. Your team wants to consult palliative care for a goals of care discussion.
    • "Ms. Smith, the last 6 months sound so challenging. Despite taking your medications, we're concerned that your COPD may be worse." - "That's what I figured. I'm tired of being in the hospital every other month."
    • "We think It may be a good Idea to introduce you to our palliative care team. Have you heard of palliative care before?" - "Is that for people with 6 months to live? I don't want that. I heard you have to stop some of your medications, and I want to use my inhalers."
    • "You might be thinking of hospice care. Palliative care is similar in that it aims to reduce suffering and maximize quality of life. It Is a specialty just like pulmonology and helps support patients with serious Illnesses like COPD. We often Involve them to support someone with a chronic Illness who has been hospitalized multiple times. They can help with managing symptoms and coming up with a plan for what interventions you would want If you were to become sicker. Think of them as an 'extra layer of support.' You do not have to stop any of your medications. I really think having the palliative care team will help us manage your care better." - Yes, I would like to speak with them!"
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