1. Palliative Care in Hospitals:
Making the Case
Nathan Goldstein, MD
Associate Professor
Hertzberg Palliative Care Institute
Brookdale Department of Geriatrics and Palliative Medicine
Mount Sinai School of Medicine
James J. Peters Veterans Affairs Medical Center
Jewish Home Lifecare
11th Annual Palliative Care Conference
November 12, 2013

2. What are your objectives?
• What do you hope to get out of this
session?
• Do you have specific questions / topics
that you want addressed?

3. Learning Objectives
After attending this presentation, the learner will
be able to better understand:
• The definition of palliative care, and how it
differs from the traditional hospice model
• Explain four reasons why palliative care is
growing as a movement in the United States
• Define how palliative care is beneficial for
patients, clinicians, and hospitals

4. What is Palliative Care?
• Palliative care is specialized medical care for people with
serious illnesses whose goal is to improve quality of life
for both the patient and the family.
• Palliative care is provided by a team of doctors, nurses,
and other specialists who work with a patient's other
doctors to provide an added layer of support.
• Palliative care is appropriate at any age and at any stage
in a serious illness, and can be provided together with
curative and disease directed treatments

5. Consumer Knowledge of
Palliative Care

6. Mount Sinai Palliative Care Service
•
•
Team made up of:
• 4 Attending Physicians (pool of ~12)
• 4 Nurse Practitioners (pool of 5)
• 1 RN (triage nurse)
• 3 Social Workers
• 7 Fellows
• Chaplain
• Massage Therapist(s), Yoga Therapist, Art
Therapist, Music Therapist
• 2-3 Third Year Medical Students
• 1-2 Other Rotators
3 Consult services + inpatient unit

7. Palliative Care in Practice
• Expert control of pain and symptoms
• Uses the crisis of the hospitalization to
facilitate communication and decisions
about goals of care with patient and family
• Coordinates care and transitions across
fragmented medical system
• Provides practical support for family and
other caregivers (+ clinicians)

8. Ms. M
• 45 year old woman with metastatic breast
cancer
• Admitted with worsening neurological
symptoms – found to have brain mets
• Person calling in pall care consult:
• “She knows everything that’s going on we just
want to make sure she is comfortable.”
• Whoops…

9. The Cure - Care Model:
The Old System
Life
Prolonging
Care
Palliative/ D
E
Hospice
A
T
Care
H
Disease Progression

10. A New Vision of Care
Disease Modifying Therapy
curative or restorative intent
Life
Closure
Diagnosis
Palliative Care
Death &
Bereavement
Hospice

11. Palliative Care

12. Aug 19 2010;363(8):733-42.

13. Palliative Care
“Modern
Medicine”
Hospice

14. Palliative Care Is
 Excellent, evidencebased
medical treatment
 Vigorous care of
pain and symptoms
throughout illness
 Care that patients
want at the same time
as efforts to cure or
prolong life
Palliative Care Is NOT
Not “giving up” on a
patient
Not in place of
curative or lifeprolonging care
Not the same as
hospice or end-oflife care

15. Why is hospital palliative
care growing so rapidly in
the United States?

16. Hospital-based Palliative Care:
The 4 Main Arguments
1.
2.
3.
4.
Clinical Quality
Patient and Family Preferences
Demographics
Financial

17. Why palliative care?
1. The Clinical Imperative
The need for better quality of care for
people with serious and complex
illnesses.

18. Everybody with serious illness spends at least
some time in a hospital...
• 98% of Medicare decedents spent at least
some time in a hospital in the year before death.
• 15-55% of decedents had at least one stay in an
ICU in the 6 months before death. Average
length of stay in the ICU is 2-11 days.
Dartmouth Atlas of Health Care 1999 & 2006

19. Symptom Burden of Patients
Hospitalized With Serious Illness at 5
U.S. Academic Medical Centers
% of 5176 patients reporting moderate to severe
pain between days 8-12 of admission
Colon Cancer
Liver Failure
Lung Cancer
COPD
CHF
60%
60%
57%
44%
43%
Desbiens & Wu. JAGS 2000;48:S183-186.

20. ICU and intervention costs rising
prior to death
50%
45%
44.4%
39.8%
39.3%
40%
Barnato et al HSR April 2004
Trends in inpatient treatment intensity among Medicare
beneficiaries a the end of life
38.0%
35%
1985
1999
30.3%
30%
25%
20%
17.8%
15%
10%
Dying in hospital
ICU during last admit
Intensive proc during last admit

21. But ICU Care Decreases
Satisfaction
• Bereaved family members (n=778) of patients who died in regions
of highest vs. lowest ICU intensity deciles surveyed re quality of eol
care.
• Highest ICU use areas: Patients more likely to die in an ICU, be
transferred in last month, and their families believe that not enough
life sustaining treatment was given.
• Higher ICU care regions associated with family reports of:
• Inadequate emotional support
• Inadequate shared decision-making
• Inadequate information on what to expect
• Lack of respect
• Lower overall satisfaction
Teno et al. JAGS 2005;53:1905-11.

22. Why palliative care?
2. Concordance with patient and
family wishes
What is the impact of serious illness on patients’
families?
What do persons with serious illness say they
want from our healthcare system?

23. What Do Patients with Serious
Illness Want?
• Pain and symptom control
• Avoid inappropriate prolongation of
the dying process
• Achieve a sense of control
• Relieve burdens on family
• Strengthen relationships with
loved ones
Singer et al. JAMA 1999;281(2):163-168.

24. “Difficult” Conversations
Improve Outcomes
• Multisite, longitudinal study of 332 patient-family
dyads
• 37% of patients reported having prognosis
discussion at baseline
• These patients had lower use of aggressive
treatments, better quality of life, and longer
hospice stays
• Family after-death interviews showed better
psychological coping for those with
conversations as compared to those without
Wright et al. JAMA 2008 300(14):1665-1673.

25. What Do Family Caregivers Want?
Study of 475 family members 1-2 years after bereavement
•
•
•
•
•
•
•
•
•
•
Loved one’s wishes honored
Inclusion in decision processes
Support/assistance at home
Practical help (transportation, medicines, equipment)
Personal care needs (bathing, feeding, toileting)
Honest information
24/7 access
To be listened to
Privacy
To be remembered and contacted after the death
Tolle et al. Oregon report card.1999 www.ohsu.edu/ethics

26. Family Perspectives on Quality of
Hospice as the Last Place of Care
As compared to hospital, nursing home, and home
care, hospice care at home superior for
•
•
•
•
•
•
•
Pain
Emotional support
Contact with MD
Respect
Family support
Knowing what to expect
Overall quality
Hospice rated excellent by 71% vs. <50% at all other sites
Teno et al. JAMA 2004;291:88-93.

27. Families Want to Talk About Prognosis
• Qualitative interviews with 179 surrogate
decision makers of ICU patients
• 93% of surrogates felt that avoiding discussions
about prognosis is an unacceptable way to
maintain hope
• Information is essential to allow family members
to prepare emotionally and logistically for the
possibility of a patient's death.
• Other themes:
• moral aversion to the idea of false hope
• physicians have an obligation to discuss prognosis
• surrogates look to physicians primarily for truth and
seek hope elsewhere
Apatira et al. Ann Intern Med. 2008;149(12):861-8

28. Why palliative care?
3. The demographic imperative
Hospitals need palliative care to
effectively treat the growing number
of persons with serious, advanced
and complex illnesses.

29. Chronically Ill, Aging Population
Is Growing
• The number of people over age 85 will double to
10 million by the year 2030.
• The 23% of Medicare patients with >4 chronic
conditions account for 68% of all Medicare
spending.
• Hospice most comprehensive insurance program
to care for these older adults with chronic disease
-- Not without its limitations
US Census Bureau, CDC, 2003.
Anderson GF. NEJM 2005;353:305
CBO High Cost Medicare Beneficiaries May 2005.

30. Medicare Hospice Benefit
• Prognosis of 6 months or less if disease
follows its usual course
• Willingness to forego regular Medicare
services focused on life-prolongation or cure
for primary illness
• Does NOT mean patient has to die in 6
months or else you give up your license

31. Are we getting the message out to
patients and families about the
benefits of hospice?
NHPCO Facts and Figures, 2010
(using data from 2009)

32. The Reality of the Last Years of Life:
Death Is Not Predictable
Cancer
100
End-Stage Organ Failure
80
Function
90
Dementia (years)
70
60
50
40
30
20
10
0
Time
(slide adapted from Joanne Lynn, MD, Rand Health/CMS)

33. Why palliative care?
4. The fiscal imperative
Hospital and insurers of the future will
have to efficiently and effectively treat
serious and complex illness in order to
survive.

34. Healthcare Spending and Quality
U.S. leads the world in per capita spending
27th in life expectancy
37th in overall quality of healthcare system (WHO)
http://ucatlas.ucsc.edu/spend.php

35. How Palliative Care Reduces
Length of Stay and Cost
Palliative care:
• Clarifies goals of care with patients and
families
• Helps families to select medical treatments
and care settings that meet their goals
• Assists with decisions to leave the hospital, or
to withhold or withdraw treatments that don’t
help to meet their goals

36. Costs and Outcomes Associated with
Hospital Palliative Care Consultation
8-hospital study
Live Discharges
Costs
Total Per
Day
Usual
Care
Palliative
Care
Hospital Deaths
P
Usual
Care
Palliative
Care
P
$1,450
$1,171
<.001
$2,468
$1,918
<.001
Directs Per
Admission
$11,1240
$9,445
.004
$22,674
$17,765
.003
Laboratory
$1,227
$803
<.001
$2,765
$1,838
<.001
ICU
$7,096
$1,917
<.001
$15,542
$7,929
<.001
Pharmacy
$2,190
$2,001
.12
$5,625
$4,081
.04
Imaging
$890
$949
.52
$1,673
$1,540
.21
Died in ICU
X
X
X
18%
4% <.001
Adjusted results, n>20,000 patients
Morrison et al. Arch Internal Med. 2008. 168 (16).

37. 8 Hospital Study:
Costs/day for patients who died with palliative
care vs. matched usual care patients
Usual care
PC consult day 8-9
PC consult day 4-5
PC consult day 10-11
PC consult day 6-7
PC consult day 12-13
2000
Direct Cost ($)
1750
1500
1250
1000
750
500
250
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21
Day of Admission

38. Cost Savings – Medicaid in NY State
Cost savings/Day for Live Discharges
Morrison et al. Health Affairs 2011 30:454-63

39. What Does All this Mean from the
Patient Perspective?
For patients, palliative care is a key to:
•
•
•
•
•
relieve symptom distress
navigate a complex medical system
understand the plan of care
help coordinate and control care options
allow simultaneous palliation of suffering along
with continued disease treatments (no
requirement to give up life prolonging care)
• provide practical and emotional support for
exhausted family caregivers

40. What Does All this Mean from the
Clinician Perspective?
For clinicians, palliative care is a key tool to:
• Save time
help to handle repeated, intensive patient-family
communications, coordination of care across
settings, comprehensive discharge planning
• Provide Symptom Control
assists with controlling pain and distress for highly
symptomatic and complex patients, 24/7
-thus supporting clinician’s treatment plan
• Promote Satisfaction
increases patients’ and families’ satisfaction with the
quality of care provided by the clinician

41. What Does All this Mean from the
Hospital Perspective?
For hospitals, palliative care is a key tool to:
• effectively treat the growing number of people
with complex advanced illness
• provide excellent patient-centered care
• increase patient and family satisfaction
• improve staff satisfaction and retention
• meet accreditation and quality standards
• rationalize the use of scarce hospital resources
• increase bed/ICU capacity, reduce costs

42. Summary
• Palliative care improves quality of care for
our sickest and most vulnerable patients
and families.
• Serious illness is a universal human
experience and palliation is a universal
health professional obligation.