EXECUTIVE SUMMARY
A new palliative care policy statement aims to reduce barriers that prevent many patients from receiving palliative care. One problem is that few hospital palliative care programs meet national staffing recommendations, found a recent study. Bioethicists can do the following:
- Promote policy for training to expand the number of healthcare providers who can deliver high-quality palliative care.
- Recommend policies supporting use of “trigger” tools and screening to identify high-need patients.
- Advocate for the integration of comprehensive palliative care as part of the emerging value-based healthcare delivery models.
A new palliative care policy statement from a leading heart and stroke organization aims to reduce barriers that prevent many patients from receiving palliative care.1
“Ethicists play a central role in addressing distributive justice and equitable access to the highest-quality and evidence-based care,” says Diane E. Meier, MD, director of the Center to Advance Palliative Care in New York City.
Meier says ethicists should advocate for standardized access to palliative care, with the use of “trigger” tools and screening to identify high-need patients who will benefit from these services. “That would be a powerful and needed lever to get our health system to match the care we deliver with what seriously ill patients and their families say is most important to them,” she says.
The statement, issued by the American Heart Association/American Stroke Association, makes the following recommendations:
- federal and state agencies should reimburse for palliative care services,
- payers and providers should share data to identify patients in need of palliative care,
- healthcare systems should develop policies for palliative care during hospitalizations, and
- training should be improved to expand the number of healthcare providers who can deliver high-quality palliative care.
Few hospital palliative care programs meet national staffing recommendations, according to a recent study.2 The findings reflect the fact that palliative care is a relatively new field and clinical service, according to Meier, one of the study’s authors. “As with any transformation, adoption and implementation are variable across the country,” she says.
There are currently no requirements from The Joint Commission, the nation’s dominant accrediting body for hospitals, either to provide palliative care, or to ensure that palliative care provided meets national quality guidelines.
“Given the strong evidence of benefit to seriously ill patients and their families, this needs to change,” says Meier.
The quality of care received by seriously ill patients should not depend on where they live, or whether their doctor understands the value of palliative care, says Meier. “The ethical principles of beneficence, self-determination, and distributive justice are, in palliative care — as in so many other elements of our healthcare system — not honored,” she says.
Joanne Spetz, PhD, FAAN, the study’s lead author and professor at the Philip R. Lee Institute for Health Policy Studies at University of California, San Francisco, expected to find that many programs did not meet national staffing guidelines. “But we were surprised at the degree to which this was true,” she says.
The researchers were also surprised by how many programs that participate in the National Palliative Care Registry are led by nurses. “We know that nurses are an integral part of nearly every palliative care program,” says Spetz. “But we were surprised to find many without a paid physician, NP, or PA on the team.” (For more information on the registry, visit: https://registry.capc.org.)
Few Patients Get Consult
Palliative care is known to lead to better patient outcomes and lower costs.3 “But more importantly, it is an approach to care that focuses on the overall well-being of the patient,” says Spetz. This is true regardless of whether the patient is aggressively pursuing treatment and expected to recover, or approaching the end of life, she says.
A small minority of hospitalized patients ever receives a palliative care consultation, however. This is the case even in hospitals with defined palliative care programs.
“Stretching the workforce this thin clearly means that patients in need are not getting the guidance they need,” says Spetz. Patients end up being “overtreated” for some things and “undertreated” for others.
Because of understaffing, “providers in palliative care also face important burnout issues, with rates being relatively high,” says Spetz.
Salimah H. Meghani, PhD, MBE, RN, FAAN, an associate professor at University of Pennsylvania, believes the success of many palliative care policy recommendations hinges on “both the buy-in and the uptake by clinicians and other stakeholders.”
Even clarifying basic differences between hospice and palliative care to clinicians remains challenging, notes Meghani. “Ethicists can work with administrators and clinicians to develop interventions for the uptake of palliative care at the institutional or community levels,” she suggests.
Bioethicists can also advocate for the integration of comprehensive palliative care as part of the emerging value-based healthcare delivery models. “It is important to do it right at the level of conceptualizing and designing these value-based programs,” Meghani says.
REFERENCES
- Braun LT, Grady KL, Kutner JS, et al. Palliative care and cardiovascular disease and stroke: A policy statement from the American Heart Association/American Stroke Association. Circulation. 2016; 134(11):e198-225.
- Spetz J, Dudley N, Trupin L, et al. Few hospital palliative care programs meet national staffing recommendations. Health Aff 2016; 35(9):1690-1697.
- National Palliative Care Registry. Research in the Field. http://bit.ly/208Pkex.
SOURCES
- Salimah H. Meghani, PhD, MBE, RN, FAAN, Associate Professor, University of Pennsylvania School of Nursing, Philadelphia. Phone: (215) 573-7128. Fax: (215) 573-7507. Email: [email protected].
- Diane E. Meier, MD, Director, Center to Advance Palliative Care, New York City. Phone: (212) 201-2673. Email: [email protected].
- Joanne Spetz, PhD, FAAN, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco. Phone: (415) 502-4443. Email: [email protected].
