By James Borders, MD
In my inaugural address, I lamented the fact that, in America, we are culturally slow to recognize and accept death as a normal part of life. Because of this, we often administer uncomfortable, dehumanizing, and expensive counter-measures to avoid death despite times when a patient’s comorbidities and overall downhill health trajectory should be obvious to the treatment team. The large number of very elderly or chronically ill patients admitted to the hospital with no advance directives supports this assertion. A very recent article published in the Journal of Palliative Medicine detailed research on 356 adults over age 65 to identify the prevalence of what is referred to as the “treatment burden” during the last three years of life. Treatment burden is defined as the difficulties arising when the treatment workload overwhelms one’s ability to take on treatment activities at the end of life. Based upon this definition of this cohort of patients with multiple chronic conditions, 43% had treatment burden, with some evidence to suggest that the likelihood was increased if one belonged to a racial minority, had cancer, or suffered from depression or anxiety.
Not only are unnecessary or futile interventions and the associated suffering imposed on such patients, the potential benefits of palliative care both on suffering and cost are often lost. Palliative care is the interdisciplinary specialty that focuses upon improving quality of life in patients with advanced illness. An article in the Archives of Internal Medicine several years ago looked at the cost of care for hospital inpatients when palliative care services were consulted. One group of nearly 3,000 patients with advanced illness who were discharged alive was randomized into two cohorts- one receiving “usual care” and another palliative care. Another group of over 2,000 patients who ultimately died in the hospital was similarly randomized to “usual care” or palliative care. Although the study was performed several years ago, the cost difference even in today’s dollars was striking- with the average direct cost savings for those discharged alive of $1,696 and those expiring of $4,908.
One could argue that any patient ill enough to qualify for inpatient hospital care these days is a likely candidate for palliative care. Beyond cost savings, the benefits of palliative care on a patient’s physical and psychological well-being, caregiver well-being, and family satisfaction are well proven. Palliative care teams can initiate or support communication regarding goals of care, care transitions, and advance care directives.
As is true for hospice care, palliative care services are often considered long after needless suffering has been experienced by the patient and family. A trained palliative care team possesses a special skill set in comfort treatment strategies and related communication and has more to offer patients and families than many physicians realize. Even when advance directives are available, many physicians tend to take stated preferences at face value, failing to realize the changing complexities that underlie decision making and the need for frequent re-assessment. Beyond clarifying advance directives, an effective palliative care management program has been demonstrated to maintain focus upon responding to patient and family emotions and care goals and less on treatment specifics.
The good news that can with rare exception be offered to any patient resigned to imminent demise is the assurance of effective comfort measures. Let us never fail to offer those as soon as they can be justified.
James Borders, M.D.