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The promise and pitfalls of palliative care

Forming teams that can help the chronically or terminally ill has show tremendous benefit and is a growing field. But questions, mostly about costs, remain.

October 24, 2011|By Melissa Healy, Los Angeles Times
  • Providing comfort, emotional support and coordination of specialized care used to be the job of the family physician.
Providing comfort, emotional support and coordination of specialized… (Valentin Casarsa / Getty…)

What if a new medication for severely ill patients had no role in curing them but made them feel much better despite being sick? Let's say this elixir were found to decrease the pain and nausea of cancer patients, improve the sleep and energy of heart failure patients, prolong the lives of people with kidney failure, drive down healthcare expenditures and ease the burdens of caregivers?

Those are the promises of a fledgling medical specialty called palliative care — not a new drug but a new way of treating patients who are living, often for years, with acute or chronic Illnesses that are life-threatening.

If palliative care were a pill, government regulators would very likely approve it for the U.S. market. Federal healthcare insurance programs would quickly agree to pay physicians and hospitals for treating patients with the new therapy. And patients would make it a blockbuster drug in no time flat.

Yet uncertainties cloud the prospects for palliative care. Among the unanswered questions: Who will pay for these services, where will this new field's workforce come from, and what is it — cost savings or compassion — that drives this new branch of medicine?

As answers to those questions emerge in the next few years, palliative care could end up on the roadside of medical progress. Or it could become a must-have service for every hospital and physicians' group claiming to deliver top-quality patient care.

Providing comfort, emotional support and coordination of specialized care used to be the job of the family physician. But few families these days have a longstanding relationship with a single physician, and even fewer doctors have the expertise or time, while trying to cure a very ill patient, to coordinate his care and tend to his physical and psychological distress.

Growing quickly over the last few years, the field of palliative medicine has begun to step into this breach.

Since 2000, the number of hospital-based palliative care programs has more than doubled, according to a report issued late last month by the Center to Advance Palliative Care and the National Palliative Care Research Center, organizations that have been active in supporting the field's growth. Today, professional teams tasked with ensuring that patients' symptoms are managed, their medical options are clearly explained and their wishes are respected are available in roughly 63% of the nation's hospitals.

The discipline, says Dr. Diane E. Meier, who directs the Center to Advance Palliative Care, "is the necessary counterbalance to a highly specialized system of medicine in which many of our patients' needs are falling through the cracks. Palliative care. Meier adds, "is needed to focus on the whole person in the context of their family — on everything from pain to spiritual needs."

For Dr. Marwa Kilani, director of palliative care at Providence Holy Cross Hospital in Mission Hills, this new branch of medicine is about adding life to patients' years, rather than years to their lives.

"I tend to think that I don't prolong peoples' lives in the sense that I don't deliver the curative medicine; I deliver the quality-of-life medicine — and if that does prolong a person's life, that's wonderful," says Kilani, whose team has been operating since 2006 and has seen 500 new patients so far this year. "I discuss what options patients have, and if a patient says, 'This sounds like the right course for me and my values,' I'm there to support that."

Palliative care is designed to be delivered by teams of physicians, nurses, social workers and chaplains. But instead of treating the condition that threatens to shorten a patient's life, palliative care professionals treat the pain, weakness, worry and decision-making pressure that come with the illness and medicine's often-aggressive efforts to treat it.

The movement to provide such care has sprung up alongside the nation's burgeoning hospice care sector. But though hospice and palliative care share many of the same workforce, goals, patients and expertise, there are two key differences:

First, to gain access to palliative care, patients need not have six months or less to live — the current condition under which hospice care is paid for by Medicare and Medicaid.

Second, patients in palliative care get full support if they wish to pursue any and all efforts to cure their disease — whereas to access hospice care, patient and doctor must have agreed that further "curative therapy" will not be pursued.

In other words, "All hospice care is palliative care, but not all palliative care is hospice," says Dr. Rick Levene, a palliative care specialist at Spectrum Health Care Inc. in West Palm Beach, Fla.

Ideally, a palliative care team would swoop in shortly after a patient's diagnosis, explaining medical options, ensuring patient and family have a treatment plan, and standing by to manage the stress and discomforts ahead.

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