October 17, 2013
By Frank Mueller, M.D.
Palliative care services help improve the quality of life of seriously ill patients, improve patient and family satisfaction, and reduce lengths of stay and readmission rates. Currently, there are active palliative care programs in more than 50 percent of United States hospitals – and the number is growing. Palliative care units could be in place in 84 percent of U.S. hospitals by next year. Palliative care programs are proving to be useful for helping patients and families while at the same time resulting in effective cost savings for the health care system. Medicaid patients who received palliative care incurred $6,900 less in hospital costs than matched controls receiving no palliative care.
The goal of palliative care, according to the Center to Advance Palliative Care (CAPC), is to match the patient’s goals of care with a medically effective treatment plan. Palliative care:Addresses the physical, emotional, spiritual and social concerns that arise with advanced illness.Is appropriate for patients in all stages of illness.Uses consultants who often co-manage patients in active, life-prolonging treatment along with oncologists and other specialists, taking an active role in relieving suffering and controlling symptoms.Helps prepare patients and families for the tough decisions that will face them and for the outcome that disease portends: the changes in performance status and quality of life, and in some cases, the specter of death from the illness.Emphasizes continued care when cure may no longer be possible.
Palliative care programs are associated with improved symptom control, increased family satisfaction and transitioning patients to the appropriate level of care. Several studies now show that patients receiving palliative care early in their illness lived longer and with better quality of life, including decreased depression.
One tool used in palliative care that helps to ensure that the patient’s wishes for care are followed is the Physician Orders for Life-Sustaining Treatment (POLST) form. POLST states what kind of medical treatment patients want toward the end of their lives, and is a document that, with the participation and signature of the physician, transforms the patient’s goals into a physician order. For patients who have been diagnosed with a terminal illness or who have less than one year to live, the POLST form is an appropriate way to record the patient’s wishes and goals of care in an immediately actionable physician order.
Here is an example of POLST at work in a palliative care setting. John, 73, has advanced COPD, and presented to the emergency room in respiratory failure. He is on day five in the ICU and on the ventilator for the fifth time, now with bilateral pneumonia, and is fully vent-dependent. Consent must be obtained for a tracheostomy. The intensivist and surgeon are ready to proceed but have asked the palliative care consultant to see John and his family. The consultant arrives, sedation is withheld, and John is alert. At the time of his last hospitalization, John’s doctor helped him to understand and fill out a POLST form. At the bedside family meeting, John’s wife tearfully reports that after his last time on the vent John told her “never again.” John hears this and confirms the decision he made in his POLST form for comfort measures only. The palliative care consultant counsels the family, talks with the intensivist and surgeon, and is able to assure them all that this is what John really wants. The consultant arranges for control of pain, anxiety and dyspnea, comforts the family and supports the staff while the withdrawal of life support protocol is carried out. Thirty minutes later, John dies peacefully and comfortably with his family at his side.
Palliative care and the POLST form combined can assure that a seriously ill patient’s wishes will be followed at the end of life and that they will get the care that they want and deserve.
The California Medical Association (CMA) publishes a POLST kit, available in English and Spanish, which includes legal forms and wallet identification cards, and answers many of the most frequently asked questions about end of life issues. These kits are available in CMA's online store.
For more information on palliative care and POLST, visit www.coalitionccc.org and www.capc.org.