How hospitalists can avoid common pitfalls of palliative care

July 2005

Published in the July 2005 issue of Today’s Hospitalist.

If you think you’re up to speed on palliative care because you’ve kept current on the latest and greatest medications to manage severe pain in critically ill and dying patients, Charles von Gunten, MD, PhD, has a message for you: You’re probably seeing only half the picture.

Dr. von Gunten, a palliative care expert who is associate clinical professor of medicine at the University of California, San Diego, and director of the Center for Palliative Studies at San Diego Hospice and Palliative Care, says that controlling pain in these patients is only the beginning. Neglect the emotional, practical and spiritual aspects of your patient’s suffering, he explains, and you’re falling short of true palliative care.

Understanding the basics

Dr. von Gunten, who will speak on palliative care at the Fall 2005 Hospitalist CME Series in September, talked to Today’s Hospitalist about some of the challenges that hospitalists face when it comes to palliative care. (For more information on the meeting series, go online)

If your hospital has a palliative medicine service, you don’t necessarily need to become an expert in the field. Nevertheless, Dr. von Gunten says, it behooves you to understand some of the basics of palliative care. If nothing else, Dr. von Gunten explains, it will give you a grasp of when to call for a palliative care consult. “When symptoms don’t come into line,” he adds, “you need a consult. But you need to know how to structure conversations with patients and families about highly emotional topics.”

The problem-oriented approach

All too often, Dr. von Gunten adds, hospitalists’ training gets in the way of providing effective palliative care. The problem oriented method of caring for complex, very sick patients may help devise a treatment strategy that provides an itemized action list, but the major issue may become lost in the list.

He gives a not atypical case of a 68-year-old woman admitted to the hospital with fever and hyperglycemia. She has a long history of hypertension, coronary artery disease, diabetes, renal insufficiency and non-healing diabetic foot ulcers, and she has had several bypass operations.

Apply a typical problem-oriented method to this patient, he says, and you’ll tackle each problem sequentially, taking a “fix-it” attitude. In such a complex patient, however, that approach may get the patient out of the hospital, but it may not lead to a plan that will “stick” with the patient after discharge. As a result, the plan will more often than not fail.

For one, this method doesn’t allow the physician to pause and ask some basic, yet critical, questions: What does the patient and her family members think of the condition, and what are their goals?

Perhaps even more importantly, it implies that if all the patients’ problems aren’t “fixed,” the physician has somehow failed.

The palliative care approach

A palliative care approach, by contrast, would start by asking the patient what she understands about her health and about her goals. The physician might step back and ask the patient what she is trying to achieve with the patient. Only after gathering some basic information, Dr. von Gunten says, would she come up with a treatment plan.

This approach brings the patient into the decision-making process, a factor that almost always leads to higher patient and family satisfaction and adherence. If the patient cannot adhere to an ADA diet, for example, it makes no sense to adjust her insulin doses to a hospital-based ADA diet that will change at discharge.

Dr. von Gunten adds that while a goal like “allowing natural death to happen” is perfectly reasonable, it is never a consideration in the traditional problem-oriented method. “Death is always viewed as an implied failure of the problem-oriented method.” Here are some pitfalls Dr. von Gunten says hospitalists who aren’t conversant in palliative care should try to avoid.

1. Assuming that nothing else can be done. In a common scenario, the patient has significant unrelieved pain, even after the hospitalist has tried everything he knows and prescribed high doses of painkillers. Instead of assuming that there is nothing else to be done with this patient, Dr. von Gunten says, you should call for a consult from a palliative care or pain team. If such a service is not available, he suggests calling the medical director of your local hospice for help.

2. Saying “We’ve never done that before.” Dr. von Gunten gives a potentially exhaustive list of “never haves” that might fit into this category of pitfall. Common problems include the following:

  • Disagreeing with a recommendation to give a medication orally, subcutaneously or rectally because it’s not the usual route.
  • Assuming that certain combinations of medications are not OK under any circumstances, even imminent death.
  • Avoiding a medication simply because “it can only be used in the ICU.”
  • Dismissing a patient’s request to see a cherished pet because “we don’t permit pets in this hospital.”

Dr. von Gunten says that if you’re not sure whether a request is allowed “or if there’s no good reason why something shouldn’t be allowed, like seeing a cherished pet “you as a hospitalist should advocate on the patient’s behalf.

3. Undervaluing other hospital staff. While most hospitalists pride themselves on their ability to work closely with nurses and therapists, those traditional working relationships often need a tune-up to function in the palliative-care setting.

Besides talking to nurses “and actually listening to them about what they see,” Dr. von Gunten recommends that hospitalists enlist the help or input of dieticians and even the housekeeping staff. He says that housekeepers, for example, often have important insight into why a patient or family member is resisting a treatment recommendation such as withdrawing mechanical ventilation. “Patients and families often tell housekeepers things they don’t tell anyone else,” he explains.

4. Waiting to “call in the troops.” Too many physicians aren’t aware of resources like chaplains and social workers that can help address tough issues.

“And many physicians think that social workers are only about discharge planning “but that’s not true,” Dr. von Gunten says. “They’re very good in family systems assessments and interventions. So call on them and say, ‘I need help.’ ”

Bonnie Darves is a freelance writer specializing in health care. She is based in Lake Oswego, Ore.