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March 10, 2015 - Kim Moore [see other posts]

Caring

When Cures Are Insufficient

I was privileged to hear Dr. Donna Meier at our annual Grantmakers in Health conference last week. She is the director of the Center to Advance Palliative Care (www.capc.org). From the experiences of the Health Ministry Fund in successfully promoting the spread of Medicare certified hospices across Kansas more than 20 years ago, I came to her presentation expecting to get confirmation of much I already knew. Instead, she improved and changed my understanding of palliative care as a major force in bringing healing with quality into our health care system for many consumers and their families.

First, let me provide the CAPC's explanation of palliative care: "It focuses on providing relief from the symptoms and stress of a serious illness--whatever the diagnosis. The goal is to improve quality of life for both the patient and the family." [emphases mine] Notice that the impact is not on eradication of a particular illness but rather the betterment of the patient's and related caregivers' quality of life. I expected that palliative care was utilized when active curative treatment had stopped, as in the case of hospice patients, but that is far from the full application today. Palliative care is a form of medical practice used contemporaneously with curative medicine when there is serious and chronic illness. It enhances the medical curative interventions by controlling pain, managing symptoms and reducing stressors and other pressures.

Palliative medicine asks "what matters to patients?" instead of "what is the matter with them?" When questions like these are asked of patients with serious, chronic illnesses, they as a group respond in this order: 1) keep me independent, 2) provide me pain and symptom relief, and 3) keep me alive. Dr. Meier gave convincing evidence that end of life care per se is not the sponge of health care expenses that I had believed. Although three-fourths of Medicare beneficiaries are in the emergency room at least once in the last six months of life, the costliest 5% of patients (using at least one-half of all health care system resources in America) can be described as:

11% in last 12 months of life;
49% with one-time high spending; and
40% with persistent high costs year after year (functional impairment, frailty, dementia, exhausted family caregivers, and serious illness. In fact, Dr. Meier explained that 50% of high risk patients have dementia and/or advanced frailty.)

The latter group is the new target for palliative care today.

One example of a palliative care intervention provided by Dr. Meier involved a patient with spinal stenosis and growing dementia. The elderly man, cared for by his aging wife, had fallen into a cycle of frequent emergency room visits and hospitalizations caused by a worn-out caregiver lacking any help with her husband's functional problems and unmanageable pain. The palliative care team used appropriate aggressive pain management, symptom relievers (including over-the-counter products), environmental alterations, and the full range of available social services to improve the circumstances for the patient and caregiver. The hospitalizations have stopped for more than two years and a relatively stable situation has ensued.

Palliative care treats the person beyond the disease. Strong palliative care teams are available 24/7 and spend a great deal of time listening to patients and caregivers. Many times, interventions include Meals on Wheels; a visiting nurse or doctor; a friendly visitor giving time away for a caregiver; small home improvements permitting easier bathing, toileting, etc.; and spiritual care. This combination of medical treatment and social work has been shown through repeated evidence to prolong life! It does this by reducing stress (a killer in many ways), reducing hospital admissions and the associated dangers of that environment (hospital-acquired infections, for example) and reducing depression. The Institute of Medicine has issued EIGHT reports on palliative care urging greater adoption to save lives, save money and improve the value of health care. See Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life, Institute of Medicine, September 2014.

You can get a better understanding of Dr. Meier's presentation at our Grantmakers in Health Conference by checking the GIH website.

We need to be demanding more availability of this branch of medicine for ourselves and our loved ones to reduce costs and secure better meaningful outcomes.