Palliative Care: Connecting The Dots Between Home Care and Hospice

Posted on | May 10, 2014 | 2 Comments

Mike Magee

In recent years I have frequently written about and discussed the need for a “parallel build-out” in order to achieve truly preventative care in the United States.(1) This refers to the challenge on the one hand of better managing our current burden of chronic disease in mostly older Americans, while at the same time creating a new infrastructure for prevention based on home-based, multi-generational lifespan health planning. “Care” and “planning” are the key words in this challenge. How can we make these two worlds intersect?

A smart first step would be to follow the lead and wise insights of this nation’s palliative care movement. Palliative care focuses on supporting the needs of individuals with complex chronic diseases with a goal of maintaining maximum quality of life, productivity and avoidance of hospitalization, isolation and despair. By 2030, a fifth of the U.S. population will be over 65, and many will face the challenges of managing one or more chronic illnesses for a significant number of years, including physical and psychological distress, functional dependency and frailty, and a need for support.

Our traditional care systems, based as they are in curing illnesses and prolonging life, are not particularly well equipped for this situation. There is very little emphasis on continuity of care that would harness the full resources of individual, family and community.

But the palliative care movement addresses this concern. Palliative care is as much a life philosophy and value position as it is a caring revolution – emphasizing an extraordinarily inclusive team effort between care providers, patients and families. The high-level goals of improved quality of life and relief from suffering are achieved through a wise mix of “care” and “planning.” Recent studies confirm that this approach increases quality, decreases depression, and increases life span as well. (2)

How would a focus on palliative care benefit the build-out of a preventive, home-centered health care model? Consider the checklist below – which offers a wish-list for a reformed health care system. Then consider this: Palliative care already incorporates each of these five critical elements (3):

Patients should be able to voice their personal needs and define their long-term and short-term goals.
Evaluation should be thorough on the front end and take into account what patients define as excellent outcomes.
Team approaches should be utilized, and the home serve, as much as possible, as the center of care.
Care should be well planned, based on these expectations, and discussions should be summarized in a formal planning directive, leaving little to chance.
Trusted home health managers, both formal and informal, should be identified, and integrated into the health care team.

Were we to embrace the palliative care approach in a reformed health care system, what would we find? More joy and pleasure; less pain and worry; less hospitalization; fewer nursing home placements; greater patient and family satisfaction; greater caregiver health and well being, and, in the end, a greater likelihood of a life lived to its full human potential.

For Health Commentary, I’m Mike Magee

References:

1. Magee M. Home-Centered Health Care. 2007. Spencer Books. NY, NY

2. Termei JS et al. Early Palliative For Patients With Metastatic Non-Small Cell Lung Cancer. NEJM. 2010; 363:733-742. http://www.nejm.org/doi/full/10.1056/NEJMoa1000678

3. Caring Connections. National Hospice and Palliative Care Organization.http://www.nhpco.org/i4a/pages/index.cfm?pageid=3254

Comments

2 Responses to “Palliative Care: Connecting The Dots Between Home Care and Hospice”

Richard Heimburger, M.D., FACS
May 10th, 2011 @ 12:04 pm

Medical professionalism has historically and traditionally been defined by ethics, most notably by the Hippocratic Oath and others as applied by physicians, but it has been significantly modified in recent years and not strictly applied. “Health Professionals” are a much wider field including nurses, therapists, psychologists, etc., who have set their own standards. Lawyers are also professionals who have their own standards. Physicians are united with other Health Professionals but should they all have the same ethical standards?
I have practiced surgery in V.A., and several university hospitals, private hospitals, and in several developing countries which all have their own rules and regulation, with slightly different ideas about professionalism and ethics. Are we to fit everyone in the same mold?
I think one of the advantages of the American Health system or “non-system” is that we have many different systems with their own methodology and standards developed by their own unique circumstances, ethics, and talents. We have spent many years and efforts trying to bring them all together and just trying to communicate with each other is imperfect.
Is the glass half empty or half full. Why are we spending so much time on our differences when we could better spend our time celebrating our accomplishments and what we agree on. We still do not agree on what “health care” is and what are the limits.
It is more than just absence of disease.

Richard A. Heimburger, M.D., FACS
Mike Magee
May 19th, 2011 @ 4:07 pm

Richard-

Thanks for your valuable insights on Medical Professionalism. Last year, as we were constructing a curriculum on “Advanced Professionalism” (see Collections), we founded as you suggest, significant differences in opinion. Some emphasized the differences in an attempt to analyze where the variability existed, presuming that variability equaled a problem versus a different approach to a solution.

Thomas Enui, in his classic 2002 AAMC paper “A Flag In The Wind” saw the inward questioning as a fundamental element of professionalism. In his words, “The processes of formation include experience and reflection, service, growth in knowledge of self and of the field, and constant attention to the inner life as well as the life of action. ‘Who am I becoming as I move towards this life of service?’ is a critical question in formation, as disciplinary acculturation and expertise increases. Acknowledging that the educational process in medicine changes – in some substantive sense – who we are as well as how we relate to others, may be the key to understanding why we need to be mindful, articulate, and reflective about the process.”

So perhaps, we are not so much over-identifying with our differences, as we are attempting to adjust to the changing needs and demands of the patients, families and communities we serve.

Mike