Tuesday, December 16, 2014

Palliative Care is a Win Win for Everyone

It's hard to believe that I was never really taught about how to control pain when I was in medical training.  Well that's not quite true.  I was told to avoid getting patients "hooked" on narcotics and this was certainly drilled into nurse training also.  We learned about disease and disease processes, but not about a holistic view of the patient in their social milieu.

Partly because of this, and our funding mechanisms, medicare and insurance companies organized to pay for disease care - especially procedures.  Procedures are easy to count and easier to control than "soft" care such as a doctor spending 30 minutes trying to sort out a confusing medical condition.  The "procedure based" specialists like radiologists, orthopedists, ophthamologists, gastroenterologists, and cardiologists do disproportionately well historically playing by established reimbursement rules, even though the procedures may be over-utilized.  Costs soar.

Finally we're beginning to look at global costs related to uncoordinated care, poverty, cultural barriers, etc.  The Institute of Medicine (IOM) has a key report on "Dying in America".  This report from the Center to Advance Palliative Care highlights the current changes in health care delivery under Medicare and Obamacare.  It's a must read.  The needed changes appear to be gaining traction.

1 comment:

  1. I just was involved in making the switch to official "palliative care" for an uncle who has multiple chronic conditions - no one alone looking like an imminent death threat - but combined with dementia, making any sort of intense intervention more of a threat than a promise. He hadn't prepared any papers beforehand to make his choices known. At a recent hospitalization after a terrible fall (brain bleed, broken ribs, lacerated liver, then pneumothorax, ...) it was clear that - in the hospital - a regional medical center - there were different specialists . assigned to look at each "part" but not even the "hospitalist" ( who seemed low on the hierarchy) would step back to draw together multiple areas of functioning to see that he was wasting away, and had been before the nearly catastrophic fall. After a brief {2 hour) bounce-back, a couple of other Drs. did pick up on the question of a palliative approach. But it was clear that without someone standing there asking questions about the goal and direction of care, considering his mental status -- every bit as much a physical health issue as the other conditions, it would be overlooked. Inserting an enteral feeding tube would have been done almost as a matter of course without letting them all know this was not a good permanent solution for someone with dementia.

    I think that with the old - old who have some level of dementia, there should almost always be a geriatric psych or just a geriatrician's consult, because otherwise the most obvious problem in someone's life can be "overlooked" as medical staff look to fixing one or another problem.