Pilot Program

Outcomes of Palliative Care Consults With Hospitalized Veterans

Fed Pract. 2018 September;35(9):44-47

References

1. El-Jawahri A, Greer JA, Temel JS. Does palliative care improve outcomes for patients with incurable illness? A review of the evidence. J Support Oncol. 2011;9(3):87-94.

2. Higginson IJ, Finlay I, Goodwin DM, et al. Do hospital-based palliative teams improve care for patients or families at the end of life? J Pain Symptom Manage. 2002;23(2):96-106.

3. Gade G, Venohr I, Conner D, et al. Impact of an inpatient palliative care team: a randomized control trial. J Palliat Med. 2008;11(2):180-190.

4. Benzar E, Hansen L, Kneitel AW, Fromme EK. Discharge planning for palliative care patients: a qualitative analysis. J Palliat Med. 2011;14(1):65-69.

5. Enguidanos S, Housen P, Penido M, Mejia B, Miller JA. Family members’ perceptions of inpatient palliative care consult services: a qualitative study. Palliat Med. 2014;28(1):42-48.

6. Granda-Cameron C, Viola SR, Lynch MP, Polomano RC. Measuring patient-oriented outcomes in palliative care: functionality and quality of life. Clin J Oncol Nurs. 2008;12(1):65-77.

7. Chand P, Gabriel T, Wallace CL, Nelson CM. Inpatient palliative care consultation: describing patient satisfaction. Perm J. 2013;17(1):53-55.

8. Tangeman JC, Rudra CB, Kerr CW, Grant PC. A hospice-hospital partnership: reducing hospitalization costs and 30-day readmissions among seriously ill adults. J Palliat Med. 2014;17(9):1005-1010.

9. Fromme EK, Bascom PB, Smith MD, et al. Survival, mortality, and location of death for patients seen by a hospital-based palliative care team. J Palliat Med. 2006;9(4):903-911.

10. Penrod JD, Deb P, Dellenbaugh C, et al. Hospital-based palliative care consultation: effects on hospital cost. J Palliat Med. 2010;13(8):973-979.

11. Ranganathan A, Dougherty M, Waite D, Casarett D. Can palliative home care reduce 30-day readmissions? Results of a propensity score matched cohort study. J Palliat Med. 2013;16(10):1290-1293.

12. Starks H, Wang S, Farber S, Owens DA, Curtis JR. Cost savings vary by length of stay for inpatients receiving palliative care consultation services. J Palliat Med. 2013;16(10):1215-1220.

13. Goldenheim A, Oates D, Parker V, Russell M, Winter M, Silliman RA. Rehospitalization of older adults discharged to home hospice care. J Palliat Med. 2014;17(7):841-844.

14. May P, Normand C, Morrison RS. Economic impact of hospital inpatient palliative care consultation: review of current evidence and directions for future research. J Palliat Med. 2014;17(9):1054-1063.

15. Granda-Cameron C, Behta M, Hovinga M, Rundio A, Mintzer D. Risk factors associated with unplanned hospital readmissions in adults with cancer. Oncol Nurs Forum. 2015;42(3):e257-e268.

16. Brody AA, Ciemins E, Newman J, Harrington C. The effects of an inpatient palliative care team on discharge disposition. J Palliat Med. 2010;13(5):541-548.

17. Penrod JD, Deb P, Luhrs C, et al. Cost and utilization outcomes of patients receiving hospital-based palliative care consultation. J Palliat Med. 2006;9(4):855-860.

18. Aldridge MD, Kelley AS. Appendix E, Epidemiology of serious illness and high utilization of health care. In: Institute of Medicine, Committee on Approaching Death: Addressing Key End of Life Issues. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington, DC: National Academies Press; 2015.

19. Pantilat SZ, Kerr KM, Billings JA, Bruno KA, O’Riordan DL. Characteristics of palliative care consultation services in California hospitals. J Palliat Med. 2012;15(5):555-560.

20. Gonsalves WI, Tashi T, Krishnamurthy J, et al. Effect of palliative care services on the aggressiveness of end-of-life care in the Veterans Affairs cancer population. J Palliat Med. 2011;14(11):1231-1235.

21. Wendler D, Rid A. Systematic review: the effect on surrogates of making treatment decisions for others. Ann Intern Med. 2011;154(5):336-346.

22. American Bar Association Commission on Law and Aging. Myths and facts about health care advance directives. https://www.americanbar.org/content/dam/aba/publications/bifocal/BIFOCALSept-Oct2015.authcheckdam.pdf. Accessed July 10, 2018.

23. Tierney WM, Dexter PR, Gramelspacher GP, Perkins AJ, Zhou X-H, Wolinsky FD. The effect of discussions about advance directives on patients’ satisfaction with primary care. J Gen Intern Med. 2001;16(1):32-40.

24. Bailey FA, Williams BR, Woodby LL, et al. Intervention to improve care at life’s end in inpatient settings: the BEACON trial. J Gen Intern Med. 2014;29(6):836-843.

25. Dalgaard K, Bergenholtz H, Nielsen M, Timm H. Early integration of palliative care in hospitals: a systematic review on methods, barriers, and outcome. Palliat Support Care. 2014;12(6):495-513.

Discussion

Although small, the proportion of patients with serious illness or multiple chronic conditions account for a disproportionately large portion of health care spending.¹⁸ Despite the high cost, evidence demonstrates that these patients receive health care of inadequate quality characterized by fragmentation, overuse, medical errors, and poor QOL. Multiple studies show that IPC consultation provides improved patient outcomes and decreased hospital costs.^9-17

From a purely outcomes-based interpretation, IPC consultation was associated with 83% of patients receiving a change in code status from full code/TSL 1. The study team drew 2 main conclusions from the data: (1) The IPC consultation is an effective way to broach GOC discussion and adjust code status; and (2) These data suggest room for earlier PC involvement. Remarkably, only 3 patients (2%) expired while inpatient with full code status.

The data also provide a unique comparison of timing of PC referrals. Pantilat and colleagues published characteristics of PC consultation services in California hospitals, and on average, patients were in the hospital 5.9 days (median 5.5; SD 3.3) prior to referral.¹⁹ This study’s average number of days for initial IPC consultation following admission was 3 days on the medical/surgical floors and 7 days in the ICU. Both time frames seem reasonable but again indicate some potential improvement for earlier IPC utilization.

Although the time frame of the intervention limited the number of patients in this study, early PC consultations in the acute care setting are a helpful intervention for veterans and families to better understand the complexity of their medical condition and prognosis and allow for a frank and open discussion about realistic goals. The importance of these discussions also were reflected in the high percentage of patients transitioning to hospice level of care (80%) and the low number of patients who remained full code (3 of 130). Other studies have shown conflicting results when interventions have been exclusively for cancer patients. In this study, 45% of patients were admitted with diagnoses other than cancer compared with 24% of patients with related diagnoses in a study by Gonsalves and colleagues.²⁰

In this study, the majority (71.6%) of family meetings were held only with family (no patient involvement), resulting in missed opportunities for earlier patient and PC involvement especially for those patients with serious medical illnesses.

A systematic review published by Wendler and colleagues found that surrogate decision makers often find that role troubling and traumatizing even with advance directive documents.²¹ Earlier identification and PC consultations could initiate discussions between patients and their loved ones to decide “when enough is enough,” and about whether or not to prolong the dying process, when compatible with the patient’s wishes.

Early PC consultations also could highlight a potential highly vulnerable population of medically unbefriended patients (elder orphans). These patients may have no one in their lives to act as surrogate decision makers. This situation calls for further interventions regarding early identification of these patients and better processes to assist in their decision making. Many physicians believe it is not appropriate to begin advance directive planning on an outpatient basis. However, multiple studies have shown that patients want their doctors to discuss advance care planning with them before they become ill.²²Many other doctors have shown a positive response from patients when advance directive discussions are held during outpatient visits.²³

The goals of this study were to evaluate the effectiveness of IPC consultation on goals of care and to address code status with patients and their families. Along with these conversations, the study team provided comprehensive PC evaluation. The PC team focused on providing excellent symptom management. The team of PC physicians, pain specialists, pain pharmacists, a chaplain, psychologists, and social workers addressed all the bio-psycho-social needs of patients/families and provided comprehensive recommendations. This multidimensional approach has gained significant acceptance.²⁴

At VASLHCS, the program has grown to about 600 new consults per year, with a dedicated inpatient hospice unit, daily outpatient clinic, and myriad learning opportunities for trainees; the center has become a main site of rotation for hospice and palliative care fellows from training programs in St. Louis.

Utilization of PC consultation to help meeting the veterans’ needs at the bio-psycho-social level will also provide a benefit for the facility as it will decrease observed/expected standardized mortality ratio (SMR) data. This reduction of SMR data will be a result of successful patient transitions to hospice level of care at least 12 months prior to their passing or if their level of care is changed to inpatient hospice after they are admitted, the patients won’t be included as acute care mortality. However, with this initial small group of patients it was not possible to retrospectively calculate the impact on SMR or SAIL (Strategic Analytics for Improvement and Learning) indicators. The long-term expectation is to have a positive impact on those indicators represented by decreased inpatient mortality and improved SAIL.