Acute renal failure (ARF) is defined as a decline in renal function over a period of hours or days, which results in an inability to maintain electrolyte homeostasis and an accumulation of nitrogenous waste products. ARF can be a presenting manifestation of a serious illness requiring hospitalization, or occur as a complication of illness or treatment in a hospitalized patient. the healthcare cost and utilization project (HCUP) estimates 141,000 discharges for ARF in 2002, with mean charges of almost $22,000 per patient. the mean length of stay was 6.7 days for these patients, with an in‐hospital mortality of 10.3%. hospitalists can advocate and initiate prevention strategies to reduce the incidence of ARF. hospitalists may also facilitate expeditious evaluation and management of ARF to improve patient outcomes, optimize resource utilization and reduce length of stay.

KNOWLEDGE

Hospitalists should be able to:

• Define the clinical significance of pre‐renal failure, intrinsic renal disease, and post‐renal failure.

• Describe the symptoms and signs of pre‐renal failure, intrinsic renal failure, and post‐renal failure.

• Distinguish the causes of pre‐renal failure, intrinsic renal failure, and post‐renal failure.

• Identify common electrolyte abnormalities that occur with acute renal failure, and institute corrective therapy.

• Describe the indicated tests required to evaluate ARF.

• Calculate estimated creatinine clearance for adjustment of medication dosage when indicated.

• Identify patients at risk for ARF and institute preventive measures, which may include intravenous fluid and acetylcysteine in patients receiving radiocontrast media.

• Identify hospitalized patients at risk for ARF and institute preventive measures.

• Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat ARF.

• Describe indications for acute hemodialysis.

• Identify clinical, laboratory and imaging studies that indicate severity of disease.

• Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.

SKILLS

Hospitalists should be able to:

• Elicit a thorough and relevant history and review the medical record for factors predisposing or contributing to the development of ARF.

• Review all drug use including prescription and over‐the‐counter medications, herbal remedies, nutritional supplements, and illicit drugs.

• Perform a physical examination to assess volume status and to identify underlying co‐morbid states that may result in ARF.

• Order and interpret indicated diagnostic studies that may include urinalysis and microscopic sediment analysis, urinary diagnostic indices, urinary protein excretion, serologic evaluation, and renal imaging.

• Avoid use of radiographic contrast agents and order non‐ionic agents when available.

• Identify patients who may benefit from early hemodialysis.

• Determine or coordinate appropriate nutritional and metabolic interventions.

• Formulate a treatment plan tailored to the individual patient, which may include fluid management, pharmacologic agents and dosing, nutritional recommendations, and patient compliance.

• Identify and treat factors that may complicate the management of ARF, including extremes of blood pressure and underlying infections.

• Adjust medications according to estimated renal function and route of excretion.

• Avoid use of nephrotoxic agents in ARF. if nephrotoxic agents are required, closely monitor drug levels and renal function.

• Assess patients with suspected ARF in a timely manner, and manage or co‐manage the patient with the primary requesting service.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the history and prognosis of ARF.

• Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from hospital.

• Communicate with patients and families to explain tests and procedures, and the use and potential side effects of pharmacologic agents.

• Communicate with patients and families to explain tests and procedures and their indications, and to obtain informed consent.

• Recognize indications for specialty consultation, which may include nephrology or urology.

• Initiate prevention measures including dietary modification and renal dosing of medications.

• Employ a multidisciplinary approach, which may include nursing, nutrition and pharmacy services in the care of patients with ARF that begins at admission and continues through all care transitions.

• Document treatment plan and provide clear discharge instructions for post‐discharge physicians.

• Facilitate discharge planning early during hospitalization, including providing the patient with contact information for follow‐up care.

• Utilize evidence based recommendations and protocols and risk stratification tools for the treatment of ARF.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, hospitalists should:

• Advocate establishing and supporting initiatives that have been shown to reduce incidence of iatrogenic ARF.

• Lead, coordinate or participate in multidisciplinary teams, which may include nephrology, nursing, pharmacy and nutrition services, to improve processes that facilitate early identification of ARF, early discharge planning, and improved patient outcomes.

• Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize management strategies for ARF.

Acute renal failure (ARF) is defined as a decline in renal function over a period of hours or days, which results in an inability to maintain electrolyte homeostasis and an accumulation of nitrogenous waste products. ARF can be a presenting manifestation of a serious illness requiring hospitalization, or occur as a complication of illness or treatment in a hospitalized patient. the healthcare cost and utilization project (HCUP) estimates 141,000 discharges for ARF in 2002, with mean charges of almost $22,000 per patient. the mean length of stay was 6.7 days for these patients, with an in‐hospital mortality of 10.3%. hospitalists can advocate and initiate prevention strategies to reduce the incidence of ARF. hospitalists may also facilitate expeditious evaluation and management of ARF to improve patient outcomes, optimize resource utilization and reduce length of stay.

KNOWLEDGE

Hospitalists should be able to:

• Define the clinical significance of pre‐renal failure, intrinsic renal disease, and post‐renal failure.

• Describe the symptoms and signs of pre‐renal failure, intrinsic renal failure, and post‐renal failure.

• Distinguish the causes of pre‐renal failure, intrinsic renal failure, and post‐renal failure.

• Identify common electrolyte abnormalities that occur with acute renal failure, and institute corrective therapy.

• Describe the indicated tests required to evaluate ARF.

• Calculate estimated creatinine clearance for adjustment of medication dosage when indicated.

• Identify patients at risk for ARF and institute preventive measures, which may include intravenous fluid and acetylcysteine in patients receiving radiocontrast media.

• Identify hospitalized patients at risk for ARF and institute preventive measures.

• Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat ARF.

• Describe indications for acute hemodialysis.

• Identify clinical, laboratory and imaging studies that indicate severity of disease.

• Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.

SKILLS

Hospitalists should be able to:

• Elicit a thorough and relevant history and review the medical record for factors predisposing or contributing to the development of ARF.

• Review all drug use including prescription and over‐the‐counter medications, herbal remedies, nutritional supplements, and illicit drugs.

• Perform a physical examination to assess volume status and to identify underlying co‐morbid states that may result in ARF.

• Order and interpret indicated diagnostic studies that may include urinalysis and microscopic sediment analysis, urinary diagnostic indices, urinary protein excretion, serologic evaluation, and renal imaging.

• Avoid use of radiographic contrast agents and order non‐ionic agents when available.

• Identify patients who may benefit from early hemodialysis.

• Determine or coordinate appropriate nutritional and metabolic interventions.

• Formulate a treatment plan tailored to the individual patient, which may include fluid management, pharmacologic agents and dosing, nutritional recommendations, and patient compliance.

• Identify and treat factors that may complicate the management of ARF, including extremes of blood pressure and underlying infections.

• Adjust medications according to estimated renal function and route of excretion.

• Avoid use of nephrotoxic agents in ARF. if nephrotoxic agents are required, closely monitor drug levels and renal function.

• Assess patients with suspected ARF in a timely manner, and manage or co‐manage the patient with the primary requesting service.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the history and prognosis of ARF.

• Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from hospital.

• Communicate with patients and families to explain tests and procedures, and the use and potential side effects of pharmacologic agents.

• Communicate with patients and families to explain tests and procedures and their indications, and to obtain informed consent.

• Recognize indications for specialty consultation, which may include nephrology or urology.

• Initiate prevention measures including dietary modification and renal dosing of medications.

• Employ a multidisciplinary approach, which may include nursing, nutrition and pharmacy services in the care of patients with ARF that begins at admission and continues through all care transitions.

• Document treatment plan and provide clear discharge instructions for post‐discharge physicians.

• Facilitate discharge planning early during hospitalization, including providing the patient with contact information for follow‐up care.

• Utilize evidence based recommendations and protocols and risk stratification tools for the treatment of ARF.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, hospitalists should:

• Advocate establishing and supporting initiatives that have been shown to reduce incidence of iatrogenic ARF.

• Lead, coordinate or participate in multidisciplinary teams, which may include nephrology, nursing, pharmacy and nutrition services, to improve processes that facilitate early identification of ARF, early discharge planning, and improved patient outcomes.

• Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize management strategies for ARF.

Acute renal failure (ARF) is defined as a decline in renal function over a period of hours or days, which results in an inability to maintain electrolyte homeostasis and an accumulation of nitrogenous waste products. ARF can be a presenting manifestation of a serious illness requiring hospitalization, or occur as a complication of illness or treatment in a hospitalized patient. the healthcare cost and utilization project (HCUP) estimates 141,000 discharges for ARF in 2002, with mean charges of almost $22,000 per patient. the mean length of stay was 6.7 days for these patients, with an in‐hospital mortality of 10.3%. hospitalists can advocate and initiate prevention strategies to reduce the incidence of ARF. hospitalists may also facilitate expeditious evaluation and management of ARF to improve patient outcomes, optimize resource utilization and reduce length of stay.

KNOWLEDGE

Hospitalists should be able to:

• Define the clinical significance of pre‐renal failure, intrinsic renal disease, and post‐renal failure.

• Describe the symptoms and signs of pre‐renal failure, intrinsic renal failure, and post‐renal failure.

• Distinguish the causes of pre‐renal failure, intrinsic renal failure, and post‐renal failure.

• Identify common electrolyte abnormalities that occur with acute renal failure, and institute corrective therapy.

• Describe the indicated tests required to evaluate ARF.

• Calculate estimated creatinine clearance for adjustment of medication dosage when indicated.

• Identify patients at risk for ARF and institute preventive measures, which may include intravenous fluid and acetylcysteine in patients receiving radiocontrast media.

• Identify hospitalized patients at risk for ARF and institute preventive measures.

• Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat ARF.

• Describe indications for acute hemodialysis.

• Identify clinical, laboratory and imaging studies that indicate severity of disease.

• Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.

SKILLS

Hospitalists should be able to:

• Elicit a thorough and relevant history and review the medical record for factors predisposing or contributing to the development of ARF.

• Review all drug use including prescription and over‐the‐counter medications, herbal remedies, nutritional supplements, and illicit drugs.

• Perform a physical examination to assess volume status and to identify underlying co‐morbid states that may result in ARF.

• Order and interpret indicated diagnostic studies that may include urinalysis and microscopic sediment analysis, urinary diagnostic indices, urinary protein excretion, serologic evaluation, and renal imaging.

• Avoid use of radiographic contrast agents and order non‐ionic agents when available.

• Identify patients who may benefit from early hemodialysis.

• Determine or coordinate appropriate nutritional and metabolic interventions.

• Formulate a treatment plan tailored to the individual patient, which may include fluid management, pharmacologic agents and dosing, nutritional recommendations, and patient compliance.

• Identify and treat factors that may complicate the management of ARF, including extremes of blood pressure and underlying infections.

• Adjust medications according to estimated renal function and route of excretion.

• Avoid use of nephrotoxic agents in ARF. if nephrotoxic agents are required, closely monitor drug levels and renal function.

• Assess patients with suspected ARF in a timely manner, and manage or co‐manage the patient with the primary requesting service.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the history and prognosis of ARF.

• Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from hospital.

• Communicate with patients and families to explain tests and procedures, and the use and potential side effects of pharmacologic agents.

• Communicate with patients and families to explain tests and procedures and their indications, and to obtain informed consent.

• Recognize indications for specialty consultation, which may include nephrology or urology.

• Initiate prevention measures including dietary modification and renal dosing of medications.

• Employ a multidisciplinary approach, which may include nursing, nutrition and pharmacy services in the care of patients with ARF that begins at admission and continues through all care transitions.

• Document treatment plan and provide clear discharge instructions for post‐discharge physicians.

• Facilitate discharge planning early during hospitalization, including providing the patient with contact information for follow‐up care.

• Utilize evidence based recommendations and protocols and risk stratification tools for the treatment of ARF.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, hospitalists should:

• Advocate establishing and supporting initiatives that have been shown to reduce incidence of iatrogenic ARF.

• Lead, coordinate or participate in multidisciplinary teams, which may include nephrology, nursing, pharmacy and nutrition services, to improve processes that facilitate early identification of ARF, early discharge planning, and improved patient outcomes.

• Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize management strategies for ARF.

Hospitalists may provide expert medical opinion regarding the care of hospitalized patients or may serve as consultants for patients under the care of other medical and surgical services. The hospitalist consultant may provide opinions and recommendations or actively manage the patient's hospital care. Effective and frequent communication between the hospitalist and the requesting physician ensures safe and quality care. Hospitalists should promote communication between services to improve the care of the hospitalized patient, optimize resource utilization, and enhance patient safety.

KNOWLEDGE

Hospitalists should be able to:

• Define the role of the hospitalist consultant.

• Describe the components of an effective consultation.

• Assess the urgency of the consultation and the questions posed by the requesting physician.

• List factors that may affect implementation of consultant's recommendations.

SKILLS

Hospitalists should be able to:

• Obtain a thorough and relevant history and review the medical record.

• Perform a relevant physical examination.

• Interpret indicated diagnostic studies.

• Synthesize a treatment plan based on the data obtained from the history, physical examination and diagnostic studies.

• Summarize the findings in the patient record.

• List concise but specific recommendations for management.

• Communicate recommendations to the consulting physician in an expedient and efficient manner.

• Assess the level of care required, and communicate with the requesting physician if a transition of care is advised.

ATTITUDES

Hospitalists should be able to:

• Determine the hospitalist consultant's role in collaboration with the requesting physician.

• Respond promptly to the requesting physician's need for consultation.

• Lead by example by performing consultations in a collegial, professional and non‐confrontational manner.

• Inform and educate the requesting physician of potential complications and opportunities for prevention of complications.

• Provide frequent follow‐up, including review of pertinent findings and laboratory data, and ensure that critical recommendations have been followed.

• Provide timely and effective communication with the requesting physician/team.

• Transmit written communication legibly and with clear contact information.

• Recognize when the hospitalist's role in the patient's care is complete, document final recommendations in the medical record, and maintain availability.

• Communicate with patient and family to convey recommendations and treatment plans.

• Recognize the importance of arranging appropriate follow‐up.

• Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization.

Hospitalists may provide expert medical opinion regarding the care of hospitalized patients or may serve as consultants for patients under the care of other medical and surgical services. The hospitalist consultant may provide opinions and recommendations or actively manage the patient's hospital care. Effective and frequent communication between the hospitalist and the requesting physician ensures safe and quality care. Hospitalists should promote communication between services to improve the care of the hospitalized patient, optimize resource utilization, and enhance patient safety.

KNOWLEDGE

Hospitalists should be able to:

• Define the role of the hospitalist consultant.

• Describe the components of an effective consultation.

• Assess the urgency of the consultation and the questions posed by the requesting physician.

• List factors that may affect implementation of consultant's recommendations.

SKILLS

Hospitalists should be able to:

• Obtain a thorough and relevant history and review the medical record.

• Perform a relevant physical examination.

• Interpret indicated diagnostic studies.

• Synthesize a treatment plan based on the data obtained from the history, physical examination and diagnostic studies.

• Summarize the findings in the patient record.

• List concise but specific recommendations for management.

• Communicate recommendations to the consulting physician in an expedient and efficient manner.

• Assess the level of care required, and communicate with the requesting physician if a transition of care is advised.

ATTITUDES

Hospitalists should be able to:

• Determine the hospitalist consultant's role in collaboration with the requesting physician.

• Respond promptly to the requesting physician's need for consultation.

• Lead by example by performing consultations in a collegial, professional and non‐confrontational manner.

• Inform and educate the requesting physician of potential complications and opportunities for prevention of complications.

• Provide frequent follow‐up, including review of pertinent findings and laboratory data, and ensure that critical recommendations have been followed.

• Provide timely and effective communication with the requesting physician/team.

• Transmit written communication legibly and with clear contact information.

• Recognize when the hospitalist's role in the patient's care is complete, document final recommendations in the medical record, and maintain availability.

• Communicate with patient and family to convey recommendations and treatment plans.

• Recognize the importance of arranging appropriate follow‐up.

• Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization.

Hospitalists may provide expert medical opinion regarding the care of hospitalized patients or may serve as consultants for patients under the care of other medical and surgical services. The hospitalist consultant may provide opinions and recommendations or actively manage the patient's hospital care. Effective and frequent communication between the hospitalist and the requesting physician ensures safe and quality care. Hospitalists should promote communication between services to improve the care of the hospitalized patient, optimize resource utilization, and enhance patient safety.

KNOWLEDGE

Hospitalists should be able to:

• Define the role of the hospitalist consultant.

• Describe the components of an effective consultation.

• Assess the urgency of the consultation and the questions posed by the requesting physician.

• List factors that may affect implementation of consultant's recommendations.

SKILLS

Hospitalists should be able to:

• Obtain a thorough and relevant history and review the medical record.

• Perform a relevant physical examination.

• Interpret indicated diagnostic studies.

• Synthesize a treatment plan based on the data obtained from the history, physical examination and diagnostic studies.

• Summarize the findings in the patient record.

• List concise but specific recommendations for management.

• Communicate recommendations to the consulting physician in an expedient and efficient manner.

• Assess the level of care required, and communicate with the requesting physician if a transition of care is advised.

ATTITUDES

Hospitalists should be able to:

• Determine the hospitalist consultant's role in collaboration with the requesting physician.

• Respond promptly to the requesting physician's need for consultation.

• Lead by example by performing consultations in a collegial, professional and non‐confrontational manner.

• Inform and educate the requesting physician of potential complications and opportunities for prevention of complications.

• Provide frequent follow‐up, including review of pertinent findings and laboratory data, and ensure that critical recommendations have been followed.

• Provide timely and effective communication with the requesting physician/team.

• Transmit written communication legibly and with clear contact information.

• Recognize when the hospitalist's role in the patient's care is complete, document final recommendations in the medical record, and maintain availability.

• Communicate with patient and family to convey recommendations and treatment plans.

• Recognize the importance of arranging appropriate follow‐up.

• Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization.

Michael J. Pistoria, DO, FACP

Associate Program Director, Internal Medicine Program; Medical Director, Hospitalist Services

Lehigh Valley Hospital, Allentown, PA

Assistant Professor of Medicine, The Pennsylvania State University College of Medicine

Hershey, PA

Alpesh N. Amin, MD, MBA, FACP

Executive Director, Hospitalist Program

Vice Chair for Clinical Affairs and Quality, Department of Medicine

Associate Program Director, Internal Medicine Residency

Medicine Clerkship Director

University of California, Irvine

Orange, CA

Daniel D. Dressler, MD, MSc

Director, Hospital Medicine Services, Emory University Hospital

Assistant Professor of Medicine, Emory University School of Medicine

Atlanta, GA

Sylvia C.W. McKean, MD

Medical Director, Brigham and Women's Faulkner Hospitalist Service

Assistant Professor of Medicine, Harvard Medical School

Boston, MA

Tina L. Budnitz, MPH

Senior Advisor for New Initiatives

Society of Hospital Medicine

Philadelphia, PA

CONTRIBUTORS

Michael J. Pistoria, DO, FACP

Associate Program Director, Internal Medicine Program; Medical Director, Hospitalist Services

Lehigh Valley Hospital, Allentown, PA

Assistant Professor of Medicine, The Pennsylvania State University College of Medicine

Hershey, PA

Alpesh N. Amin, MD, MBA, FACP

Executive Director, Hospitalist Program

Vice Chair for Clinical Affairs and Quality, Department of Medicine

Associate Program Director, Internal Medicine Residency

Medicine Clerkship Director

University of California, Irvine

Orange, CA

Daniel D. Dressler, MD, MSc

Director, Hospital Medicine Services, Emory University Hospital

Assistant Professor of Medicine, Emory University School of Medicine

Atlanta, GA

Sylvia C.W. McKean, MD

Medical Director, Brigham and Women's Faulkner Hospitalist Service

Assistant Professor of Medicine, Harvard Medical School

Boston, MA

Tina L. Budnitz, MPH

Senior Advisor for New Initiatives

Society of Hospital Medicine

Philadelphia, PA

CONTRIBUTORS

Michael J. Pistoria, DO, FACP

Associate Program Director, Internal Medicine Program; Medical Director, Hospitalist Services

Lehigh Valley Hospital, Allentown, PA

Assistant Professor of Medicine, The Pennsylvania State University College of Medicine

Hershey, PA

Alpesh N. Amin, MD, MBA, FACP

Executive Director, Hospitalist Program

Vice Chair for Clinical Affairs and Quality, Department of Medicine

Associate Program Director, Internal Medicine Residency

Medicine Clerkship Director

University of California, Irvine

Orange, CA

Daniel D. Dressler, MD, MSc

Director, Hospital Medicine Services, Emory University Hospital

Assistant Professor of Medicine, Emory University School of Medicine

Atlanta, GA

Sylvia C.W. McKean, MD

Medical Director, Brigham and Women's Faulkner Hospitalist Service

Assistant Professor of Medicine, Harvard Medical School

Boston, MA

Tina L. Budnitz, MPH

Senior Advisor for New Initiatives

Society of Hospital Medicine

Philadelphia, PA

CONTRIBUTORS

Chest radiographs (CXRs) utilize low‐level radiation to form images of the chest anatomy. They are non‐invasive and readily available. CXRs are an integral part of the initial evaluation of cardiopulmonary pathology. Hospitalists interpret the results of CXRs, often before radiologists, to diagnose disease and develop treatment plans in hospitalized patients.

KNOWLEDGE

Hospitalists should be able to:

• Explain the normal anatomy of the thorax with particular attention to spatial relationships.

• Explain the images seen on a CXR, including bone and soft tissue structures, airway, lungs, cardiac structure and silhouette, aorta, and diaphragm.

• List the indications for ordering a CXR.

• Describe evidence based national guidelines for ordering CXRs.

• Compare the diagnostic utility and limitations of portable radiographs to posteroanterior and lateral radiographs.

• Explain the indications for a lateral decubitus CXR.

• Describe the effects of film exposure, inspiratory effort, and patient position on the radiographic image.

• Explain the effect of cardiovascular, systemic, and traumatic processes on the CXR.

• Explain the limitations of various CXR findings.

SKILLS

Hospitalists should be able to:

• Review a CXR utilizing a systemic approach.

• Identify normal variants.

• Identify abnormalities shown on a CSR and, when possible, correlate with clinical presentation and/or prior procedures.

• Correlate physical examination findings with CXR abnormalities.

• Synthesize CXR findings with other clinical and diagnostic information to diagnose disease and develop a clinical plan.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain results of CXRs and how the findings influence the care plan.

• Personally and promptly interpret CXRs and compare them to previously obtained CXRs, when available.

• Review each CXR with a standard and consistent approach.

• Consult and collaborate with radiologists in interpreting complex CXRs and in ordering further diagnostic studies or procedures based on CXR interpretation.

• Utilize evidence based national guidelines to ensure cost efficiency and to minimize unnecessary patient imaging.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve quality and efficiency within their organizations, Hospitalists should:

• Lead, coordinate or participate in efforts to develop protocols to minimize unnecessary CXRs.

• Identify and convey the need for system improvements related to acquisition and interpretation of CXRs for hospitalized patients.

Chest radiographs (CXRs) utilize low‐level radiation to form images of the chest anatomy. They are non‐invasive and readily available. CXRs are an integral part of the initial evaluation of cardiopulmonary pathology. Hospitalists interpret the results of CXRs, often before radiologists, to diagnose disease and develop treatment plans in hospitalized patients.

KNOWLEDGE

Hospitalists should be able to:

• Explain the normal anatomy of the thorax with particular attention to spatial relationships.

• Explain the images seen on a CXR, including bone and soft tissue structures, airway, lungs, cardiac structure and silhouette, aorta, and diaphragm.

• List the indications for ordering a CXR.

• Describe evidence based national guidelines for ordering CXRs.

• Compare the diagnostic utility and limitations of portable radiographs to posteroanterior and lateral radiographs.

• Explain the indications for a lateral decubitus CXR.

• Describe the effects of film exposure, inspiratory effort, and patient position on the radiographic image.

• Explain the effect of cardiovascular, systemic, and traumatic processes on the CXR.

• Explain the limitations of various CXR findings.

SKILLS

Hospitalists should be able to:

• Review a CXR utilizing a systemic approach.

• Identify normal variants.

• Identify abnormalities shown on a CSR and, when possible, correlate with clinical presentation and/or prior procedures.

• Correlate physical examination findings with CXR abnormalities.

• Synthesize CXR findings with other clinical and diagnostic information to diagnose disease and develop a clinical plan.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain results of CXRs and how the findings influence the care plan.

• Personally and promptly interpret CXRs and compare them to previously obtained CXRs, when available.

• Review each CXR with a standard and consistent approach.

• Consult and collaborate with radiologists in interpreting complex CXRs and in ordering further diagnostic studies or procedures based on CXR interpretation.

• Utilize evidence based national guidelines to ensure cost efficiency and to minimize unnecessary patient imaging.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve quality and efficiency within their organizations, Hospitalists should:

• Lead, coordinate or participate in efforts to develop protocols to minimize unnecessary CXRs.

• Identify and convey the need for system improvements related to acquisition and interpretation of CXRs for hospitalized patients.

Chest radiographs (CXRs) utilize low‐level radiation to form images of the chest anatomy. They are non‐invasive and readily available. CXRs are an integral part of the initial evaluation of cardiopulmonary pathology. Hospitalists interpret the results of CXRs, often before radiologists, to diagnose disease and develop treatment plans in hospitalized patients.

KNOWLEDGE

Hospitalists should be able to:

• Explain the normal anatomy of the thorax with particular attention to spatial relationships.

• Explain the images seen on a CXR, including bone and soft tissue structures, airway, lungs, cardiac structure and silhouette, aorta, and diaphragm.

• List the indications for ordering a CXR.

• Describe evidence based national guidelines for ordering CXRs.

• Compare the diagnostic utility and limitations of portable radiographs to posteroanterior and lateral radiographs.

• Explain the indications for a lateral decubitus CXR.

• Describe the effects of film exposure, inspiratory effort, and patient position on the radiographic image.

• Explain the effect of cardiovascular, systemic, and traumatic processes on the CXR.

• Explain the limitations of various CXR findings.

SKILLS

Hospitalists should be able to:

• Review a CXR utilizing a systemic approach.

• Identify normal variants.

• Identify abnormalities shown on a CSR and, when possible, correlate with clinical presentation and/or prior procedures.

• Correlate physical examination findings with CXR abnormalities.

• Synthesize CXR findings with other clinical and diagnostic information to diagnose disease and develop a clinical plan.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain results of CXRs and how the findings influence the care plan.

• Personally and promptly interpret CXRs and compare them to previously obtained CXRs, when available.

• Review each CXR with a standard and consistent approach.

• Consult and collaborate with radiologists in interpreting complex CXRs and in ordering further diagnostic studies or procedures based on CXR interpretation.

• Utilize evidence based national guidelines to ensure cost efficiency and to minimize unnecessary patient imaging.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve quality and efficiency within their organizations, Hospitalists should:

• Lead, coordinate or participate in efforts to develop protocols to minimize unnecessary CXRs.

• Identify and convey the need for system improvements related to acquisition and interpretation of CXRs for hospitalized patients.

Sepsis syndrome is defined as infection associated with the Systemic Inflammatory Response Syndrome (SIRS). Sepsis has various etiologies and clinical presentations. It accounts for substantial morbidity and mortality. The Healthcare Cost and Utilization Project (HCUP) estimated 300,000 discharges for sepsis syndrome in 2002, with an in‐hospital mortality of 18.6%. The mean length‐of‐stay was 7.3 days with approximately $26,000 in charges per patient. Sepsis requires expeditious diagnosis and standardized treatment plans to favorably impact patient morbidity and mortality. Hospitalists play a key role in the early identification of patients with sepsis, and practice aggressive evidence based evaluation and interventions. Hospitalists lead their institutions to implement early diagnostic strategies, initiate evidence based medical therapies, and incorporate multidisciplinary approaches to the care of patients with sepsis.

KNOWLEDGE

Hospitalists should be able to:

• Define and differentiate bacteremia and the clinical spectrum of SIRS, sepsis, severe sepsis, and septic shock.

• Describe the symptoms and signs of SIRS, sepsis, severe sepsis, and septic shock.

• Describe the inflammatory cascade that leads to SIRS and sepsis.

• Distinguish infectious causes of SIRS from other etiologies.

• Distinguish septic shock from other causes of shock.

• Describe the indicated tests required to evaluate sepsis.

• Identify patient groups with increased risk for the development of sepsis, increased morbidity or mortality, or uncommon etiologic organisms.

• Discuss the evidence based diagnostic choices available in the evaluation of sepsis.

• Describe the indications, contraindications and side effects of therapeutic agents including fluids, vasopressors, antibiotics, steroids, activated protein C, and blood products in the treatment of sepsis.

• Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat sepsis syndrome.

• Describe the indications for and limitations of central venous access and its value for hemodynamic monitoring and administration of vasoactive agents.

• Describe the role of established scoring systems to estimate the severity of sepsis.

• Explain patient characteristics that on admission portend poor prognosis.

• Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.

SKILLS

Hospitalists should be able to:

• Utilize all available information, including medical records and history provided by patient and care givers, to identify factors that contribute to the development of sepsis.

• Perform a rapid and targeted physical examination to identify potential sources of sepsis.

• Recognize the value and limitations of the history and physical examination in determining the cause of sepsis.

• Order indicated diagnostic testing to identify the source of sepsis and determine severity of organ dysfunction.

• Rapidly identify patients with septic shock and aggressively treat in parallel with transfer to a critical care setting.

• Assess cardiopulmonary stability and implement aggressive fluid resuscitation, airway maintenance and circulatory support.

• Initiate empiric antimicrobial therapy based on the suspected etiologic source of infection.

• Assess the need for central venous access and monitoring; when needed, coordinate or establish central venous access.

• Determine or coordinate appropriate nutritional and metabolic interventions.

• Support organ function and correct metabolic derangements when indicated.

• Implement measures to ensure strict glycemic control.

• Adopt measures to prevent complications, which may include aspiration precautions, stress ulcer and VTE prophylaxis, and decubitus ulcer prevention.

• Measure and interpret indicated hemodynamic monitoring parameters.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the history and prognosis of sepsis and indicators of functional improvement or decline.

• Communicate with patients and families to explain goals of care plan, including clinical stability criteria, discharge instructions and management after release from hospital.

• Communicate with patients and families to explain tests and procedures and their indications, and to obtain informed consent.

• Recognize the indications for specialty consultations, which may include critical care medicine.

• Employ an early and multidisciplinary approach, which may include respiratory therapy, nursing, pharmacy, nutrition, rehabilitation and social services, that begins at admission and continues through all care transitions.

• Establish and maintain an open dialogue with patients and families regarding care goals and limitations, including palliative care and end‐of‐life wishes.

• Address resuscitation status early during hospital stay, and discuss and implement end of life decisions by patient or family when indicated or desired.

• Ensure good communication with patients and receiving physicians during care transitions.

• Utilize evidence based recommendations to guide diagnosis, monitoring and treatment of sepsis.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, Hospitalists should:

• Lead, coordinate or participate in the development and promotion of guidelines and/or pathways that facilitate efficient and timely evaluation and treatment of patients with sepsis.

• Implement systems to ensure hospital‐wide adherence to national standards, and document those measures as specified by recognized organizations.

• Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization.

• Lead, coordinate or participate in intra‐ and inter‐institutional efforts to develop protocols for the rapid identification and transfer of patients with sepsis to appropriate facilities.

• Lead, coordinate or participate in multidisciplinary teams, which may include nutrition, pharmacy, rehabilitation, social services and respiratory therapy, early in the hospital course to improve patient function and outcomes.

• Integrate outcomes research, institution‐specific laboratory policies, and hospital formulary to create indicated and cost‐effective diagnostic and management strategies for patients with sepsis.

Sepsis syndrome is defined as infection associated with the Systemic Inflammatory Response Syndrome (SIRS). Sepsis has various etiologies and clinical presentations. It accounts for substantial morbidity and mortality. The Healthcare Cost and Utilization Project (HCUP) estimated 300,000 discharges for sepsis syndrome in 2002, with an in‐hospital mortality of 18.6%. The mean length‐of‐stay was 7.3 days with approximately $26,000 in charges per patient. Sepsis requires expeditious diagnosis and standardized treatment plans to favorably impact patient morbidity and mortality. Hospitalists play a key role in the early identification of patients with sepsis, and practice aggressive evidence based evaluation and interventions. Hospitalists lead their institutions to implement early diagnostic strategies, initiate evidence based medical therapies, and incorporate multidisciplinary approaches to the care of patients with sepsis.

KNOWLEDGE

Hospitalists should be able to:

• Define and differentiate bacteremia and the clinical spectrum of SIRS, sepsis, severe sepsis, and septic shock.

• Describe the symptoms and signs of SIRS, sepsis, severe sepsis, and septic shock.

• Describe the inflammatory cascade that leads to SIRS and sepsis.

• Distinguish infectious causes of SIRS from other etiologies.

• Distinguish septic shock from other causes of shock.

• Describe the indicated tests required to evaluate sepsis.

• Identify patient groups with increased risk for the development of sepsis, increased morbidity or mortality, or uncommon etiologic organisms.

• Discuss the evidence based diagnostic choices available in the evaluation of sepsis.

• Describe the indications, contraindications and side effects of therapeutic agents including fluids, vasopressors, antibiotics, steroids, activated protein C, and blood products in the treatment of sepsis.

• Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat sepsis syndrome.

• Describe the indications for and limitations of central venous access and its value for hemodynamic monitoring and administration of vasoactive agents.

• Describe the role of established scoring systems to estimate the severity of sepsis.

• Explain patient characteristics that on admission portend poor prognosis.

• Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.

SKILLS

Hospitalists should be able to:

• Utilize all available information, including medical records and history provided by patient and care givers, to identify factors that contribute to the development of sepsis.

• Perform a rapid and targeted physical examination to identify potential sources of sepsis.

• Recognize the value and limitations of the history and physical examination in determining the cause of sepsis.

• Order indicated diagnostic testing to identify the source of sepsis and determine severity of organ dysfunction.

• Rapidly identify patients with septic shock and aggressively treat in parallel with transfer to a critical care setting.

• Assess cardiopulmonary stability and implement aggressive fluid resuscitation, airway maintenance and circulatory support.

• Initiate empiric antimicrobial therapy based on the suspected etiologic source of infection.

• Assess the need for central venous access and monitoring; when needed, coordinate or establish central venous access.

• Determine or coordinate appropriate nutritional and metabolic interventions.

• Support organ function and correct metabolic derangements when indicated.

• Implement measures to ensure strict glycemic control.

• Adopt measures to prevent complications, which may include aspiration precautions, stress ulcer and VTE prophylaxis, and decubitus ulcer prevention.

• Measure and interpret indicated hemodynamic monitoring parameters.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the history and prognosis of sepsis and indicators of functional improvement or decline.

• Communicate with patients and families to explain goals of care plan, including clinical stability criteria, discharge instructions and management after release from hospital.

• Communicate with patients and families to explain tests and procedures and their indications, and to obtain informed consent.

• Recognize the indications for specialty consultations, which may include critical care medicine.

• Employ an early and multidisciplinary approach, which may include respiratory therapy, nursing, pharmacy, nutrition, rehabilitation and social services, that begins at admission and continues through all care transitions.

• Establish and maintain an open dialogue with patients and families regarding care goals and limitations, including palliative care and end‐of‐life wishes.

• Address resuscitation status early during hospital stay, and discuss and implement end of life decisions by patient or family when indicated or desired.

• Ensure good communication with patients and receiving physicians during care transitions.

• Utilize evidence based recommendations to guide diagnosis, monitoring and treatment of sepsis.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, Hospitalists should:

• Lead, coordinate or participate in the development and promotion of guidelines and/or pathways that facilitate efficient and timely evaluation and treatment of patients with sepsis.

• Implement systems to ensure hospital‐wide adherence to national standards, and document those measures as specified by recognized organizations.

• Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization.

• Lead, coordinate or participate in intra‐ and inter‐institutional efforts to develop protocols for the rapid identification and transfer of patients with sepsis to appropriate facilities.

• Lead, coordinate or participate in multidisciplinary teams, which may include nutrition, pharmacy, rehabilitation, social services and respiratory therapy, early in the hospital course to improve patient function and outcomes.

• Integrate outcomes research, institution‐specific laboratory policies, and hospital formulary to create indicated and cost‐effective diagnostic and management strategies for patients with sepsis.

Sepsis syndrome is defined as infection associated with the Systemic Inflammatory Response Syndrome (SIRS). Sepsis has various etiologies and clinical presentations. It accounts for substantial morbidity and mortality. The Healthcare Cost and Utilization Project (HCUP) estimated 300,000 discharges for sepsis syndrome in 2002, with an in‐hospital mortality of 18.6%. The mean length‐of‐stay was 7.3 days with approximately $26,000 in charges per patient. Sepsis requires expeditious diagnosis and standardized treatment plans to favorably impact patient morbidity and mortality. Hospitalists play a key role in the early identification of patients with sepsis, and practice aggressive evidence based evaluation and interventions. Hospitalists lead their institutions to implement early diagnostic strategies, initiate evidence based medical therapies, and incorporate multidisciplinary approaches to the care of patients with sepsis.

KNOWLEDGE

Hospitalists should be able to:

• Define and differentiate bacteremia and the clinical spectrum of SIRS, sepsis, severe sepsis, and septic shock.

• Describe the symptoms and signs of SIRS, sepsis, severe sepsis, and septic shock.

• Describe the inflammatory cascade that leads to SIRS and sepsis.

• Distinguish infectious causes of SIRS from other etiologies.

• Distinguish septic shock from other causes of shock.

• Describe the indicated tests required to evaluate sepsis.

• Identify patient groups with increased risk for the development of sepsis, increased morbidity or mortality, or uncommon etiologic organisms.

• Discuss the evidence based diagnostic choices available in the evaluation of sepsis.

• Describe the indications, contraindications and side effects of therapeutic agents including fluids, vasopressors, antibiotics, steroids, activated protein C, and blood products in the treatment of sepsis.

• Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat sepsis syndrome.

• Describe the indications for and limitations of central venous access and its value for hemodynamic monitoring and administration of vasoactive agents.

• Describe the role of established scoring systems to estimate the severity of sepsis.

• Explain patient characteristics that on admission portend poor prognosis.

• Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.

SKILLS

Hospitalists should be able to:

• Utilize all available information, including medical records and history provided by patient and care givers, to identify factors that contribute to the development of sepsis.

• Perform a rapid and targeted physical examination to identify potential sources of sepsis.

• Recognize the value and limitations of the history and physical examination in determining the cause of sepsis.

• Order indicated diagnostic testing to identify the source of sepsis and determine severity of organ dysfunction.

• Rapidly identify patients with septic shock and aggressively treat in parallel with transfer to a critical care setting.

• Assess cardiopulmonary stability and implement aggressive fluid resuscitation, airway maintenance and circulatory support.

• Initiate empiric antimicrobial therapy based on the suspected etiologic source of infection.

• Assess the need for central venous access and monitoring; when needed, coordinate or establish central venous access.

• Determine or coordinate appropriate nutritional and metabolic interventions.

• Support organ function and correct metabolic derangements when indicated.

• Implement measures to ensure strict glycemic control.

• Adopt measures to prevent complications, which may include aspiration precautions, stress ulcer and VTE prophylaxis, and decubitus ulcer prevention.

• Measure and interpret indicated hemodynamic monitoring parameters.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the history and prognosis of sepsis and indicators of functional improvement or decline.

• Communicate with patients and families to explain goals of care plan, including clinical stability criteria, discharge instructions and management after release from hospital.

• Communicate with patients and families to explain tests and procedures and their indications, and to obtain informed consent.

• Recognize the indications for specialty consultations, which may include critical care medicine.

• Employ an early and multidisciplinary approach, which may include respiratory therapy, nursing, pharmacy, nutrition, rehabilitation and social services, that begins at admission and continues through all care transitions.

• Establish and maintain an open dialogue with patients and families regarding care goals and limitations, including palliative care and end‐of‐life wishes.

• Address resuscitation status early during hospital stay, and discuss and implement end of life decisions by patient or family when indicated or desired.

• Ensure good communication with patients and receiving physicians during care transitions.

• Utilize evidence based recommendations to guide diagnosis, monitoring and treatment of sepsis.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, Hospitalists should:

• Lead, coordinate or participate in the development and promotion of guidelines and/or pathways that facilitate efficient and timely evaluation and treatment of patients with sepsis.

• Implement systems to ensure hospital‐wide adherence to national standards, and document those measures as specified by recognized organizations.

• Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization.

• Lead, coordinate or participate in intra‐ and inter‐institutional efforts to develop protocols for the rapid identification and transfer of patients with sepsis to appropriate facilities.

• Lead, coordinate or participate in multidisciplinary teams, which may include nutrition, pharmacy, rehabilitation, social services and respiratory therapy, early in the hospital course to improve patient function and outcomes.

• Integrate outcomes research, institution‐specific laboratory policies, and hospital formulary to create indicated and cost‐effective diagnostic and management strategies for patients with sepsis.

Palliative care refers to a collaborative, comprehensive, interdisciplinary approach to improve the quality of life of patients living with debilitating, chronic or terminal illness. Palliative care is appropriate at any stage of illness and should be provided simultaneously with all other medical treatments. This approach includes the prevention and relief of suffering by means of early identification, assessment, and treatment of pain and other distressing symptoms such as dyspnea, nausea, fatigue, anxiety and depression; and attention to the physical, psychosocial and spiritual needs of patients and their families.

Hospitalists provide palliative care in multiple realms including 1) patients dying in the hospital; 2) patients discharged to home or another institution for end‐of‐life care; 3) patients with newly diagnosed life‐threatening illness; 4) patients requiring complex inpatient symptom management interventions; 5) patients for whom it is appropriate to shift the goal of care away from disease cure or stabilization and toward the maximization of comfort; and 6) patients with serious, chronic illness such as heart failure, COPD, liver disease, dementia, and cancer. Hospitalists lead, coordinate, and participate in initiatives to improve the identification and treatment of patients and families in need of palliative care.

KNOWLEDGE

Hospitalists should be able to:

• Determine effective management strategies for patients requiring palliative care.

• Describe potential adverse effects from medications and procedures directed at palliation.

• Formulate strategies for prevention and treatment of complications of palliative care interventions.

• Assess the impact of interventions including feeding tubes, parenteral nutrition, mechanical ventilation, and intravenous fluids on patient comfort and prognosis.

• Describe the concept of double effect with respect to palliative care intervention.

• Name the basic tenets of hospice care and the Medicare hospice benefit.

• Identify indicators of clinical stability that allow for safe transitions of care and continuity after discharge.

• Explain the role of palliative care throughout the course of illness and how it can be provided alongside all other appropriate medical treatments.

• Describe signs and symptoms of the last 24 hours of life and how to discuss these observations with families.

• Describe the responsibilities of the hospitalist after a patient dies, including pronouncing a person dead, completing the death certificate, requesting an autopsy, notifying family and PCP, and contacting the organ donor network.

SKILLS

Hospitalists should be able to:

• Obtain a thorough and relevant history, review the medical record, and perform a comprehensive physical examination to identify symptoms, co‐morbidities, medications or social influences that impact the palliative care plan.

• Direct individual patient's palliative care delivery from admission to discharge.

• Formulate a communication plan for delivering prognostic information.

• Conduct effective and compassionate family meetings.

• Formulate specific patient centered palliative care plans that include pain management; integration of psychiatric, social, spiritual and other support services; and discharge planning.

• Recognize and address the psychosocial effects of complex, acute life threatening illness in hospitalized patients.

• Assess and respond to patient's symptoms, which may include pain, dyspnea, nausea, constipation, fatigue, anorexia, anxiety, depression and delirium.

• Anticipate adverse effects and double effect from interventions and initiate measures to minimize such problems.

• Communicate effectively with patients and families about patient's values and goals of care.

• Communicate effectively with patients and families about hospice and know how to refer a patient to hospice.

• Respond to patient requests for assisted suicide and identify and address other important ethical issues.

ATTITUDES

Hospitalists should be able to:

• Convey diagnosis, prognosis, treatment and support options available for patients and families in a clear, concise, compassionate, culturally sensitive and timely manner.

• Determine patient and family understanding of severity of illness, prognosis and their role in determining the goals of their care.

• Promote the ethical imperative of frequent pain assessment and adequate control.

• Appreciate that all pain is subjective and acknowledge patient's self reports of pain.

• Discuss with patients and families goals for pain management strategies and functional status and set targets for pain control.

• Appreciate that good palliative care for patients with certain conditions often involves the use of therapies typically thought of as curative.

• Conduct meetings with patients and families to establish goals of care that reflect the patient's wishes.

• Determine existence of advance directives and provide patients and families with resources to understand and execute such directives.

• Advocate incorporation of patient wishes into care plans.

• Recognize the need for frequent family meetings.

• Address resuscitation status and patient preferences for care early during hospital stay.

• Maintain rapport with patients and families and a consistent approach to management during transfers of care.

• Recognize impact of cultural and spiritual factors to the provision of palliative care.

• Appreciate the role of other members of the healthcare team including nursing and social services, pharmacy, psychology and pastoral care in providing comprehensive palliative care, and work closely with these team members in caring for patients with serious, chronic and terminal illnesses and their families.

• Provide reassurance to patients and families that clinical providers will be available to provide ongoing care and relief of symptoms.

• Formulate a comprehensive discharge plan that will empower the patient, family and subsequent providers to anticipate and manage changing symptoms, emergency situations, and increasing dependency.

• Lead, coordinate or participate in efforts to establish or improve palliative care in the hospital, which may include establishing a palliative care consultation service.

• Consider palliative care issues at hospital management and committee meetings.

• Engage providers and administrators in the study of local palliative care delivery to include efficacy of pain assessment and intervention, patient and family satisfaction with care delivery, impact on hospital occupancy and costs, and fulfilled expectations of referring and collaborating providers and services.

Palliative care refers to a collaborative, comprehensive, interdisciplinary approach to improve the quality of life of patients living with debilitating, chronic or terminal illness. Palliative care is appropriate at any stage of illness and should be provided simultaneously with all other medical treatments. This approach includes the prevention and relief of suffering by means of early identification, assessment, and treatment of pain and other distressing symptoms such as dyspnea, nausea, fatigue, anxiety and depression; and attention to the physical, psychosocial and spiritual needs of patients and their families.

Hospitalists provide palliative care in multiple realms including 1) patients dying in the hospital; 2) patients discharged to home or another institution for end‐of‐life care; 3) patients with newly diagnosed life‐threatening illness; 4) patients requiring complex inpatient symptom management interventions; 5) patients for whom it is appropriate to shift the goal of care away from disease cure or stabilization and toward the maximization of comfort; and 6) patients with serious, chronic illness such as heart failure, COPD, liver disease, dementia, and cancer. Hospitalists lead, coordinate, and participate in initiatives to improve the identification and treatment of patients and families in need of palliative care.

KNOWLEDGE

Hospitalists should be able to:

• Determine effective management strategies for patients requiring palliative care.

• Describe potential adverse effects from medications and procedures directed at palliation.

• Formulate strategies for prevention and treatment of complications of palliative care interventions.

• Assess the impact of interventions including feeding tubes, parenteral nutrition, mechanical ventilation, and intravenous fluids on patient comfort and prognosis.

• Describe the concept of double effect with respect to palliative care intervention.

• Name the basic tenets of hospice care and the Medicare hospice benefit.

• Identify indicators of clinical stability that allow for safe transitions of care and continuity after discharge.

• Explain the role of palliative care throughout the course of illness and how it can be provided alongside all other appropriate medical treatments.

• Describe signs and symptoms of the last 24 hours of life and how to discuss these observations with families.

• Describe the responsibilities of the hospitalist after a patient dies, including pronouncing a person dead, completing the death certificate, requesting an autopsy, notifying family and PCP, and contacting the organ donor network.

SKILLS

Hospitalists should be able to:

• Obtain a thorough and relevant history, review the medical record, and perform a comprehensive physical examination to identify symptoms, co‐morbidities, medications or social influences that impact the palliative care plan.

• Direct individual patient's palliative care delivery from admission to discharge.

• Formulate a communication plan for delivering prognostic information.

• Conduct effective and compassionate family meetings.

• Formulate specific patient centered palliative care plans that include pain management; integration of psychiatric, social, spiritual and other support services; and discharge planning.

• Recognize and address the psychosocial effects of complex, acute life threatening illness in hospitalized patients.

• Assess and respond to patient's symptoms, which may include pain, dyspnea, nausea, constipation, fatigue, anorexia, anxiety, depression and delirium.

• Anticipate adverse effects and double effect from interventions and initiate measures to minimize such problems.

• Communicate effectively with patients and families about patient's values and goals of care.

• Communicate effectively with patients and families about hospice and know how to refer a patient to hospice.

• Respond to patient requests for assisted suicide and identify and address other important ethical issues.

ATTITUDES

Hospitalists should be able to:

• Convey diagnosis, prognosis, treatment and support options available for patients and families in a clear, concise, compassionate, culturally sensitive and timely manner.

• Determine patient and family understanding of severity of illness, prognosis and their role in determining the goals of their care.

• Promote the ethical imperative of frequent pain assessment and adequate control.

• Appreciate that all pain is subjective and acknowledge patient's self reports of pain.

• Discuss with patients and families goals for pain management strategies and functional status and set targets for pain control.

• Appreciate that good palliative care for patients with certain conditions often involves the use of therapies typically thought of as curative.

• Conduct meetings with patients and families to establish goals of care that reflect the patient's wishes.

• Determine existence of advance directives and provide patients and families with resources to understand and execute such directives.

• Advocate incorporation of patient wishes into care plans.

• Recognize the need for frequent family meetings.

• Address resuscitation status and patient preferences for care early during hospital stay.

• Maintain rapport with patients and families and a consistent approach to management during transfers of care.

• Recognize impact of cultural and spiritual factors to the provision of palliative care.

• Appreciate the role of other members of the healthcare team including nursing and social services, pharmacy, psychology and pastoral care in providing comprehensive palliative care, and work closely with these team members in caring for patients with serious, chronic and terminal illnesses and their families.

• Provide reassurance to patients and families that clinical providers will be available to provide ongoing care and relief of symptoms.

• Formulate a comprehensive discharge plan that will empower the patient, family and subsequent providers to anticipate and manage changing symptoms, emergency situations, and increasing dependency.

• Lead, coordinate or participate in efforts to establish or improve palliative care in the hospital, which may include establishing a palliative care consultation service.

• Consider palliative care issues at hospital management and committee meetings.

• Engage providers and administrators in the study of local palliative care delivery to include efficacy of pain assessment and intervention, patient and family satisfaction with care delivery, impact on hospital occupancy and costs, and fulfilled expectations of referring and collaborating providers and services.

Palliative care refers to a collaborative, comprehensive, interdisciplinary approach to improve the quality of life of patients living with debilitating, chronic or terminal illness. Palliative care is appropriate at any stage of illness and should be provided simultaneously with all other medical treatments. This approach includes the prevention and relief of suffering by means of early identification, assessment, and treatment of pain and other distressing symptoms such as dyspnea, nausea, fatigue, anxiety and depression; and attention to the physical, psychosocial and spiritual needs of patients and their families.

Hospitalists provide palliative care in multiple realms including 1) patients dying in the hospital; 2) patients discharged to home or another institution for end‐of‐life care; 3) patients with newly diagnosed life‐threatening illness; 4) patients requiring complex inpatient symptom management interventions; 5) patients for whom it is appropriate to shift the goal of care away from disease cure or stabilization and toward the maximization of comfort; and 6) patients with serious, chronic illness such as heart failure, COPD, liver disease, dementia, and cancer. Hospitalists lead, coordinate, and participate in initiatives to improve the identification and treatment of patients and families in need of palliative care.

KNOWLEDGE

Hospitalists should be able to:

• Determine effective management strategies for patients requiring palliative care.

• Describe potential adverse effects from medications and procedures directed at palliation.

• Formulate strategies for prevention and treatment of complications of palliative care interventions.

• Assess the impact of interventions including feeding tubes, parenteral nutrition, mechanical ventilation, and intravenous fluids on patient comfort and prognosis.

• Describe the concept of double effect with respect to palliative care intervention.

• Name the basic tenets of hospice care and the Medicare hospice benefit.

• Identify indicators of clinical stability that allow for safe transitions of care and continuity after discharge.

• Explain the role of palliative care throughout the course of illness and how it can be provided alongside all other appropriate medical treatments.

• Describe signs and symptoms of the last 24 hours of life and how to discuss these observations with families.

• Describe the responsibilities of the hospitalist after a patient dies, including pronouncing a person dead, completing the death certificate, requesting an autopsy, notifying family and PCP, and contacting the organ donor network.

SKILLS

Hospitalists should be able to:

• Obtain a thorough and relevant history, review the medical record, and perform a comprehensive physical examination to identify symptoms, co‐morbidities, medications or social influences that impact the palliative care plan.

• Direct individual patient's palliative care delivery from admission to discharge.

• Formulate a communication plan for delivering prognostic information.

• Conduct effective and compassionate family meetings.

• Formulate specific patient centered palliative care plans that include pain management; integration of psychiatric, social, spiritual and other support services; and discharge planning.

• Recognize and address the psychosocial effects of complex, acute life threatening illness in hospitalized patients.

• Assess and respond to patient's symptoms, which may include pain, dyspnea, nausea, constipation, fatigue, anorexia, anxiety, depression and delirium.

• Anticipate adverse effects and double effect from interventions and initiate measures to minimize such problems.

• Communicate effectively with patients and families about patient's values and goals of care.

• Communicate effectively with patients and families about hospice and know how to refer a patient to hospice.

• Respond to patient requests for assisted suicide and identify and address other important ethical issues.

ATTITUDES

Hospitalists should be able to:

• Convey diagnosis, prognosis, treatment and support options available for patients and families in a clear, concise, compassionate, culturally sensitive and timely manner.

• Determine patient and family understanding of severity of illness, prognosis and their role in determining the goals of their care.

• Promote the ethical imperative of frequent pain assessment and adequate control.

• Appreciate that all pain is subjective and acknowledge patient's self reports of pain.

• Discuss with patients and families goals for pain management strategies and functional status and set targets for pain control.

• Appreciate that good palliative care for patients with certain conditions often involves the use of therapies typically thought of as curative.

• Conduct meetings with patients and families to establish goals of care that reflect the patient's wishes.

• Determine existence of advance directives and provide patients and families with resources to understand and execute such directives.

• Advocate incorporation of patient wishes into care plans.

• Recognize the need for frequent family meetings.

• Address resuscitation status and patient preferences for care early during hospital stay.

• Maintain rapport with patients and families and a consistent approach to management during transfers of care.

• Recognize impact of cultural and spiritual factors to the provision of palliative care.

• Appreciate the role of other members of the healthcare team including nursing and social services, pharmacy, psychology and pastoral care in providing comprehensive palliative care, and work closely with these team members in caring for patients with serious, chronic and terminal illnesses and their families.

• Provide reassurance to patients and families that clinical providers will be available to provide ongoing care and relief of symptoms.

• Formulate a comprehensive discharge plan that will empower the patient, family and subsequent providers to anticipate and manage changing symptoms, emergency situations, and increasing dependency.

• Lead, coordinate or participate in efforts to establish or improve palliative care in the hospital, which may include establishing a palliative care consultation service.

• Consider palliative care issues at hospital management and committee meetings.

• Engage providers and administrators in the study of local palliative care delivery to include efficacy of pain assessment and intervention, patient and family satisfaction with care delivery, impact on hospital occupancy and costs, and fulfilled expectations of referring and collaborating providers and services.

Community‐acquired pneumonia (cap) is an infection of the lung parenchyma that begins in the community and is diagnosed within 48 hours of admission to the hospital. in the u.s. each year, cap is the most common infectious cause of death and the sixth leading cause of death overall in the united states. the healthcare cost and utilization project (hcup) attributed 831,000 discharges to the diagnosis related group (drg) for simple pneumonia in 2002. these patients were hospitalized for a mean of 5.4 days and had an in‐hospital mortality of 4.9%. the mean charges for these patients were $13,000 per patient and the mean length‐of‐stay was 4.7 days with in‐house mortality of 1.7%. quality indicators have been created around the key processes of care for patients with cap, and these indicators are used to evaluate performance of states, healthcare organizations, physician groups, and individual physicians. from admission to discharge, hospitalists apply evidence based practice guidelines to the management of cap and lead initiatives to improve quality of care and reduce practice variability.

KNOWLEDGE

Hospitalists should be able to:

• Define cap, list the likely etiologies and signs and symptoms, and distinguish from hospital‐acquired pneumonia.

• Differentiate cap from other processes that may mimic cap or other causes of infiltrates on chest x‐ray.

• Describe the indicated tests required to evaluate and treat cap.

• Explain indications for respiratory isolation.

• Identify patients with co‐morbidities (such as the immunocompromised patient and those with diabetes mellitus) and extremes of age (the elderly and very young) who are at risk for a complicated course of cap.

• Identify specific pathogens that predispose patients to a complicated course of cap.

• Explain patient specific risk factors and presence of specific organisms that predispose patients to a complicated course of cap.

• Describe indicated therapeutic modalities for cap including oxygen therapy, respiratory care modalities and antibiotic selection.

• Predict patient risk for morbidity and mortality from cap using an evidence based tool such as the pneumonia patient outcomes research team (port) / pneumonia severity index (psi) validated risk score.

• Explain goals for hospital discharge, including evidence based measures of clinical stability for safe care transition.

SKILLS

Hospitalists should be able to:

• Elicit a focused history to identify symptoms consistent with cap and demographic factors that may predispose patients to cap.

• Perform a targeted physical examination to elicit signs consistent with cap and differentiate it from other mimicking conditions.

• Select and interpret indicated laboratory, microbiologic and radiological studies to confirm diagnosis of cap, and risk stratify patients.

• Apply evidence based tools such as the pneumonia severity index, to triage decisions and identify factors that support the need for intensive care unit (icu) admission.

• Initiate empiric antibiotic selection based on exposure to long term or group care, severity of illness, and evidence based national guidelines, taking into account local resistance patterns.

• Formulate a subsequent treatment plan that includes narrowing antibiotic therapies based on available culture data and patient response to treatment.

• Recognize and address complications of cap and/or inadequate response to therapy including respiratory failure and emerging parapneumonic effusions.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the history and prognosis of cap.

• Communicate with patients and families to explain the goals of care plan, including clinical stability criteria, the importance of prevention measures such as smoking cessation, and required follow‐up care.

• Communicate with patients and families to explain tests and procedures, and the use and potential side effects of pharmacologic agents.

• Recognize indications for specialty consultation.

• Promote prevention strategies, which may include smoking cessation and indicated vaccinations.

• Collaborate with primary care physicians and emergency physicians in making the admission decision.

• Document treatment plan and discharge instructions, and identify the outpatient clinician responsible for follow‐up of pending tests.

• Recognize and address barriers to follow‐up care and anticipated post‐discharge requirements.

• Utilize evidence based recommendations for the treatment of patients with cap

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate or participate in efforts to identify, address and monitor quality indicators for cap including assessment of oxygenation, obtaining blood cultures prior to administration of antibiotics, prompt administration of antibiotics, and providing indicated vaccinations and smoking cessation education.

• Implement systems to ensure hospital wide adherence to national standards and document those measures as specified by recognized organizations (jcaho, idsa, ats)

• Integrate port score / psi in conjunction with patient specific factors and clinical judgment into the admission decision.

• Lead, coordinate or participate in multidisciplinary initiatives, which may include collaboration with infectious disease and pulmonary specialists, to promote patient safety and cost effective diagnostic and management strategies for patients with cap.

• Lead efforts to educate staff on the importance of smoking cessation counseling and other prevention measures.

Community‐acquired pneumonia (cap) is an infection of the lung parenchyma that begins in the community and is diagnosed within 48 hours of admission to the hospital. in the u.s. each year, cap is the most common infectious cause of death and the sixth leading cause of death overall in the united states. the healthcare cost and utilization project (hcup) attributed 831,000 discharges to the diagnosis related group (drg) for simple pneumonia in 2002. these patients were hospitalized for a mean of 5.4 days and had an in‐hospital mortality of 4.9%. the mean charges for these patients were $13,000 per patient and the mean length‐of‐stay was 4.7 days with in‐house mortality of 1.7%. quality indicators have been created around the key processes of care for patients with cap, and these indicators are used to evaluate performance of states, healthcare organizations, physician groups, and individual physicians. from admission to discharge, hospitalists apply evidence based practice guidelines to the management of cap and lead initiatives to improve quality of care and reduce practice variability.

KNOWLEDGE

Hospitalists should be able to:

• Define cap, list the likely etiologies and signs and symptoms, and distinguish from hospital‐acquired pneumonia.

• Differentiate cap from other processes that may mimic cap or other causes of infiltrates on chest x‐ray.

• Describe the indicated tests required to evaluate and treat cap.

• Explain indications for respiratory isolation.

• Identify patients with co‐morbidities (such as the immunocompromised patient and those with diabetes mellitus) and extremes of age (the elderly and very young) who are at risk for a complicated course of cap.

• Identify specific pathogens that predispose patients to a complicated course of cap.

• Explain patient specific risk factors and presence of specific organisms that predispose patients to a complicated course of cap.

• Describe indicated therapeutic modalities for cap including oxygen therapy, respiratory care modalities and antibiotic selection.

• Predict patient risk for morbidity and mortality from cap using an evidence based tool such as the pneumonia patient outcomes research team (port) / pneumonia severity index (psi) validated risk score.

• Explain goals for hospital discharge, including evidence based measures of clinical stability for safe care transition.

SKILLS

Hospitalists should be able to:

• Elicit a focused history to identify symptoms consistent with cap and demographic factors that may predispose patients to cap.

• Perform a targeted physical examination to elicit signs consistent with cap and differentiate it from other mimicking conditions.

• Select and interpret indicated laboratory, microbiologic and radiological studies to confirm diagnosis of cap, and risk stratify patients.

• Apply evidence based tools such as the pneumonia severity index, to triage decisions and identify factors that support the need for intensive care unit (icu) admission.

• Initiate empiric antibiotic selection based on exposure to long term or group care, severity of illness, and evidence based national guidelines, taking into account local resistance patterns.

• Formulate a subsequent treatment plan that includes narrowing antibiotic therapies based on available culture data and patient response to treatment.

• Recognize and address complications of cap and/or inadequate response to therapy including respiratory failure and emerging parapneumonic effusions.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the history and prognosis of cap.

• Communicate with patients and families to explain the goals of care plan, including clinical stability criteria, the importance of prevention measures such as smoking cessation, and required follow‐up care.

• Communicate with patients and families to explain tests and procedures, and the use and potential side effects of pharmacologic agents.

• Recognize indications for specialty consultation.

• Promote prevention strategies, which may include smoking cessation and indicated vaccinations.

• Collaborate with primary care physicians and emergency physicians in making the admission decision.

• Document treatment plan and discharge instructions, and identify the outpatient clinician responsible for follow‐up of pending tests.

• Recognize and address barriers to follow‐up care and anticipated post‐discharge requirements.

• Utilize evidence based recommendations for the treatment of patients with cap

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate or participate in efforts to identify, address and monitor quality indicators for cap including assessment of oxygenation, obtaining blood cultures prior to administration of antibiotics, prompt administration of antibiotics, and providing indicated vaccinations and smoking cessation education.

• Implement systems to ensure hospital wide adherence to national standards and document those measures as specified by recognized organizations (jcaho, idsa, ats)

• Integrate port score / psi in conjunction with patient specific factors and clinical judgment into the admission decision.

• Lead, coordinate or participate in multidisciplinary initiatives, which may include collaboration with infectious disease and pulmonary specialists, to promote patient safety and cost effective diagnostic and management strategies for patients with cap.

• Lead efforts to educate staff on the importance of smoking cessation counseling and other prevention measures.

Community‐acquired pneumonia (cap) is an infection of the lung parenchyma that begins in the community and is diagnosed within 48 hours of admission to the hospital. in the u.s. each year, cap is the most common infectious cause of death and the sixth leading cause of death overall in the united states. the healthcare cost and utilization project (hcup) attributed 831,000 discharges to the diagnosis related group (drg) for simple pneumonia in 2002. these patients were hospitalized for a mean of 5.4 days and had an in‐hospital mortality of 4.9%. the mean charges for these patients were $13,000 per patient and the mean length‐of‐stay was 4.7 days with in‐house mortality of 1.7%. quality indicators have been created around the key processes of care for patients with cap, and these indicators are used to evaluate performance of states, healthcare organizations, physician groups, and individual physicians. from admission to discharge, hospitalists apply evidence based practice guidelines to the management of cap and lead initiatives to improve quality of care and reduce practice variability.

KNOWLEDGE

Hospitalists should be able to:

• Define cap, list the likely etiologies and signs and symptoms, and distinguish from hospital‐acquired pneumonia.

• Differentiate cap from other processes that may mimic cap or other causes of infiltrates on chest x‐ray.

• Describe the indicated tests required to evaluate and treat cap.

• Explain indications for respiratory isolation.

• Identify patients with co‐morbidities (such as the immunocompromised patient and those with diabetes mellitus) and extremes of age (the elderly and very young) who are at risk for a complicated course of cap.

• Identify specific pathogens that predispose patients to a complicated course of cap.

• Explain patient specific risk factors and presence of specific organisms that predispose patients to a complicated course of cap.

• Describe indicated therapeutic modalities for cap including oxygen therapy, respiratory care modalities and antibiotic selection.

• Predict patient risk for morbidity and mortality from cap using an evidence based tool such as the pneumonia patient outcomes research team (port) / pneumonia severity index (psi) validated risk score.

• Explain goals for hospital discharge, including evidence based measures of clinical stability for safe care transition.

SKILLS

Hospitalists should be able to:

• Elicit a focused history to identify symptoms consistent with cap and demographic factors that may predispose patients to cap.

• Perform a targeted physical examination to elicit signs consistent with cap and differentiate it from other mimicking conditions.

• Select and interpret indicated laboratory, microbiologic and radiological studies to confirm diagnosis of cap, and risk stratify patients.

• Apply evidence based tools such as the pneumonia severity index, to triage decisions and identify factors that support the need for intensive care unit (icu) admission.

• Initiate empiric antibiotic selection based on exposure to long term or group care, severity of illness, and evidence based national guidelines, taking into account local resistance patterns.

• Formulate a subsequent treatment plan that includes narrowing antibiotic therapies based on available culture data and patient response to treatment.

• Recognize and address complications of cap and/or inadequate response to therapy including respiratory failure and emerging parapneumonic effusions.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the history and prognosis of cap.

• Communicate with patients and families to explain the goals of care plan, including clinical stability criteria, the importance of prevention measures such as smoking cessation, and required follow‐up care.

• Communicate with patients and families to explain tests and procedures, and the use and potential side effects of pharmacologic agents.

• Recognize indications for specialty consultation.

• Promote prevention strategies, which may include smoking cessation and indicated vaccinations.

• Collaborate with primary care physicians and emergency physicians in making the admission decision.

• Document treatment plan and discharge instructions, and identify the outpatient clinician responsible for follow‐up of pending tests.

• Recognize and address barriers to follow‐up care and anticipated post‐discharge requirements.

• Utilize evidence based recommendations for the treatment of patients with cap

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate or participate in efforts to identify, address and monitor quality indicators for cap including assessment of oxygenation, obtaining blood cultures prior to administration of antibiotics, prompt administration of antibiotics, and providing indicated vaccinations and smoking cessation education.

• Implement systems to ensure hospital wide adherence to national standards and document those measures as specified by recognized organizations (jcaho, idsa, ats)

• Integrate port score / psi in conjunction with patient specific factors and clinical judgment into the admission decision.

• Lead, coordinate or participate in multidisciplinary initiatives, which may include collaboration with infectious disease and pulmonary specialists, to promote patient safety and cost effective diagnostic and management strategies for patients with cap.

• Lead efforts to educate staff on the importance of smoking cessation counseling and other prevention measures.

The field of palliative care has grown rapidly in recent years in response to patient need and clinician interest in effective approaches to managing chronic life‐threatening illness.1 This article reviews the clinical, educational, demographic, and financial imperatives driving this growth, describes the clinical components of palliative care and the range of service models available, defines the relationship of hospital‐based palliative care to hospice, summarizes the literature on palliative care outcomes, and presents practical resources for clinicians seeking knowledge and skills in the field.

DEFINITION

Palliative care is medical care focused on the relief of suffering and support for the best possible quality of life for patients facing serious, life‐threatening illness and their families. It aims to identify and address the physical, psychological, and practical burdens of illness. Palliative care in the United States grew out of the hospice movement that originated in both the United Kingdom and the United States about 30 years ago. Hospice care was developed specifically to address the needs of the dying and their families and was codified in the United States by the addition in 1983 of a federal Medicare benefit for hospice care. In the last 30 years the Medicare hospice benefit has enabled more than 7 million patients and their families to receive intensive palliative care for the terminally ill, primarily in the home. The growth in the number and needs of seriously and chronically ill patients who are not clearly terminally ill has led to the development of palliative care services outside the hospice benefit provided by Medicare (and other insurers). Both hospice and nonhospice professionals have participated in extending the hospice approach through development of palliative care services. Palliative care may be delivered simultaneously with all appropriate curative and life‐prolonging interventions. In practice, palliative care practitioners provide assessment and treatment of pain and other symptom distress; employ communication skills with patients, families, and colleagues; support complex medical decision making and goal setting based on identifying and respecting patient wishes and goals; and promote medically informed care coordination, continuity, and practical support for patients, family caregivers, and professional colleagues across healthcare settings and through the trajectory of an illness.1, 2

Palliative care is both a general approach to health care and a growing practice specialty for professionals committing most or all of their time to the delivery of palliative care services.3 The term palliative medicine refers to the physician discipline within the larger field of palliative care. As of 2005, more than 1890 physicians have received specialty certification through a palliative care credentialing exam given by the American Board of Hospice and Palliative Medicine.4 Formal recognition of the subspecialty is currently being sought in collaboration with the American Board of Medical Specialties.5 As of August 2005, there were more than 50 postgraduate palliative care subspecialty fellowship programs in the United States.6 Between 2000 and 2003, the American Hospital Association (AHA) annual survey recorded a 67% growth in the number of hospital‐based palliative care programs reported, from 632 to 1027, for a total of 25% of responding AHA member hospitals.7

REASONS FOR GROWTH IN PALLIATIVE CARE

A primary justification for the rapid growth in palliative care programs in institutional settings is the abundant data demonstrating the high prevalence of pain and symptom distress in hospitals,811 nursing homes,12, 13 and community settings.14 Virtually all persons with serious illness spend at least some time in a hospital, usually on multiple occasions, in the course of their disease or condition.15 Despite the finding that when polled more than 90% of Americans say they would prefer to die at home, more than 75% of adult deaths occur in institutional settings (hospital or nursing homes)more than 50% in hospitals and 25% in nursing homesand 85% of pediatric deaths occur in hospitals.16, 17 Further, more than half of persons older than age 85 die in a nursing home and 43% of persons older than age 65 reside in a long‐term care facility at some time before they die,1821 a figure projected to rise substantially over the next several decades. The much larger number of patients who are not dying but are living with chronic, debilitating, and life‐threatening illness also need expert symptom management, communication and decision‐making support, and coordination of care across settings. In one national survey, physicians reported that poor care coordination resulted in patient communication problems, lack of emotional support for patients, adverse drug reactions, unnecessary hospitalization, patients not functioning to potential, and unnecessary pain.22 In addition to studies demonstrating high degrees of symptom distress across all age groups in hospitalized and nursing home patients,814 other works have shown high use of burdensome, nonbeneficial technologies among the seriously ill,2327 caregiver burden on families,2831 and communication problems between these patients, their families, and their treating physicians about the goals of care and the medical decisions that should follow.32, 33 Other studies have reported broad dissatisfaction with the general quality of care for the seriously ill and dying in hospitals and nursing homes,18, 34 specifically, perceptions of impersonal and indifferent care. Several studies of patients and their families have identified relief of suffering, practical support needs, open communication, and opportunities to relieve burdens on and strengthen relationships with family as the top‐priority needs from the healthcare system.3440

The growth in the number and needs of the elderly with multiple chronic conditions who will turn to the healthcare system in coming years underscores the need to create a delivery system in the United States that can be responsive to these priorities. By 2030 the number of persons with chronic conditions will exceed 157 million.4144 With the possible exception of advanced cancer conditions (accounting for 24% of adult deaths), in which prognosis is somewhat more reliably linked to performance status,4243 prognostication of outcome is a highly inexact science for the chronically ill of all ages and in a range of diagnostic categories, including stroke, dementia, and end‐stage cardiac, renal, hepatic, and pulmonary diseases. This has been a major part of the impetus for the growth in palliative care services not predicated on a link to terminal prognoses.4143 Hospitals and nursing homes are under increasing pressure to structure care processes in a manner fitted to the needs of the seriously ill because of studies demonstrating poor quality of care, demands from patients and families, accreditation requirements, and the costs of care for this patient population. More than 95% of Medicare spending goes to the 63% of Medicare patients with two or more chronic conditions, and three quarters of Medicare dollars go to hospitals.44 Hospital costs have risen nearly 10% per year in each of the last 2 years, because of both the increasing numbers of patients turning to them for care and the growth in the number and expense of effective life‐prolonging therapies. These forces have stimulated the development of new models for the efficient and effective care of patients with serious and complex illness.2227, 44

CLINICAL COMPONENTS

The three primary domains of palliative care clinical practice are assessment and treatment of pain and other symptom distress, including psychiatric symptoms64; communication about goals of care and support for complex medical decision making; and provision of practical and psychosocial support, care coordination, and continuity, as well as bereavement services if death occurs.1, 2, 65 Palliative care specialists work to support primary and specialist physicians in the care of complex and seriously ill patients by providing intensive bedside treatment and reassessment of multiple‐symptom distress, by helping with time‐consuming and difficult interactions with distressed patients and family members, and by attempting to ensure a seamless, safe, and well‐communicated discharge and follow‐up process after the patient leaves the hospital.66 Resources for physicians seeking more knowledge or training in the treatment of symptom distress and other aspects of palliative care are given in Table 1.

The core components of symptom management67, 68 include: 1) Routine and repeated formal assessment, without which most symptoms will be neither identified nor addressed; 2) Expertise in prescribing, including the safe use of opioid analgesics, adjuvant approaches to pain management, and management of a wide range of other common and distressing symptoms and syndromes including, for example, delirium, dyspnea, fatigue, nausea, bowel obstruction, and depression69; and 3) Skillful management of treatment side effects, which is required to successfully control symptoms.

Communication skills and effective support for making decisions about clinical care goals include not only fundamental physician responsibilities such as communicating bad news and elucidating patient wishes for future care, but also the ability to promote communication and consensus about care goals among multiple specialist consultants, to address and resolve disagreements and conflicts among patients, families, and providers about goals of care, and to assist in the evolving process of balancing the benefits with the burdens of various medical interventions.32, 7073

The great majority of care for an illness is provided at home by family members neither trained nor emotionally prepared for these responsibilities.51, 74 The burden on family caregivers is one of the top concerns of seriously ill patients.35 Patients and families often struggle with anxieties about doing the wrong thing, difficulty traveling to physicians' offices, social isolation, and a high prevalence of preventable suffering of all types.3440 Palliative care clinicians attempt to improve the success and sustainability of the discharge plan by providing medically informed and therefore more appropriate care management recommendations and by mobilizing a range of community resources to increase the likelihood that families will be able to manage the care at home with the necessary supports and backups in place, including appropriate screening and referrals for complicated grief and bereavement.51, 75, 76 Several small prospective studies of palliative care have suggested that palliative care has resulted in reduction in the number of emergency department visits and hospitalizations and in the length of hospital stays, presumably because of the efficacy and comprehensiveness of care coordination in averting crises.54, 55, 61, 9798

CLINICAL MODELS

Given the multifaceted approach needed to support patient quality of life throughout advanced illness, one profession or individual cannot be expected to provide all aspects of palliative care. As described in the recently completed National Consensus Project Guidelines for Quality Palliative Care,2 specialty‐level palliative care is optimally delivered through an interdisciplinary team consisting of appropriately trained and credentialed physicians, nurses, and social workers with additional support and contributions from chaplains, rehabilitative experts, psychiatrists, and other professionals as indicated. Clearly, however, the staffing of a palliative care program will depend critically on the needs and capacities of the setting. A full interdisciplinary team is needed for a large tertiary‐care teaching hospital, whereas a part‐time advance‐practice nurse with backup from colleagues as needed may suffice for a small rural hospital or long‐term care setting. Specialist‐level palliative care is delivered through a range of clinical models and settings, including inpatient consultation services, dedicated inpatient units, and outpatient practices, among others.77, 78 Programs within the United States are housed in a range of clinical subspecialties including oncology, geriatrics, nursing, case management, hospitalist, and other programs, depending on the locus of leadership and administrative support.77, 78 Most programs are supported by utilizing diverse sources,77 including physician and nurse‐practitioner billing through insurers such as Medicare Part B,53, 81 as well as hospital support typically predicated on cost avoidance analyses, foundation and other grants, and philanthropy. Detailed guidance on appropriate documentation and billing for palliative care physician services may be found in Schapiro et al.,53 von Gunten,79 and on the Web site of the Center to Advance Palliative Care (www.capc.org).77

RELATIONSHIP TO HOSPICE

Although new clinical specialties in palliative medicine and nursing are emerging, in the United States palliative care for those in the terminal stages of illness has been delivered through hospice programs for more than 30 years. Under current regulatory and payment guidelines hospice care is delivered to patients who are certified by their physicians as likely to die within 6 months if the disease follows its usual course and who are willing to give up insurance coverage for medical treatment primarily focused on cure or prolongation of life. It is noteworthy that there is great variability among United States hospices, with some able to support continued disease‐modifying treatments such as chemotherapy and radiation if a patient so desires.2 Hospice programs aim to create increased opportunity for death at home, focusing on symptom control and the psychological and spiritual issues that are paramount to persons in the terminal phases of illness. Once the hospice benefit has been accessed, patients and families receive comprehensive case‐managed services across all settings of care (although the great majority of hospice care is delivered at home) from an interdisciplinary team, coverage for medications and equipment related to the terminal illness, and practical, psychosocial, respite, and bereavement support for caregivers.80, 81 Several recent studies have confirmed the findings of an earlier work82 in demonstrating the beneficial outcomes of hospice care including reduced mortality in spouses and high levels of family satisfaction.18, 83 Palliative care programs based in both hospital and community settings have led to increases in hospice referral rates and hospice length of stay, promoting continuity of palliative care and the intensive palliation and family support needed as death approaches.55 Coordination and partnerships between palliative care and hospice programs are critical to achieving continuity of palliative care throughout the full course of an illness and across the continuum of care settings.2

IMPACT OF PALLIATIVE CARE ON QUALITY OF CARE

Reports on palliative care specialist services utilizing diverse models and approaches have suggested a range of benefits from palliative care, including reduced pain4547 and other symptom distress,45, 48, 49 improved health‐related quality of life,95 high patient and family satisfaction18, 4951, 96 with care and with physician communication, and increased likelihood of the location of death being outside a hospital.33, 49, 52, 9799

Because it can help to demonstrate care structures, processes, and outcomes associated with improved quality (such as routine assessment of pain in the hospital), a palliative care program may help hospitals measure and meet Joint Commission for Accreditation of Healthcare Organizations (JCAHO) requirements in the domains of pain management, communication, family and patient education, and continuity of care, among others.53 Several groups have reported marked increases in hospice referral rate and hospice length of stay as a result of hospital‐ and nursing‐home‐based palliative care programs, presumably as a result of enhanced case identification, counseling, and referral processes.54, 55 Case control and observational studies of palliative care and ethics consultation services have demonstrated reductions in costs per day and in hospital and ICU lengths of stay, presumably because of enhanced support for discussions about the goals of care and the resulting facilitation of patient and family decisions about the types and settings of future care.50, 5561 Hospitals have begun to invest in palliative care services, both to enhance quality of care and because of their measurable impact on reducing ICU and total bed days and their efficacy in supporting transitions from high‐intensity, high‐cost hospital settings to more appropriate and desired care settings, such as the home.5563, 9798 Observational studies have yielded no differences in mortality between patients receiving palliative care and controls receiving the usual care.48, 55, 56

EDUCATION IN PALLIATIVE CARE

Curricular content on palliative care has been noticeably lacking from medical and nursing education curricula, textbooks, and certifying examinations, although this is beginning to change.8491 Both the Liaison Committee for Medical Education (LCME) and the Accreditation Council for Graduate Medical Education (ACGME) now require or strongly encourage programs to provide under‐ and postgraduate training in palliative care in order to be accredited.89, 90 As of 2005, more than 50% of teaching hospitals had established palliative care clinical services,92 which constitute the necessary platform for clinical training. The rapid growth in the availability of postgraduate fellowship training in palliative medicine will produce the faculty leaders needed for these educational and research programs in medical school and residency training programs.93, 94 Physicians in practice may gain knowledge and skills through a range of national courses and Web‐based resources and through preparation for the certifying exam given annually by the American Board of Hospice and Palliative Medicine4 (Table 1).

CONCLUSIONS

The growth in palliative care specialists and programs in hospitals in the United States represents a grass roots professional response to the needs of a patient population with chronic advanced illnesses and family care burdens within a healthcare system structured to provide care for acute intercurrent illness. Rapid increases in the number of new hospital programs, as well as early studies indicating improved clinical, satisfaction, and utilization outcomes, suggest that palliative care services are likely to become a routine and well‐integrated part of the healthcare continuum in the United States over the next several years. A number of resources are available to healthcare professionals seeking more training as well as to hospitals or nursing homes wishing to establish their own clinical or educational programs. Such programs have provided a platform for both newly graduated and seasoned professionals to continue to serve the needs of their patients through the assessment and relief of suffering, provided simultaneously with efforts to cure or mitigate disease.

The field of palliative care has grown rapidly in recent years in response to patient need and clinician interest in effective approaches to managing chronic life‐threatening illness.1 This article reviews the clinical, educational, demographic, and financial imperatives driving this growth, describes the clinical components of palliative care and the range of service models available, defines the relationship of hospital‐based palliative care to hospice, summarizes the literature on palliative care outcomes, and presents practical resources for clinicians seeking knowledge and skills in the field.

DEFINITION

Palliative care is medical care focused on the relief of suffering and support for the best possible quality of life for patients facing serious, life‐threatening illness and their families. It aims to identify and address the physical, psychological, and practical burdens of illness. Palliative care in the United States grew out of the hospice movement that originated in both the United Kingdom and the United States about 30 years ago. Hospice care was developed specifically to address the needs of the dying and their families and was codified in the United States by the addition in 1983 of a federal Medicare benefit for hospice care. In the last 30 years the Medicare hospice benefit has enabled more than 7 million patients and their families to receive intensive palliative care for the terminally ill, primarily in the home. The growth in the number and needs of seriously and chronically ill patients who are not clearly terminally ill has led to the development of palliative care services outside the hospice benefit provided by Medicare (and other insurers). Both hospice and nonhospice professionals have participated in extending the hospice approach through development of palliative care services. Palliative care may be delivered simultaneously with all appropriate curative and life‐prolonging interventions. In practice, palliative care practitioners provide assessment and treatment of pain and other symptom distress; employ communication skills with patients, families, and colleagues; support complex medical decision making and goal setting based on identifying and respecting patient wishes and goals; and promote medically informed care coordination, continuity, and practical support for patients, family caregivers, and professional colleagues across healthcare settings and through the trajectory of an illness.1, 2

Palliative care is both a general approach to health care and a growing practice specialty for professionals committing most or all of their time to the delivery of palliative care services.3 The term palliative medicine refers to the physician discipline within the larger field of palliative care. As of 2005, more than 1890 physicians have received specialty certification through a palliative care credentialing exam given by the American Board of Hospice and Palliative Medicine.4 Formal recognition of the subspecialty is currently being sought in collaboration with the American Board of Medical Specialties.5 As of August 2005, there were more than 50 postgraduate palliative care subspecialty fellowship programs in the United States.6 Between 2000 and 2003, the American Hospital Association (AHA) annual survey recorded a 67% growth in the number of hospital‐based palliative care programs reported, from 632 to 1027, for a total of 25% of responding AHA member hospitals.7

REASONS FOR GROWTH IN PALLIATIVE CARE

A primary justification for the rapid growth in palliative care programs in institutional settings is the abundant data demonstrating the high prevalence of pain and symptom distress in hospitals,811 nursing homes,12, 13 and community settings.14 Virtually all persons with serious illness spend at least some time in a hospital, usually on multiple occasions, in the course of their disease or condition.15 Despite the finding that when polled more than 90% of Americans say they would prefer to die at home, more than 75% of adult deaths occur in institutional settings (hospital or nursing homes)more than 50% in hospitals and 25% in nursing homesand 85% of pediatric deaths occur in hospitals.16, 17 Further, more than half of persons older than age 85 die in a nursing home and 43% of persons older than age 65 reside in a long‐term care facility at some time before they die,1821 a figure projected to rise substantially over the next several decades. The much larger number of patients who are not dying but are living with chronic, debilitating, and life‐threatening illness also need expert symptom management, communication and decision‐making support, and coordination of care across settings. In one national survey, physicians reported that poor care coordination resulted in patient communication problems, lack of emotional support for patients, adverse drug reactions, unnecessary hospitalization, patients not functioning to potential, and unnecessary pain.22 In addition to studies demonstrating high degrees of symptom distress across all age groups in hospitalized and nursing home patients,814 other works have shown high use of burdensome, nonbeneficial technologies among the seriously ill,2327 caregiver burden on families,2831 and communication problems between these patients, their families, and their treating physicians about the goals of care and the medical decisions that should follow.32, 33 Other studies have reported broad dissatisfaction with the general quality of care for the seriously ill and dying in hospitals and nursing homes,18, 34 specifically, perceptions of impersonal and indifferent care. Several studies of patients and their families have identified relief of suffering, practical support needs, open communication, and opportunities to relieve burdens on and strengthen relationships with family as the top‐priority needs from the healthcare system.3440

The growth in the number and needs of the elderly with multiple chronic conditions who will turn to the healthcare system in coming years underscores the need to create a delivery system in the United States that can be responsive to these priorities. By 2030 the number of persons with chronic conditions will exceed 157 million.4144 With the possible exception of advanced cancer conditions (accounting for 24% of adult deaths), in which prognosis is somewhat more reliably linked to performance status,4243 prognostication of outcome is a highly inexact science for the chronically ill of all ages and in a range of diagnostic categories, including stroke, dementia, and end‐stage cardiac, renal, hepatic, and pulmonary diseases. This has been a major part of the impetus for the growth in palliative care services not predicated on a link to terminal prognoses.4143 Hospitals and nursing homes are under increasing pressure to structure care processes in a manner fitted to the needs of the seriously ill because of studies demonstrating poor quality of care, demands from patients and families, accreditation requirements, and the costs of care for this patient population. More than 95% of Medicare spending goes to the 63% of Medicare patients with two or more chronic conditions, and three quarters of Medicare dollars go to hospitals.44 Hospital costs have risen nearly 10% per year in each of the last 2 years, because of both the increasing numbers of patients turning to them for care and the growth in the number and expense of effective life‐prolonging therapies. These forces have stimulated the development of new models for the efficient and effective care of patients with serious and complex illness.2227, 44

CLINICAL COMPONENTS

The three primary domains of palliative care clinical practice are assessment and treatment of pain and other symptom distress, including psychiatric symptoms64; communication about goals of care and support for complex medical decision making; and provision of practical and psychosocial support, care coordination, and continuity, as well as bereavement services if death occurs.1, 2, 65 Palliative care specialists work to support primary and specialist physicians in the care of complex and seriously ill patients by providing intensive bedside treatment and reassessment of multiple‐symptom distress, by helping with time‐consuming and difficult interactions with distressed patients and family members, and by attempting to ensure a seamless, safe, and well‐communicated discharge and follow‐up process after the patient leaves the hospital.66 Resources for physicians seeking more knowledge or training in the treatment of symptom distress and other aspects of palliative care are given in Table 1.

The core components of symptom management67, 68 include: 1) Routine and repeated formal assessment, without which most symptoms will be neither identified nor addressed; 2) Expertise in prescribing, including the safe use of opioid analgesics, adjuvant approaches to pain management, and management of a wide range of other common and distressing symptoms and syndromes including, for example, delirium, dyspnea, fatigue, nausea, bowel obstruction, and depression69; and 3) Skillful management of treatment side effects, which is required to successfully control symptoms.

Communication skills and effective support for making decisions about clinical care goals include not only fundamental physician responsibilities such as communicating bad news and elucidating patient wishes for future care, but also the ability to promote communication and consensus about care goals among multiple specialist consultants, to address and resolve disagreements and conflicts among patients, families, and providers about goals of care, and to assist in the evolving process of balancing the benefits with the burdens of various medical interventions.32, 7073

The great majority of care for an illness is provided at home by family members neither trained nor emotionally prepared for these responsibilities.51, 74 The burden on family caregivers is one of the top concerns of seriously ill patients.35 Patients and families often struggle with anxieties about doing the wrong thing, difficulty traveling to physicians' offices, social isolation, and a high prevalence of preventable suffering of all types.3440 Palliative care clinicians attempt to improve the success and sustainability of the discharge plan by providing medically informed and therefore more appropriate care management recommendations and by mobilizing a range of community resources to increase the likelihood that families will be able to manage the care at home with the necessary supports and backups in place, including appropriate screening and referrals for complicated grief and bereavement.51, 75, 76 Several small prospective studies of palliative care have suggested that palliative care has resulted in reduction in the number of emergency department visits and hospitalizations and in the length of hospital stays, presumably because of the efficacy and comprehensiveness of care coordination in averting crises.54, 55, 61, 9798

CLINICAL MODELS

Given the multifaceted approach needed to support patient quality of life throughout advanced illness, one profession or individual cannot be expected to provide all aspects of palliative care. As described in the recently completed National Consensus Project Guidelines for Quality Palliative Care,2 specialty‐level palliative care is optimally delivered through an interdisciplinary team consisting of appropriately trained and credentialed physicians, nurses, and social workers with additional support and contributions from chaplains, rehabilitative experts, psychiatrists, and other professionals as indicated. Clearly, however, the staffing of a palliative care program will depend critically on the needs and capacities of the setting. A full interdisciplinary team is needed for a large tertiary‐care teaching hospital, whereas a part‐time advance‐practice nurse with backup from colleagues as needed may suffice for a small rural hospital or long‐term care setting. Specialist‐level palliative care is delivered through a range of clinical models and settings, including inpatient consultation services, dedicated inpatient units, and outpatient practices, among others.77, 78 Programs within the United States are housed in a range of clinical subspecialties including oncology, geriatrics, nursing, case management, hospitalist, and other programs, depending on the locus of leadership and administrative support.77, 78 Most programs are supported by utilizing diverse sources,77 including physician and nurse‐practitioner billing through insurers such as Medicare Part B,53, 81 as well as hospital support typically predicated on cost avoidance analyses, foundation and other grants, and philanthropy. Detailed guidance on appropriate documentation and billing for palliative care physician services may be found in Schapiro et al.,53 von Gunten,79 and on the Web site of the Center to Advance Palliative Care (www.capc.org).77

RELATIONSHIP TO HOSPICE

Although new clinical specialties in palliative medicine and nursing are emerging, in the United States palliative care for those in the terminal stages of illness has been delivered through hospice programs for more than 30 years. Under current regulatory and payment guidelines hospice care is delivered to patients who are certified by their physicians as likely to die within 6 months if the disease follows its usual course and who are willing to give up insurance coverage for medical treatment primarily focused on cure or prolongation of life. It is noteworthy that there is great variability among United States hospices, with some able to support continued disease‐modifying treatments such as chemotherapy and radiation if a patient so desires.2 Hospice programs aim to create increased opportunity for death at home, focusing on symptom control and the psychological and spiritual issues that are paramount to persons in the terminal phases of illness. Once the hospice benefit has been accessed, patients and families receive comprehensive case‐managed services across all settings of care (although the great majority of hospice care is delivered at home) from an interdisciplinary team, coverage for medications and equipment related to the terminal illness, and practical, psychosocial, respite, and bereavement support for caregivers.80, 81 Several recent studies have confirmed the findings of an earlier work82 in demonstrating the beneficial outcomes of hospice care including reduced mortality in spouses and high levels of family satisfaction.18, 83 Palliative care programs based in both hospital and community settings have led to increases in hospice referral rates and hospice length of stay, promoting continuity of palliative care and the intensive palliation and family support needed as death approaches.55 Coordination and partnerships between palliative care and hospice programs are critical to achieving continuity of palliative care throughout the full course of an illness and across the continuum of care settings.2

IMPACT OF PALLIATIVE CARE ON QUALITY OF CARE

Reports on palliative care specialist services utilizing diverse models and approaches have suggested a range of benefits from palliative care, including reduced pain4547 and other symptom distress,45, 48, 49 improved health‐related quality of life,95 high patient and family satisfaction18, 4951, 96 with care and with physician communication, and increased likelihood of the location of death being outside a hospital.33, 49, 52, 9799

Because it can help to demonstrate care structures, processes, and outcomes associated with improved quality (such as routine assessment of pain in the hospital), a palliative care program may help hospitals measure and meet Joint Commission for Accreditation of Healthcare Organizations (JCAHO) requirements in the domains of pain management, communication, family and patient education, and continuity of care, among others.53 Several groups have reported marked increases in hospice referral rate and hospice length of stay as a result of hospital‐ and nursing‐home‐based palliative care programs, presumably as a result of enhanced case identification, counseling, and referral processes.54, 55 Case control and observational studies of palliative care and ethics consultation services have demonstrated reductions in costs per day and in hospital and ICU lengths of stay, presumably because of enhanced support for discussions about the goals of care and the resulting facilitation of patient and family decisions about the types and settings of future care.50, 5561 Hospitals have begun to invest in palliative care services, both to enhance quality of care and because of their measurable impact on reducing ICU and total bed days and their efficacy in supporting transitions from high‐intensity, high‐cost hospital settings to more appropriate and desired care settings, such as the home.5563, 9798 Observational studies have yielded no differences in mortality between patients receiving palliative care and controls receiving the usual care.48, 55, 56

EDUCATION IN PALLIATIVE CARE

Curricular content on palliative care has been noticeably lacking from medical and nursing education curricula, textbooks, and certifying examinations, although this is beginning to change.8491 Both the Liaison Committee for Medical Education (LCME) and the Accreditation Council for Graduate Medical Education (ACGME) now require or strongly encourage programs to provide under‐ and postgraduate training in palliative care in order to be accredited.89, 90 As of 2005, more than 50% of teaching hospitals had established palliative care clinical services,92 which constitute the necessary platform for clinical training. The rapid growth in the availability of postgraduate fellowship training in palliative medicine will produce the faculty leaders needed for these educational and research programs in medical school and residency training programs.93, 94 Physicians in practice may gain knowledge and skills through a range of national courses and Web‐based resources and through preparation for the certifying exam given annually by the American Board of Hospice and Palliative Medicine4 (Table 1).

CONCLUSIONS

The growth in palliative care specialists and programs in hospitals in the United States represents a grass roots professional response to the needs of a patient population with chronic advanced illnesses and family care burdens within a healthcare system structured to provide care for acute intercurrent illness. Rapid increases in the number of new hospital programs, as well as early studies indicating improved clinical, satisfaction, and utilization outcomes, suggest that palliative care services are likely to become a routine and well‐integrated part of the healthcare continuum in the United States over the next several years. A number of resources are available to healthcare professionals seeking more training as well as to hospitals or nursing homes wishing to establish their own clinical or educational programs. Such programs have provided a platform for both newly graduated and seasoned professionals to continue to serve the needs of their patients through the assessment and relief of suffering, provided simultaneously with efforts to cure or mitigate disease.

The field of palliative care has grown rapidly in recent years in response to patient need and clinician interest in effective approaches to managing chronic life‐threatening illness.1 This article reviews the clinical, educational, demographic, and financial imperatives driving this growth, describes the clinical components of palliative care and the range of service models available, defines the relationship of hospital‐based palliative care to hospice, summarizes the literature on palliative care outcomes, and presents practical resources for clinicians seeking knowledge and skills in the field.

DEFINITION

Palliative care is medical care focused on the relief of suffering and support for the best possible quality of life for patients facing serious, life‐threatening illness and their families. It aims to identify and address the physical, psychological, and practical burdens of illness. Palliative care in the United States grew out of the hospice movement that originated in both the United Kingdom and the United States about 30 years ago. Hospice care was developed specifically to address the needs of the dying and their families and was codified in the United States by the addition in 1983 of a federal Medicare benefit for hospice care. In the last 30 years the Medicare hospice benefit has enabled more than 7 million patients and their families to receive intensive palliative care for the terminally ill, primarily in the home. The growth in the number and needs of seriously and chronically ill patients who are not clearly terminally ill has led to the development of palliative care services outside the hospice benefit provided by Medicare (and other insurers). Both hospice and nonhospice professionals have participated in extending the hospice approach through development of palliative care services. Palliative care may be delivered simultaneously with all appropriate curative and life‐prolonging interventions. In practice, palliative care practitioners provide assessment and treatment of pain and other symptom distress; employ communication skills with patients, families, and colleagues; support complex medical decision making and goal setting based on identifying and respecting patient wishes and goals; and promote medically informed care coordination, continuity, and practical support for patients, family caregivers, and professional colleagues across healthcare settings and through the trajectory of an illness.1, 2

Palliative care is both a general approach to health care and a growing practice specialty for professionals committing most or all of their time to the delivery of palliative care services.3 The term palliative medicine refers to the physician discipline within the larger field of palliative care. As of 2005, more than 1890 physicians have received specialty certification through a palliative care credentialing exam given by the American Board of Hospice and Palliative Medicine.4 Formal recognition of the subspecialty is currently being sought in collaboration with the American Board of Medical Specialties.5 As of August 2005, there were more than 50 postgraduate palliative care subspecialty fellowship programs in the United States.6 Between 2000 and 2003, the American Hospital Association (AHA) annual survey recorded a 67% growth in the number of hospital‐based palliative care programs reported, from 632 to 1027, for a total of 25% of responding AHA member hospitals.7

REASONS FOR GROWTH IN PALLIATIVE CARE

A primary justification for the rapid growth in palliative care programs in institutional settings is the abundant data demonstrating the high prevalence of pain and symptom distress in hospitals,811 nursing homes,12, 13 and community settings.14 Virtually all persons with serious illness spend at least some time in a hospital, usually on multiple occasions, in the course of their disease or condition.15 Despite the finding that when polled more than 90% of Americans say they would prefer to die at home, more than 75% of adult deaths occur in institutional settings (hospital or nursing homes)more than 50% in hospitals and 25% in nursing homesand 85% of pediatric deaths occur in hospitals.16, 17 Further, more than half of persons older than age 85 die in a nursing home and 43% of persons older than age 65 reside in a long‐term care facility at some time before they die,1821 a figure projected to rise substantially over the next several decades. The much larger number of patients who are not dying but are living with chronic, debilitating, and life‐threatening illness also need expert symptom management, communication and decision‐making support, and coordination of care across settings. In one national survey, physicians reported that poor care coordination resulted in patient communication problems, lack of emotional support for patients, adverse drug reactions, unnecessary hospitalization, patients not functioning to potential, and unnecessary pain.22 In addition to studies demonstrating high degrees of symptom distress across all age groups in hospitalized and nursing home patients,814 other works have shown high use of burdensome, nonbeneficial technologies among the seriously ill,2327 caregiver burden on families,2831 and communication problems between these patients, their families, and their treating physicians about the goals of care and the medical decisions that should follow.32, 33 Other studies have reported broad dissatisfaction with the general quality of care for the seriously ill and dying in hospitals and nursing homes,18, 34 specifically, perceptions of impersonal and indifferent care. Several studies of patients and their families have identified relief of suffering, practical support needs, open communication, and opportunities to relieve burdens on and strengthen relationships with family as the top‐priority needs from the healthcare system.3440

The growth in the number and needs of the elderly with multiple chronic conditions who will turn to the healthcare system in coming years underscores the need to create a delivery system in the United States that can be responsive to these priorities. By 2030 the number of persons with chronic conditions will exceed 157 million.4144 With the possible exception of advanced cancer conditions (accounting for 24% of adult deaths), in which prognosis is somewhat more reliably linked to performance status,4243 prognostication of outcome is a highly inexact science for the chronically ill of all ages and in a range of diagnostic categories, including stroke, dementia, and end‐stage cardiac, renal, hepatic, and pulmonary diseases. This has been a major part of the impetus for the growth in palliative care services not predicated on a link to terminal prognoses.4143 Hospitals and nursing homes are under increasing pressure to structure care processes in a manner fitted to the needs of the seriously ill because of studies demonstrating poor quality of care, demands from patients and families, accreditation requirements, and the costs of care for this patient population. More than 95% of Medicare spending goes to the 63% of Medicare patients with two or more chronic conditions, and three quarters of Medicare dollars go to hospitals.44 Hospital costs have risen nearly 10% per year in each of the last 2 years, because of both the increasing numbers of patients turning to them for care and the growth in the number and expense of effective life‐prolonging therapies. These forces have stimulated the development of new models for the efficient and effective care of patients with serious and complex illness.2227, 44

CLINICAL COMPONENTS

The three primary domains of palliative care clinical practice are assessment and treatment of pain and other symptom distress, including psychiatric symptoms64; communication about goals of care and support for complex medical decision making; and provision of practical and psychosocial support, care coordination, and continuity, as well as bereavement services if death occurs.1, 2, 65 Palliative care specialists work to support primary and specialist physicians in the care of complex and seriously ill patients by providing intensive bedside treatment and reassessment of multiple‐symptom distress, by helping with time‐consuming and difficult interactions with distressed patients and family members, and by attempting to ensure a seamless, safe, and well‐communicated discharge and follow‐up process after the patient leaves the hospital.66 Resources for physicians seeking more knowledge or training in the treatment of symptom distress and other aspects of palliative care are given in Table 1.

The core components of symptom management67, 68 include: 1) Routine and repeated formal assessment, without which most symptoms will be neither identified nor addressed; 2) Expertise in prescribing, including the safe use of opioid analgesics, adjuvant approaches to pain management, and management of a wide range of other common and distressing symptoms and syndromes including, for example, delirium, dyspnea, fatigue, nausea, bowel obstruction, and depression69; and 3) Skillful management of treatment side effects, which is required to successfully control symptoms.

Communication skills and effective support for making decisions about clinical care goals include not only fundamental physician responsibilities such as communicating bad news and elucidating patient wishes for future care, but also the ability to promote communication and consensus about care goals among multiple specialist consultants, to address and resolve disagreements and conflicts among patients, families, and providers about goals of care, and to assist in the evolving process of balancing the benefits with the burdens of various medical interventions.32, 7073

The great majority of care for an illness is provided at home by family members neither trained nor emotionally prepared for these responsibilities.51, 74 The burden on family caregivers is one of the top concerns of seriously ill patients.35 Patients and families often struggle with anxieties about doing the wrong thing, difficulty traveling to physicians' offices, social isolation, and a high prevalence of preventable suffering of all types.3440 Palliative care clinicians attempt to improve the success and sustainability of the discharge plan by providing medically informed and therefore more appropriate care management recommendations and by mobilizing a range of community resources to increase the likelihood that families will be able to manage the care at home with the necessary supports and backups in place, including appropriate screening and referrals for complicated grief and bereavement.51, 75, 76 Several small prospective studies of palliative care have suggested that palliative care has resulted in reduction in the number of emergency department visits and hospitalizations and in the length of hospital stays, presumably because of the efficacy and comprehensiveness of care coordination in averting crises.54, 55, 61, 9798

CLINICAL MODELS

Given the multifaceted approach needed to support patient quality of life throughout advanced illness, one profession or individual cannot be expected to provide all aspects of palliative care. As described in the recently completed National Consensus Project Guidelines for Quality Palliative Care,2 specialty‐level palliative care is optimally delivered through an interdisciplinary team consisting of appropriately trained and credentialed physicians, nurses, and social workers with additional support and contributions from chaplains, rehabilitative experts, psychiatrists, and other professionals as indicated. Clearly, however, the staffing of a palliative care program will depend critically on the needs and capacities of the setting. A full interdisciplinary team is needed for a large tertiary‐care teaching hospital, whereas a part‐time advance‐practice nurse with backup from colleagues as needed may suffice for a small rural hospital or long‐term care setting. Specialist‐level palliative care is delivered through a range of clinical models and settings, including inpatient consultation services, dedicated inpatient units, and outpatient practices, among others.77, 78 Programs within the United States are housed in a range of clinical subspecialties including oncology, geriatrics, nursing, case management, hospitalist, and other programs, depending on the locus of leadership and administrative support.77, 78 Most programs are supported by utilizing diverse sources,77 including physician and nurse‐practitioner billing through insurers such as Medicare Part B,53, 81 as well as hospital support typically predicated on cost avoidance analyses, foundation and other grants, and philanthropy. Detailed guidance on appropriate documentation and billing for palliative care physician services may be found in Schapiro et al.,53 von Gunten,79 and on the Web site of the Center to Advance Palliative Care (www.capc.org).77

RELATIONSHIP TO HOSPICE

Although new clinical specialties in palliative medicine and nursing are emerging, in the United States palliative care for those in the terminal stages of illness has been delivered through hospice programs for more than 30 years. Under current regulatory and payment guidelines hospice care is delivered to patients who are certified by their physicians as likely to die within 6 months if the disease follows its usual course and who are willing to give up insurance coverage for medical treatment primarily focused on cure or prolongation of life. It is noteworthy that there is great variability among United States hospices, with some able to support continued disease‐modifying treatments such as chemotherapy and radiation if a patient so desires.2 Hospice programs aim to create increased opportunity for death at home, focusing on symptom control and the psychological and spiritual issues that are paramount to persons in the terminal phases of illness. Once the hospice benefit has been accessed, patients and families receive comprehensive case‐managed services across all settings of care (although the great majority of hospice care is delivered at home) from an interdisciplinary team, coverage for medications and equipment related to the terminal illness, and practical, psychosocial, respite, and bereavement support for caregivers.80, 81 Several recent studies have confirmed the findings of an earlier work82 in demonstrating the beneficial outcomes of hospice care including reduced mortality in spouses and high levels of family satisfaction.18, 83 Palliative care programs based in both hospital and community settings have led to increases in hospice referral rates and hospice length of stay, promoting continuity of palliative care and the intensive palliation and family support needed as death approaches.55 Coordination and partnerships between palliative care and hospice programs are critical to achieving continuity of palliative care throughout the full course of an illness and across the continuum of care settings.2

IMPACT OF PALLIATIVE CARE ON QUALITY OF CARE

Reports on palliative care specialist services utilizing diverse models and approaches have suggested a range of benefits from palliative care, including reduced pain4547 and other symptom distress,45, 48, 49 improved health‐related quality of life,95 high patient and family satisfaction18, 4951, 96 with care and with physician communication, and increased likelihood of the location of death being outside a hospital.33, 49, 52, 9799

Because it can help to demonstrate care structures, processes, and outcomes associated with improved quality (such as routine assessment of pain in the hospital), a palliative care program may help hospitals measure and meet Joint Commission for Accreditation of Healthcare Organizations (JCAHO) requirements in the domains of pain management, communication, family and patient education, and continuity of care, among others.53 Several groups have reported marked increases in hospice referral rate and hospice length of stay as a result of hospital‐ and nursing‐home‐based palliative care programs, presumably as a result of enhanced case identification, counseling, and referral processes.54, 55 Case control and observational studies of palliative care and ethics consultation services have demonstrated reductions in costs per day and in hospital and ICU lengths of stay, presumably because of enhanced support for discussions about the goals of care and the resulting facilitation of patient and family decisions about the types and settings of future care.50, 5561 Hospitals have begun to invest in palliative care services, both to enhance quality of care and because of their measurable impact on reducing ICU and total bed days and their efficacy in supporting transitions from high‐intensity, high‐cost hospital settings to more appropriate and desired care settings, such as the home.5563, 9798 Observational studies have yielded no differences in mortality between patients receiving palliative care and controls receiving the usual care.48, 55, 56

EDUCATION IN PALLIATIVE CARE

Curricular content on palliative care has been noticeably lacking from medical and nursing education curricula, textbooks, and certifying examinations, although this is beginning to change.8491 Both the Liaison Committee for Medical Education (LCME) and the Accreditation Council for Graduate Medical Education (ACGME) now require or strongly encourage programs to provide under‐ and postgraduate training in palliative care in order to be accredited.89, 90 As of 2005, more than 50% of teaching hospitals had established palliative care clinical services,92 which constitute the necessary platform for clinical training. The rapid growth in the availability of postgraduate fellowship training in palliative medicine will produce the faculty leaders needed for these educational and research programs in medical school and residency training programs.93, 94 Physicians in practice may gain knowledge and skills through a range of national courses and Web‐based resources and through preparation for the certifying exam given annually by the American Board of Hospice and Palliative Medicine4 (Table 1).

CONCLUSIONS

The growth in palliative care specialists and programs in hospitals in the United States represents a grass roots professional response to the needs of a patient population with chronic advanced illnesses and family care burdens within a healthcare system structured to provide care for acute intercurrent illness. Rapid increases in the number of new hospital programs, as well as early studies indicating improved clinical, satisfaction, and utilization outcomes, suggest that palliative care services are likely to become a routine and well‐integrated part of the healthcare continuum in the United States over the next several years. A number of resources are available to healthcare professionals seeking more training as well as to hospitals or nursing homes wishing to establish their own clinical or educational programs. Such programs have provided a platform for both newly graduated and seasoned professionals to continue to serve the needs of their patients through the assessment and relief of suffering, provided simultaneously with efforts to cure or mitigate disease.

I'm used to feeling inadequate. Oftentimes, what ails my patients I'm not able to address, let alone fix. But one time I crossed the line from absorber of sorrows to active agent.

All set with my preconceived notions, I went into the hospital room to see Stan. He had severe hypertension and had had several previous transient ischemic attacks, and now he was back with another. His renal function was minimal, with dialysis coming soon. Despite our repeatedly having social work arrange outpatient appointments, he had never followed up. Last admission, they even gave him a month's worth of his antihypertensive medications, but here he was 6 weeks later off meds and admitted again.

I spoke with him but we got nowhere. He maintained that he could not afford his medication. I asked him why he didn't work. He said that he did do odd jobs, and besides, in a few months he would qualify for Social Security. I guess I was in a bad mood, so I heard myself ask, Do you realize you are playing with fire here? You will end up with a real stroke? Simply saying you want to wait for Social Security is not a plan.

Stan looked at me closely. Probably judging me to be about half his age, he said, Whatever, doc. Don't you have someone else to lecture? I sat down, took a deep breath, and tried to sound kind when I said, Do you realize that you will need dialysis soon? Stan replied that he had no intention of going on dialysis. We went in circles, with me trying to determine if he was delusional, suicidal, or trying to shock me. We left it as it was. The medical system would do its best, but his life was his to run.

Bending the HIPPA rules, I went to the nurse's station and called Stan's daughter to get some background, answers to questions like why she couldn't help him buy his medication. I was wholly in my righteous problem‐solving mode. Yet she was not alarmed by my dire prognostics. When the call was about to end, I asked if all of us could meet when she came to pick him up the next day. After a pause, she stated, I'm not coming up. Tell him to wait in the lobby for me. I'll be there to pick him up sometime after 5. Collecting her dad from the hospital on Christmas Eve, and she couldn't be bothered to enter the building? I hung up, sat back in my chair, and stared at my progress note.

I subsequently found out from the case manager that after being discharged, unlike before, he was going to a homeless shelter, not his daughter's house. I thought he must have been an awful father for a child to turn her own dad away on Christmas Eve.

Clearly, she had had no intention of picking him up from the hospital before my call; I had inadvertently shamed her into it.

I went back to talk with Stan. I decided to make inquiries of him based only on the information I was supposed to have. The case manager tells me you're going to the homeless shelter tomorrow. Don't you live with your daughter?

Not realizing that the doctors and case managers were on the same team, he seemed somewhat taken aback. I found a chair and sat down as he spoke. I wasn't always like this, you know. I'm not a drinker, nuts, or anything; I just was put out to pasture. I'm a computer programmer but not the new kind. I worked on those huge 1960s types. The personal computer revolution put me out of business. Before I had a chance to say anything, he continued, I know what you're thinking, I should have gotten trained or something to keep up, but I didn't, you know, I just didn't. I should've.

He must have seen a flicker of compassion on my face, as he went on, I've been staying with my daughter on and off for years. I'd get some job, get a place, but never for long. I don't like to stay with her. She has her own life, her own problems. She doesn't need me getting in the way, especially around Christmas. Around the holidays, I go to the shelter. My grandkids don't need me ruining the season.

He may well have been a lousy father, but I didn't see his medical noncompliance as a personal affront anymore. He should have made some different decisions in the past, but now he was a 64‐year‐old homeless man, alone. So, besides lecturing him on his blood pressure and work habits, could I do anything really helpful?

It didn't take me long to come up with something. The problem was how to approach it. Feeling like I was breaking some rule, I trailed him to the hospital lobby right after discharge. To my chagrin, he didn't so much as slow down. He saw his daughter's car, walked out, and got in her car before I knew what to do. Feeling like a fool, I stood at the window, noted how slate gray and dour the sky was, in complete contrast to the festive lobby, and thought about how useless I really was in the end. All my good intentions aside, he was no better off for having me as his doctor.

I bought myself a cup of coffee and while walking lost in thought, I literally bumped into Stan coming through the hospital's main doors. Laughing awkwardly, he said, I forgot my jacket in my room. He looked more scared now than he did after hearing my dire pronouncements of doom. He seemed like a child whose mother was angry at his forgetfulness. As he shuffled off, I couldn't stand it any longer. I didn't want him rushing around worried that his daughter would get fed up and leave. I told him to tell his daughter that I knew where his jacket was and that I'd be right back with it.

I got the coat, and when I approached him back in the lobby, I gave it to him. I then handed him the money I had set aside in my white coat. Trying to make myself sound casual, I said, Use this to take your grandkids out to dinner and buy them something. Neither wanting to give him a chance to say no nor wishing to make it more awkward for him, I quickly turned around and left without looking back.

As I resumed my $2 cup of coffee, I wondered if I had acted as a doctor, as a good Samaritan, or as an egoist? I was not deluded into believing I could buy his pride back for long with my pocket change. But maybe I could be a good person in addition to a caring, up‐to‐date doctor.

Later that day in the ER, a very sad place on Christmas Eve, I imagined Stan buying gifts or a fancy dinner for his family, just like he used to. He will need dialysis and probably will end up back in the shelter. I don't think he even knew my name, but maybe because I cared a little bit about what happened to him, he will, too.

I'm used to feeling inadequate. Oftentimes, what ails my patients I'm not able to address, let alone fix. But one time I crossed the line from absorber of sorrows to active agent.

All set with my preconceived notions, I went into the hospital room to see Stan. He had severe hypertension and had had several previous transient ischemic attacks, and now he was back with another. His renal function was minimal, with dialysis coming soon. Despite our repeatedly having social work arrange outpatient appointments, he had never followed up. Last admission, they even gave him a month's worth of his antihypertensive medications, but here he was 6 weeks later off meds and admitted again.

I spoke with him but we got nowhere. He maintained that he could not afford his medication. I asked him why he didn't work. He said that he did do odd jobs, and besides, in a few months he would qualify for Social Security. I guess I was in a bad mood, so I heard myself ask, Do you realize you are playing with fire here? You will end up with a real stroke? Simply saying you want to wait for Social Security is not a plan.

Stan looked at me closely. Probably judging me to be about half his age, he said, Whatever, doc. Don't you have someone else to lecture? I sat down, took a deep breath, and tried to sound kind when I said, Do you realize that you will need dialysis soon? Stan replied that he had no intention of going on dialysis. We went in circles, with me trying to determine if he was delusional, suicidal, or trying to shock me. We left it as it was. The medical system would do its best, but his life was his to run.

Bending the HIPPA rules, I went to the nurse's station and called Stan's daughter to get some background, answers to questions like why she couldn't help him buy his medication. I was wholly in my righteous problem‐solving mode. Yet she was not alarmed by my dire prognostics. When the call was about to end, I asked if all of us could meet when she came to pick him up the next day. After a pause, she stated, I'm not coming up. Tell him to wait in the lobby for me. I'll be there to pick him up sometime after 5. Collecting her dad from the hospital on Christmas Eve, and she couldn't be bothered to enter the building? I hung up, sat back in my chair, and stared at my progress note.

I subsequently found out from the case manager that after being discharged, unlike before, he was going to a homeless shelter, not his daughter's house. I thought he must have been an awful father for a child to turn her own dad away on Christmas Eve.

Clearly, she had had no intention of picking him up from the hospital before my call; I had inadvertently shamed her into it.

I went back to talk with Stan. I decided to make inquiries of him based only on the information I was supposed to have. The case manager tells me you're going to the homeless shelter tomorrow. Don't you live with your daughter?

Not realizing that the doctors and case managers were on the same team, he seemed somewhat taken aback. I found a chair and sat down as he spoke. I wasn't always like this, you know. I'm not a drinker, nuts, or anything; I just was put out to pasture. I'm a computer programmer but not the new kind. I worked on those huge 1960s types. The personal computer revolution put me out of business. Before I had a chance to say anything, he continued, I know what you're thinking, I should have gotten trained or something to keep up, but I didn't, you know, I just didn't. I should've.

He must have seen a flicker of compassion on my face, as he went on, I've been staying with my daughter on and off for years. I'd get some job, get a place, but never for long. I don't like to stay with her. She has her own life, her own problems. She doesn't need me getting in the way, especially around Christmas. Around the holidays, I go to the shelter. My grandkids don't need me ruining the season.

He may well have been a lousy father, but I didn't see his medical noncompliance as a personal affront anymore. He should have made some different decisions in the past, but now he was a 64‐year‐old homeless man, alone. So, besides lecturing him on his blood pressure and work habits, could I do anything really helpful?

It didn't take me long to come up with something. The problem was how to approach it. Feeling like I was breaking some rule, I trailed him to the hospital lobby right after discharge. To my chagrin, he didn't so much as slow down. He saw his daughter's car, walked out, and got in her car before I knew what to do. Feeling like a fool, I stood at the window, noted how slate gray and dour the sky was, in complete contrast to the festive lobby, and thought about how useless I really was in the end. All my good intentions aside, he was no better off for having me as his doctor.

I bought myself a cup of coffee and while walking lost in thought, I literally bumped into Stan coming through the hospital's main doors. Laughing awkwardly, he said, I forgot my jacket in my room. He looked more scared now than he did after hearing my dire pronouncements of doom. He seemed like a child whose mother was angry at his forgetfulness. As he shuffled off, I couldn't stand it any longer. I didn't want him rushing around worried that his daughter would get fed up and leave. I told him to tell his daughter that I knew where his jacket was and that I'd be right back with it.

I got the coat, and when I approached him back in the lobby, I gave it to him. I then handed him the money I had set aside in my white coat. Trying to make myself sound casual, I said, Use this to take your grandkids out to dinner and buy them something. Neither wanting to give him a chance to say no nor wishing to make it more awkward for him, I quickly turned around and left without looking back.

As I resumed my $2 cup of coffee, I wondered if I had acted as a doctor, as a good Samaritan, or as an egoist? I was not deluded into believing I could buy his pride back for long with my pocket change. But maybe I could be a good person in addition to a caring, up‐to‐date doctor.

Later that day in the ER, a very sad place on Christmas Eve, I imagined Stan buying gifts or a fancy dinner for his family, just like he used to. He will need dialysis and probably will end up back in the shelter. I don't think he even knew my name, but maybe because I cared a little bit about what happened to him, he will, too.

I'm used to feeling inadequate. Oftentimes, what ails my patients I'm not able to address, let alone fix. But one time I crossed the line from absorber of sorrows to active agent.

All set with my preconceived notions, I went into the hospital room to see Stan. He had severe hypertension and had had several previous transient ischemic attacks, and now he was back with another. His renal function was minimal, with dialysis coming soon. Despite our repeatedly having social work arrange outpatient appointments, he had never followed up. Last admission, they even gave him a month's worth of his antihypertensive medications, but here he was 6 weeks later off meds and admitted again.

I spoke with him but we got nowhere. He maintained that he could not afford his medication. I asked him why he didn't work. He said that he did do odd jobs, and besides, in a few months he would qualify for Social Security. I guess I was in a bad mood, so I heard myself ask, Do you realize you are playing with fire here? You will end up with a real stroke? Simply saying you want to wait for Social Security is not a plan.

Stan looked at me closely. Probably judging me to be about half his age, he said, Whatever, doc. Don't you have someone else to lecture? I sat down, took a deep breath, and tried to sound kind when I said, Do you realize that you will need dialysis soon? Stan replied that he had no intention of going on dialysis. We went in circles, with me trying to determine if he was delusional, suicidal, or trying to shock me. We left it as it was. The medical system would do its best, but his life was his to run.

Bending the HIPPA rules, I went to the nurse's station and called Stan's daughter to get some background, answers to questions like why she couldn't help him buy his medication. I was wholly in my righteous problem‐solving mode. Yet she was not alarmed by my dire prognostics. When the call was about to end, I asked if all of us could meet when she came to pick him up the next day. After a pause, she stated, I'm not coming up. Tell him to wait in the lobby for me. I'll be there to pick him up sometime after 5. Collecting her dad from the hospital on Christmas Eve, and she couldn't be bothered to enter the building? I hung up, sat back in my chair, and stared at my progress note.

I subsequently found out from the case manager that after being discharged, unlike before, he was going to a homeless shelter, not his daughter's house. I thought he must have been an awful father for a child to turn her own dad away on Christmas Eve.

Clearly, she had had no intention of picking him up from the hospital before my call; I had inadvertently shamed her into it.