Leadership
Needs Assessment
Writing A Business Plan
Reimbursement
Delivery Models
Inter-Disciplinary Team
Physician
Nursing
Social Work
Pastoral Care/Chaplaincy
Program Operations
Quality Assessment






Physician

In a landmark article in the Journal of the American Medical Association titled "Initiating End-of-Life Discussions with Seriously Ill Patients" (2000; 284(19): 2502-07), Timothy E. Quill, MD, captures the essence of end-of-life care from the physician perspective: "Helping patients achieve as good and meaningful death as possible is part of what we do as physicians. When a physician provides patients with the honesty, expertise, advocacy, compassion and commitment they would want for themselves, they provide the highest care possible."

Unfortunately, however, many patients and families do not have the long-term relationship with a physician that facilitates this level of care. And even when such a relationship exists, it is often strained as the patient moves through the continuum of care -- for example, from outpatient care delivered by a primary care physician, to inpatient care given by a hospitalist, to home care delivered by hospice. Although the physician who has an established relationship with a patient often is in the best position to make palliative care decisions for that patient, this ideal is not always possible.

Nevertheless, one physician-whether he/she is the patient's primary care provider or not-should be responsible for coordinating the patient's palliative care. This responsibility is defined by a focus on relief of suffering -- physical, psychological, social and spiritual -- and on communicating with patient and family. It includes whole patient assessment, pain assessment and management, assessment and management of other symptoms, both physical and psychosocial and communication with patient and family (see table). In addition, as head of an interdisciplinary palliative care team, the physician should encourage the participation of all team members -- nurse, social worker, pharmacists, clergy, and others.

Interdisciplinary Team Physician
General Responsibilities

Aspect of Care Definition Comments
Whole Patient Assessment
  • Assessment for the patient at the end of life is organized by symptoms and functional activities rather than by organ system or anatomy.
  • Assessment includes disease history, physical symptoms, psychological symptoms, decision-making capacity, social circumstances, spiritual needs, practical needs, physical exam to provide baseline information.
  • Other members of the interdisciplinary team can conduct portions of this assessment.
  • Pain Assessment and Management
  • Assessment includes determining the nature, cause and personal context of pain. Diagnosis and treatment of the underlying causes should not delay use of analgesics to relieve pain.
  • Pain management plans are tailored to the individual. Management includes pharmacological and nonpharmacological interventions; patient /family/caregiver education; ongoing assessment of treatment outcomes; regular review of the plan of care.
  • Assessment of pain serves as a model for the full spectrum of other physical symptoms. It can serve as a gateway to assessment of other symptoms and dimensions of illness.
  • Adequate pain control is possible in more than 90% of patients if therapeutic approaches are applied systematically.
  • Involvement of other interdisciplinary team members is key to pain assessment and management.
  • Symptom Management
  • In the curative care model, symptoms are regarded as clues leading to diagnosis. Physicians assume symptoms will get better as the diseases get better.
  • In the palliative care model, symptoms are treated regardless of their relationship to the underlying disease.
  • Physiologic changes that occur at the end of life are complex. Treatment requires an understanding of underlying pathophysiology and appropriate pharmacology.
  • Many physicians have been trained to focus on diagnosis and treatment of disease via a problem-oriented method that does not emphasize symptom relief.
  • Anxiety, delirium and depression are common symptoms but are underrecognized and undertreated. Input from the family and interdisciplinary team members is valuable in recognizing and treating these symptoms.
  • Establishment of Goals of Care
  • The patient determines his/her course of care with help from family and guidance from the physician and other members of the interdisciplinary care team.
  • Goals of care can range from prevention to cure and from prolongation of life to achievement of a good death. Multiple goals may apply simultaneously, eg, restoring health and relieving suffering.
  • Physicians must be able to identify what is a reasonable prognosis, clarify patient and family goals/expectations, make adjustments according to the patient's culture, use appropriate language.
  • In order to strive for the same outcomes and avoid conflicting expectations, the physician should review priorities, goals and plans of care regularly with patient, family and other members of the interdisciplinary care team.
  • Adapted from: Emanuel LL, von Gunten CF, Ferris FD. The Education for Physicians on End-of-Life Care (EPEC) Curriculum, 1999.

    The Hospitalist's Role in Palliative Care

    A hospitalist is a physician-usually an internal medicine or family practice practitioner-who assumes responsibility from primary care providers for the care of hospitalized patients. The hospitalist spends at least 25% of his/her time in this role.

    The advantages of having hospitalists deliver palliative care include:

    • Availability to patients and families;
    • Familiarity with inpatient care issues;
    • Dedication to improving hospital care;
    • Responsibility for patients on all services; and
    • Ability to increase hospice referrals.

    Challenges facing hospitalists who provide palliative care include:

    • Lack of training;
    • Discontinuity inherent in the concept of transferring responsibility for patient from primary care provider to hospitalist and vice versa (upon patient's discharge);
    • Lack of prior relationship with patient; and 
    • Focus on aggressive care.

    Related References

    1. American Board of Internal Medicine. Caring for the Dying: Identification and Promotion of Physician Competency. Philadelphia: American Board of Internal Medicine; 1996.

    2. American Medical Association. The Education for Physicians on End-of-Life Care (EPEC) Project, 1997. Chicago: American Medical Association; 1997.

    3. Baines MJ. ABC of palliative care: Nausea, vomiting, and intestinal obstruction. BMJ 1997;315:1148-1150.
    http://bmj.com/cgi/content/full/315/7116/1148

    4. Billings JA. Recent advances: Palliative care. BMJ 2000;321:555-558.
    http://bmj.com/cgi/content/full/321/7260/555

    5. Brammer C, Gerrard G, Macdonald R. Clinical oncology. BMJ 1998;317:2.
    http://www.bmj.org/cgi/content/full/317/7156/S2-7156

    6. Colorectal Cancer Collaborative Group. Palliative chemotherapy for advanced colorectal cancer: Systematic review and meta-analysis BMJ 2000;321:531-535.
    http://www.bmj.org/cgi/content/full/321/7260/531

    7. Davis CL. ABC of palliative care: Breathlessness, cough, and other respiratory problems. BMJ 1997;315:931-934.
    http://bmj.com/cgi/content/full/315/7113/931

    8. Detmar SB, Muller MJ, Wever LDV, Schornagel JH, Aaronson NK. Patient-Physician Communication During Outpatient Palliative Treatment Visits: An Observational Study. JAMA 2001;285:1351.
    http://jama.ama-assn.org

    9. Faber-Langendoen K, Lanken PN for the ACP ASIM End-of-Life Care Consensus Panel. Dying Patients in the Intensive Care Unit: Forgoing Treatment, Maintaining Care. Ann Intern Med 2000;133:886-893.
    http://www.annals.org

    10. Falk S, Fallon M. ABC of palliative care: Emergencies. BMJ 1997;315:1525-1528.
    http://bmj.com/cgi/content/full/315/7121/1525

    11. Goldman A. ABC of palliative care: Special problems of children. BMJ 1998;316:49-52.
    http://bmj.com/cgi/content/full/316/7124/49

    12. Goodlin SJ, Jette AM, Lynn J, Wasson JH. Community physicians describe management issues for patients expected to live less than twelve months. J Palliat Care 1998;14:30-5.

    13. Hamel MB, Teno JM, Goldman L, Lynn J, Davis RB, Galanos AN, Desbiens N, Connors AF, Wenger N, Phillips RS for the SUPPORT Investigators. Patient Age and Decisions To Withhold Life-Sustaining Treatments from Seriously Ill, Hospitalized Adults. Ann Intern Med 1999;130:116-125.
    http://www.annals.org

    14. Hobbs FDR. ABC of colorectal cancer: The role of primary care. BMJ 2000;321:1068-1070.
    http://bmj.com/cgi/content/full/321/7268/1068

    15. Larson DG, Tobin DR. End-of-Life Conversations: Evolving Practice and Theory. JAMA 2000;284:1573.
    http://jama.ama-assn.org

    16. Lloyd-Williams M. Palliative medicine. BMJ 1999;319:2.
    http://bmj.com/cgi/content/full/319/7204/S2-7204

    17. O'Brien T, Welsh J, Dunn FG. ABC of palliative care: Non-malignant conditions. BMJ 1998;316:286-289.
    http://bmj.com/cgi/content/full/316/7127/286

    18. O'Neill B, Fallon M. ABC of palliative care: Principles of palliative care and pain control. BMJ 1997;315:801-804.
    http://bmj.com/cgi/content/full/315/7111/801

    19. Saunderson EM, Ridsdale L,  Jewell D. General practitioners' beliefs and attitudes about how to respond to death and bereavement: qualitative study  Commentary: Use of personal experience should be legitimized. BMJ 1999;319:293-296.
    http://www.bmj.org/cgi/content/full/319/7205/293

    20. Sykes J, Johnson R, Hanks GW. ABC of palliative care: Difficult pain problems. BMJ 1997;315:867-869.
    http://bmj.com/cgi/content/full/315/7112/867

    21. Wood CGA, Whittet S, Bradbeer CS. ABC of palliative care: HIV infection and AIDS. BMJ 1997;315:1433-1436.
    http://bmj.com/cgi/content/full/315/7120/1433

    PubMed, a service of the National Library of Medicine, provides access to over 11 million citations from MEDLINE and additional life science journals. PubMed includes links to many sites providing full text articles and other related resources.  Visit:  http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed


    Additional Resources

    Session A: Medicare Payments to Physicians

    Session C: Medicare Payments to Physicians

    Billing for the Professional Services of Physicians
    How to Fund Your Palliative Care Program
    Concurrent Session A
    June 2002, Seattle, WA
    Charles F. von Gunten, MD, PhD. FACP
    PowerPoint Presentation

    Billing Revision Bulletin
    How to Fund Your Palliative Care Program
    Concurrent Session D Part 1
    Reinbursement for Hospice Services
    June 2002, Seattle, WA
    Gretchen M. Brown, MSW & Susan Swinford, BSW, MSW

    Careplan Oversight Communication
    How to Fund Your Palliative Care Program
    Concurrent Session D Part 1
    Reinbursement for Hospice Services
    June 2002, Seattle, WA
    Gretchen M. Brown, MSW & Susan Swinford, BSW, MSW

    Hospice Physician Billing Chart
    How to Fund Your Palliative Care Program
    Concurrent Session D Part 1
    Reinbursement for Hospice Services
    June 2002, Seattle, WA
    Gretchen M. Brown, Connie A. Raffa, JD, LLM & Susan Swinford, BSW, MSW

    Medicare Part B Carrier Manual Revision
    How to Fund Your Palliative Care Program
    Concurrent Session D Part 1
    Reinbursement for Hospice Services
    June 2002, Seattle, WA
    Gretchen M. Brown, MSW & Susan Swinford, BSW, MSW

    Physician Billing Flowchart
    How to Fund Your Palliative Care Program
    Concurrent Session D Part 1
    June 2002, Seattle, WA
    Gretchen M. Brown, MSW & Susan Swinford, BSW, MSW PowerPoint Document

    Physician Certification
    How to Fund Your Palliative Care Program
    Concurrent Session D Part 1
    Reinbursement for Hospice Services
    June 2002, Seattle, WA
    Gretchen M. Brown, MSW & Susan Swinford, BSW, MSW

    Physician's Survey: a Needs Assessment Tool to Build Support
    This downloadable survey is designed for leadership to distribute within their institution. It can be used as a marketing tool to help assess attitudes, educate colleagues, solicit input and build a strong case for creating a palliative care program.

    Hospitalists: Opportunities and Challenges for Improving Inpatient Palliative Care
    A CAPC Management Training Seminar
    February, 2002 Tampa, FL
    PowerPoint Presentation

    Changing Physician Behavior -Grand Rounds
    Andrew Epstein, MD, partner, and Mark Wenneker, MD, MPH, Senior Consultant, discusses changing physician behavior about palliative care. The audio file is available for download.

    Impact of Palliative Care Education on Students
    Pull Up Three Chairs: Teaching Palliative Care at Mount Sinai School of Medicine, NY

    This video download shows physicians, physicians-in-training and nurse practitioners discussing their rotation in palliative care.

    US Palliative Medicine Fellowship Programs

    End-of-Life Care Curriculum Development
    Lebanon VA Medical Center

    Prospective Planning for Interventions in Patients Near the End of Life
    American Society of Anesthesiologists Newsletter
    Volume 65, Number 3

    Principles for Care of Patients at the End of Life: An Emerging Consensus among the Specialties of Medicine

    A Physician's Guide To Talking About End-of-Life Care
    This paper presents a practical four-step approach to conducting end-of-life discussions with patients and their families.

    The Palliative Care Consultation as a Teaching Tool
    A CAPC Fall Forum 2000 Workshop
    Audio Presentation

    Education for Physicians on End-Of-Life Care (EPEC)
    Educates physicians, through its core curriculum, on essential clinical competencies required to provide quality end-of-life care.


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