Palliative care's place in noncancer morbidity

There's rarely a time when only disease-modifying therapy is what's right for the patient, or only comfort measures. Having an integrated plan is best.

Imagine a firefighter rushing toward a burning house and being greeted by a member of the household.

“The house is on fire!” says the fireman.

“I worry that if you go in there, it might send the wrong message to the family,” says the homeowner.

“But I'm with the fire department,” the fireman responds.

“If you tell the family that, they might lose all hope,” says the homeowner.

That's how interactions between primary care doctors and palliative care consultants often go, said Rebecca N. Hutchinson, MD, FACP. She played a comic video about a firefighter and homeowner to the audience at her talk, “Palliative Care in the Noncancer Inpatient” to illustrate her point. The video has made its rounds among the palliative care community, proclaiming, “Palliative care. We're the fire department, not the fire.”

Ideally, palliative care should be integrated into treatment, Dr. Hutchinson said. “It's really just good, patient-centered care, and it's beneficial throughout the disease trajectory.”

There's rarely a time when only disease-modifying therapy is what's right for the patient, or only comfort measures. Having an integrated plan is best, she said. “You can do everything and palliate at the same time.”

One complication is that the trajectory of an illness in noncancer care is much different than cancer's trajectory. Dr. Hutchinson described the latter as a horizontal line, with a strong sudden dip downward as cancer progresses.

Noncancer's trajectory is more like a gentle swoop downward, but with sudden dips that represent repeated exacerbations or hospitalizations. The challenge is that physicians don't know which dip is the final one. In this trajectory, palliative care can help patients adjust to their chronic conditions and help them cope with a long-term illness.

Another key difference between cancer and noncancer palliative care is the continuation of treatment until the end of life. With cancer, chemotherapy is eventually stopped, Dr. Hutchinson said, while, for example, in chronic obstructive pulmonary disease (COPD), diuretics and bronchodilators are consistent with comfort. “In heart failure and COPD, there is no time when stopping disease-modifying medications is actually helpful.”

All conditions have palliative care needs, she continued. Studies are continually published showing that palliative care can benefit treatment of COPD, heart failure, pulmonary hypertension, trauma, liver failure, and multimorbidity.

Another obstacle to providing palliative care is who delivers it. There is one palliative care specialist for every 1,200 patients with a serious illness. Dr. Hutchinson compared that to the one cardiologist for every 71 patients with a myocardial infarction and one oncologist for every 141 cancer patients.

“The good news is while there aren't palliative care providers everywhere, all physicians can provide palliative care,” Dr. Hutchinson said. Internists and hospitalists already communicate with patients and families, control symptoms, coordinate care with subspecialists, and bring in psychological support.

A palliative specialist comes into play when managing complex and refractory symptoms, including behavioral and psychological ones. They also can referee disputes between physicians, frame prognostic conversations, help patients and families understand the process, and cope with uncertainty in decision making, she said.

Prognostic conversations are a challenge, Dr. Hutchinson noted. “We have to accept a certain degree of prognostic uncertainty. Just because you're uncertain doesn't mean that you don't have a clue,” she said. Not being certain can lead physicians to shut down and not communicate anything to the patient about a disease. “And that's really not helpful to patients and families. You do have an idea, and it's our job to communicate that.”

Another wrinkle is physicians being overly optimistic about how much time a patient may have left, often overestimating by a factor of four to six. The longer the duration of the patient-physician relationship, the greater the overestimate.

“It's a statement of how much we as physicians really care about our patients,” she said. “We care about these people, and we don't want them to die.”

One clue to how much time a patient may have left is functional status. Dr. Hutchinson described a patient who said that a year ago, he was walking and driving. Over the course of a year, that was cut back to use of a cane, next a walker, and finally a wheelchair. That's a really bad prognostic sign, and the rate of change matters even more, she said.

Dr. Hutchinson offered as another prognostic sign the “surprise question”: “Would you be surprised if this patient died in the next year?”

“This is a question that you can add to your rounds,” she said. “You can have this conversation with your team. Engage in thinking about the person's diagnosis.”