Utah's 'comfort care' gets a C from palliative care advocates
Access to palliative care for seriously ill Utahns lags behind most of the nation, despite many studies that show patients who receive comfort care even when they are near death live better and longer, a new state-by-state analysis says.
The report by the Center to Advance Palliative Care and the National Palliative Care Research Center crunched numbers on patients hospitalized for serious or life-threatening illnesses, including heart disease and cancer. Half of the states received a B grade for their efforts; Utah received a C, largely because only one of the state's for-profit hospitals included in the study had a palliative care team.
Across the nation, "the laggards seem to be the for-profits," said study co-author Sean Morrison, director of the National Palliative Care Research Center with the Mt. Sinai School of Medicine in New York.
"We don't have a good sense of why they would be," he said. "Palliative care teams reduce unnecessary and unwanted procedures."
The study looked at 28 Utah hospitals. Of the 15 hospitals with more than 50 beds, nine have a palliative care program. Five of the smaller hospitals have comfort care programs.
All but one of the Utah hospitals with palliative programs are nonprofits, with St. Mark's in Salt Lake City the sole exception.
Given 60 points in the analysis, Utah was one point shy of landing a B, the report shows. But even the higher grade represents a continued lack of patient access to palliative care in hospitals.
Palliative care teams can contribute to substantial cost savings by matching treatment with patients' goals, improving their quality of life and providing support for home care.
But there is one palliative specialist for every 1,200 people living with a serious or life-threatening illness, the report said. In Utah, just 25 doctors, 60 advanced-practice nurses and 70 registered nurses are certified for palliative medicine.
At the U., which has palliative care teams at the hospital and the Huntsman Cancer Institute, the doctors and nurses have duties other than comfort care, said Bruce Chamberlain, newly named to direct the University of Utah Palliative Care Service. Chamberlain works half-time as a hospitalist and the other half with the comfort care team.
"The need certainly outstrips demand," he said. "Hopefully we will grow to the point where my position can be supported full-time in palliative care."
About 90 million Americans are living with serious illness; that number is expected to more than double over the next 25 years, the Dartmouth Institute for Health Policy and Clinical practice has reported. By 2030, people over age 65 will account for 20 percent of the nation's population.
The boomer generation will achieve unprecedented longevity those who reach 65 are expected to live into their mid-80s but most will live with multiple chronic illnesses and could be helped by coordinated comfort care.
While hospitals have steadily added team-based palliative care, millions of Americans do not yet have access to it from diagnosis through the course of their illness, according to the report.
Morrison said his best guess for why for-profit hospitals are lagging is that their business models favor giving care instead of forgoing it, as palliative medicine patients tend to do.
America's health system, especially Medicare, was set up in the 1950s and '60s, when infectious disease largely had been conquered but before medical advances transformed heart disease, cancer and other serious ailments from killers into chronic illnesses that can be managed over time.
"What's happened," Morrison said, "is patients have changed."
According to the study, about 10 percent of all Medicare beneficiaries have five or more chronic conditions. Two-thirds of Medicare spending goes to cover this group's care. But that doesn't mean more profits.
"Nobody's making money on that 10 percent," Morrison said.
The for-profit IASIS hospitals in Utah examined in the report including Salt Lake Regional Medical Center and Davis Hospital and Medical Center were listed as not having palliative teams. But IASIS has partnerships with hospice and palliative care providers who care for patients in their hospitals, said Tedd Adair, vice president of clinical operations,
"Since the beginning of the year we have cared for 73 patients who were in need of hospice/palliative care in our IASIS hospitals," he said in a statement.
St. Mark's Hospital, part of the MountainStar Healthcare Network, established its palliative care teams in 2007, according to Becky Holgreen, assistant chief nursing officer. They include physicians, nurses, case managers and the pastoral care team.
The goal is to coordinate care in a manner that honors patient wishes and their right to choose among, refuse, or withdraw different treatment options, Holgreen said in a statement.
While palliative care is not formalized at other MountainStar hospitals, physicians and support teams work with community organizations to provide coordinated, specialized care to patients with serious illnesses, said public relations director Audrey Glasby.
One of the main obstacles to wider acceptance of palliative care is its association with hospice, which also is misunderstood, Chamberlain said.
Hospice is meant for people considered within six months of dying, while patients "don't have to be dying or even terminally ill" to receive comfort care, Chamberlain said. Palliative care can accompany curative and even aggressive treatment, or no treatment at all.
Palliative care can head off significant disability, Chamberlain said, pointing to a 2010 study published in the New England Journal of Medicine. It found giving palliative care to early-stage lung cancer patients led to significant improvements in mood and quality of life. Compared with patients receiving standard care, they had less aggressive care at the end of their lives but lived longer.
Often, patients believe that if they decline aggressive care, their doctors will abandon them which does happen when doctors tell patients who don't want chemotherapy that there's nothing else they can offer.
"We take the time to sit down with patients and family and really explore the care they want," Chamberlain said. "We talk to them realistically about what they can achieve, what they want to achieve."
What is palliative care?
Palliative, or comfort, care focuses on providing relief from the symptoms, stress and pain of any serious or life-threatening illness. It is appropriate for patients of any age and any stage of illness and can accompany curative treatment. The goal is to improve the quality of life and preserve the dignity of the patient and the family.
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