Palliative Care: Matching Patient Goals and Treatment Options
When people are admitted to the hospital, many find that the default approach to care is an aggressive one. But is that what elderly patients want? How many doctors take the time to discuss how their recommended treatment will impact the patient’s quality of life? In many instances, older patients could benefit from a conversation with the hospital’s palliative care team.
The Center to Advance Palliative Care (CAPC) estimated that in 2016, 75% of hospitals in the United States with more than 50 beds had a palliative care team. Palliative care is not the same as hospice (as a side note, hospice is a topic I’ll discuss in a future blog post). So, what is palliative care? The National Institutes of Health define palliative care as:
Appropriate for anyone with a serious illness
Care that can be provided in tandem with curative treatment
Care that focuses on patient comfort
Palliative care teams help patients clarify and articulate the goals they have for their own care. With that information, the palliative care specialists help ensure that treatment options are compatible with the patient’s wishes. Patients feel that they have more control over their quality of life.
If you are caring for an elderly parent and they have been hospitalized, has the clinical team ever offered to bring the palliative care team in for a consult? Unfortunately, many medical facilities and physicians lean toward aggressive treatments and palliative care an afterthought (if it’s thought of at all). This may be due to a treatment-focused culture or financial incentives that accompany fee-for-service care. Unfortunately, inadequate communication can lead to unwanted care or poor outcomes for older patients.
I have seen this dynamic in action with my own family. In 2017, my 88-year-old mother fell and broke five ribs. She was released from the hospital after one night and then went on to develop internal bleeding in her lung. She was readmitted to the hospital, where the doctors drained the blood, but her lung remained in a collapsed state. The specialists recommended a multi-hour, invasive procedure, called decortication, which would clear the residual blood from her lung.
At 88, my mother wasn’t interested in invasive surgery and a difficult recovery, despite the knowledge that opting out of the procedure could shorten her life. We learned that the hospital had a palliative care team, but it seemed to take days to get the attending physicians to connect us with that group. Unlike many families, we are blessed with a family member who is a geriatrician. She offered objective information to inform our decision-making. My mother and I had long conversations about her goals for treatment. She was clear that she didn’t want the procedure. We finally did get to speak to the palliative care team, but by that time, we’d reached our own conclusions. Earlier intervention from that team would have been beneficial.
For older individuals and their caregivers, I’d offer three takeaways if you are faced with hospitalization:
Ask if the hospital has a palliative care team. If you would like to discuss the goals for your treatment or you’d like to avoid aggressive interventions, request to engage with them early. As noted earlier, palliative care does NOT prevent patients from receiving curative treatments.
Get the facts about care options in a balanced and quantitative way. When it comes to surgical options, I have found that many physicians are reluctant to offer quantitative risk information based on the patient’s specific characteristics. This includes probability of dying during the procedure, probability of complications during the procedure, and likelihood of recovering to previous functional levels. Saying “all procedures have risks” is meaningless. The elderly have experienced a lot in their decades of living and deserve to hear the hard facts. This is the only way to make an informed decision.
Consider whether surgery and aggressive treatments are the right solution for your situation. The surgical remedy to a health issue that’s appropriate for a 40-year old isn’t necessarily the right answer for an 80 or 90-year old. Will the outcome be a well-functioning lung, heart, or other organ in the body of a person who is unable to recover fully and is ravaged physically and mentally by the toll of anesthesia, surgery, and painkillers? One benefit that palliative care specialists can provide is an evaluation of the “big picture” and data about the pros and cons of different options (including doing nothing).
It’s now a year and half since my Mom opted out of the invasive lung surgery. She is healthy, walks easily with her walker, and her cognitive state is good, despite some short-term memory issues. We took a gamble with palliative care and for us, it was the right decision. Even if my Mom’s outcome had been different and it easily could have been (e.g., pneumonia, complications, or death), we knew that we had aligned her treatment with her personal goals for her own care.
Photo Source: Unsplash