Allan Ramsay, MD, is medical director of Fletcher Allen’s Palliative Care Service.
Before I became a palliative care physician I was a family doctor for 30 years. Family physicians care for people through the entire life cycle- birth to death. Now I focus on making the last phase of our lives as full and productive as it can be. In this role, I find that my relationships with my patients and their families are very different – but equally rewarding. As the medical director of the Fletcher Allen Palliative Care Service, I get many questions like the ones below. I hope you’ll take a moment to read these – and feel free to ask me any other questions you might have.
“I have congestive heart failure and my doctor suggested a palliative care consult. Why would I need that?”
Palliative care is a relatively new field of medicine. Palliative care specialists are trained to provide the best possible symptom relief for people with chronic or life- limiting conditions. The most common problems we manage include pain, shortness of breath, anxiety, confusion, or even constipation.
Another common reason for a palliative care consultation is to help people understand what might happen to them in the future. Most studies show that over 80% of people facing a life-limiting disease want “all possible information” about their prognosis. Being able to discuss this in a way that is hopeful and focuses on a person’s goals is a special skill of palliative care consultants.
Fletcher Allen has had palliative care specialists since 1998 and the Palliative Care Service has grown significantly in the past two years. Palliative care consultations are provided at Fletcher Allen by board certified physicians or advanced practice nurses.
“My family said palliative care is just like hospice, I am not ready for hospice yet.”
While there are similarities between palliative care and hospice, they are not the same. Both provide expertise in controlling symptoms, and both believe in the importance of making every day of remaining life as good as it can be. In addition, they both share the philosophy that a person’s values should determine what medical care he or she receives.
But there are significant differences. Enrollment in hospice generally requires that the person’s estimated life expectancy is six months. In palliative care, there is no specific prognosis or life expectancy. Determining an exact prognosis in a condition like congestive heart failure is difficult because there are so many treatments that can prolong a person’s life.
Many people are afraid of the term hospice. They think it means the end is near. This is not true. Medicare studies have found that people with congestive heart failure who enroll in hospice care live longer than those who don’t. Improving the quality of our lives makes us live longer – whatever health problems we are facing!
Palliative care is available to anyone at Fletcher Allen and is provided by the Visiting Nurse Association when a person goes home. Vermont is fortunate to have the best palliative care availability of any state. One hundred percent of Vermont hospitals (larger than 50 beds) have a palliative care program.
“You talk about a person’s goals and values. I have an advance directive, won’t that tell my other doctors what I do and don’t want?”
Advance directives have been available since the mid-nineties. Only a small percentage of people have completed their advance directives and they are rarely updated. The interventions for keeping people alive have changed dramatically over the past fifteen years. Many of these are burdensome and only keep people alive; they do not restore meaningful life. Palliative care is the specialty in the hospital that tries to understand the whole person – their medical condition, their family, their spirituality, and most importantly, their values. When that is done well, complicated decisions about life-supporting therapies are made more effectively.
If you would like to learn more about the Palliative Care Service at Fletcher Allen go to the following site:
http://www.fletcherallen.org/services/other_services/specialties/end_of_life_care/
Read more about palliative care, including the following:
www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande?printable=true
Allan Ramsay, MD, is medical director of Fletcher Allen’s Palliative Care Service.
Great commentary, Allan. Many patients and families I speak with are terrified of the term “hospice” because they feel they are giving up on their loved ones. As well, when they hear the phrase “hospice and palliative care” together, they sometimes feel they are synonymous….which as you clearly explain, they are not. There are meaningful differences – yet each has an important role in quality patient care. Thank you for explaining the differences and similarities so clearly. Well done!
It seems like palliative care could also be applied to situations where the patient is considering “quitting” medications that may reduce chances of recurrence, due to the severity of side effects. For example, breast cancer patients taking tamoxifen or aromatase inhibitors.
Does this happen frequently?
Palliative care experts are trained to treat symptoms and provide
comfort. This includes the side effects of disease modifying therapies
such as chemotherapy or hormonal therapies like tamoxifen or
aromatase inhibitors. If the therapy is able to control the disease process
and prolong life every effort should be made to make it acceptable. If
the burden of the therapy becomes overwhelming palliative care
consultants are also able to discuss whether it is achieiving the right goal.
Hi Allan,
Great post! Are there any differences in what insurance will pay for? Or will they generally pay for both hospice (if you have less than 6 months to live) and palliative care?
Thanks!