Editor’s note: The opinions expressed in this article are those of the author and do not reflect an official stance by the CSU Shiley Institute for Palliative Care.
The elevator doors opened and a white-haired physician entered without making eye contact. His hospital badge indicated Internal Medicine. I said “good morning” and he looked at me and scrutinized my badge quietly, without returning any greeting. Then he said, “Are you new here? I haven’t seen you around before.”
That seemed to be my moment to feel proud of the new role I had undertaken so I told him I had recently been hired onto the Palliative Medicine consulting service as a PA. His quiet, reserved expression changed very subtly. I saw it and felt a familiar discomfort rising in me.
As he got off the elevator, without looking at me, he said, “How depressing for you.”
The elevator went up two floors with no additional conversation between us. As he got off the elevator, without looking at me, he said “How depressing for you.” With his four-word pronouncement the depth of his bias against the meaning and role of palliative care threw a bucket of cold water on my enthusiasm. In my head arose a familiar refrain: “Here we go again.”
Even in this large hospital, which served a large military veteran population along with a low-to-middle income community, and which boasted an actual dedicated interdisciplinary palliative care team, the survival of our team would depend on great public relations by us toward everyone from cafeteria staff to hospital administration. I had faced this bias before in other settings and learned that we only would get one chance to do it right. If we falter there is little love to be found for our work.
Sadly such bias against palliative care, if not addressed whenever and wherever it exists, can create barriers to better understanding and collaboration, and to patients receiving access to palliative services. Some finesse is required to overcome those barriers—to effectively communicate about what we do and why it’s important to all medical providers, and to seriously ill patients and their loved ones.
Barriers to Accessing Palliative Care
After more than 20 years as a PA in various internal medicine specialties, and for the last two years in palliative medicine, I have compiled a list of the barriers I’ve encountered most often to patients’ access to palliative care. I have also thought deeply about how to address those barriers based on misinformation.
The art of discussing palliative care requires both respect for deeply held cultural and religious beliefs and courage of one’s convictions in demonstrating the benefits of palliative medicine. First, my list of common barriers:
- Long-held traditional, religious or more conservative professional perspectives about why “real” medicine, including procedures, surgeries, or aggressive treatment is always the standard of care in the hospital setting
- Regional and endemic geo-cultural beliefs that views palliative care as “giving up” on the patient
- Perceptions that the palliative care interdisciplinary teams are “stealing” patients from other physicians
- Lack of widely available community and ongoing family educational programs highlighting the benefits of palliative care for both patients and loved ones during critical and life-limiting illnesses
- Absence of a palliative medicine curriculum in most medical schools and PA programs
- Suboptimal ongoing outreach to healthcare administrators, health insurers, CMS, and physician groups for ongoing education about QOL improvements and cost benefits accompanying palliative care
Education Is the Answer to Expanding Access
Here are some elements to consider in addressing the known barriers to palliative care as we move forward in our specialty and within primary and emergency care. In the world of real estate the operative words are location, location, location. The corollary words in palliative care must be education, education, education.
Using the first principle of community health education (know your audience) we, as professionals in palliative medicine, will be well served by defining and understanding our four most appropriate audiences:
- Medical and PA students, nursing students, and medical residents in all disciplines
- Physicians, PAs, and NPs in all disciplines
- The community of patients, from NICU to the oldest old, and their loved ones
- CMS, health insurers, and the financial principals with every health organization and in academe
The following comprises possible strategies for each of the defined audiences.
Medical, PA, and nursing students, and medical residents, in all disciplines:
- Construct a required one semester course in palliative medicine for all first year and third year students in the above mentioned student groups
- Construct a mandatory rotation of at least two weeks in palliative medicine for ALL medical residency programs, including radiation, anesthesiology, surgery and subspecialty surgery, emergency medicine and psychiatry. Those in family medicine and internal medicine would complete this in year one and year three. All other medical and surgical residents would complete these rotations in year one and year four.
- If Fellowship training follows Residency completion, an additional two-week rotation with the palliative medicine team would be recommended for all Fellows, including those in infectious disease, allergy & immunology, and dermatology, to broaden their perspectives. The goal is to encourage least harm in the most vulnerable populations and creation of well-defined goals of care driven by patient wishes, first and foremost for every physician.
Physicians, PAs and NPs in all disciplines:
- Provide essential conceptual and conversational tools for all healthcare personnel and administrators to increase understanding of the role and timing of palliative care
- Every national board exam and ongoing CME cycle for all physicians and PAs and regularly required CEUs for NPs, would include a percentage of test questions about palliative medicine, hospice care and best practices.
Patients, families, payers, and academics:
- Encourage and facilitate community health discussions about what palliative care is, how it differs from hospice and how it benefits patients and families from birth to death.
Putting Patients and Families First
These ideas are not meant as abstractions; rather, they are intended to drive forward discussions that challenge the last century misconception that palliative care is depressing for those of us who operate under its guidance and wisdom.
In the 21st century, our charge as palliative care providers is to be bold in the pursuit of a strategy that says less is more: more compassionate, more life affirming, more cost effective and more patient-centered.
About the author:
Martie Lynch, PA, received her Master of Science in Physician Assistant Studies from Stanford University School of Medicine. She has worked as a PA for more than 20 years with practice experience in diverse areas including oncology, geriatrics, abdominal organ transplant, disaster medicine, academics, hospice and palliative medicine.