Episode 1: Palliative Care
Alongside the common fear of dying alone, many patients fear suffering at the end of life. This first episode of The Talk looks at the often misunderstood field of palliative care as an option for addressing pain and helping patients define their goals of care. Physicians discuss common misperceptions about what palliative care offers and suggestions for initiating earlier conversations with patients and families about the benefits of palliative care during the complete trajectory of an illness.
Palliative care is often incorrectly assumed to mean an automatic end to medical treatment of a disease or “giving up” when, in fact, it can be used alongside treatment as a way to minimize discomfort. Christina Ritchie, a geriatrician and palliative care physician in San Francisco, clarifies that the aim of palliative care is to “help people live as well as they can for as long as they can,” by addressing symptoms, suffering and distress.
Given the shortage of board-certified hospice and palliative medicine specialists in California and the aging California population, nursing home and hospice director Karl Steinberg believes “we need to deputize the primary care workforce – family physicians, internists, nurse practitioners and PAs – to carry some of that burden of this huge patient population who are in need of palliative care services.”
With some additional training in communication skills and pain management, family physicians may be especially suited to take on this task given their core belief in the importance of communication and trust within the doctor/patient relationship. Retired family physician Bo Greaves agrees that “palliative care is the most important thing for family medicine to evolve into.”
Physicians in a variety of practice settings share tips on how to facilitate conversations about palliative care with patients and families, as well as the benefits and challenges of implementing palliative care into an existing primary care practice.
Discussions about palliative care may be prompted by a serious or terminal diagnosis. When giving such a diagnosis, physicians should keep in mind that patients may not hear much more than the first few words. They share helpful techniques for giving bad news, helping patients make decisions around course of treatment and focusing on what outcomes are important to them. These conversations can help determine what patients are both willing and unwilling to go through to reach these goals and thereby guide the course of care.
Dr. Ritchie encourages physicians not to underestimate the power of remaining quiet after a serious diagnosis. Palliative care physician Gregg VandeKieft often follows a diagnosis with an intentionally open-ended question: “one of the first questions I always ask a patient and their family is ‘what do you understand about your situation?’” These communication approaches can help build trust and encourage patient and family engagement.
In addition to addressing specific symptoms, palliative care offers an opportunity to help patients define what quality of life means to them and to articulate their specific goals for the time they have left. These goals may be physiological – to avoid pain, incontinence or immobility – as well as psychological or emotional – to repair a relationship, attend a loved one’s graduation or milestone event. Conversations about palliative care can help clarify what these goals are and how, in turn, to design a care plan to best honor those wishes.
Family physician Chris Flores observes that, “We have a tendency in medicine to view a terminal diagnosis as a failure of medical care, to view that as a hopeless situation,” but encourages physicians to consider the possibility that patients can experience great happiness and joy even in their final months of life. Palliative care conversations may help make that possible.
For more information on palliative care, CAFP recommends the following resources:
- Weaving Palliative Care into Primary Care: A Guide for Family and Primary Care Physicians and Their Practice Teams
- California Hospice and Palliative Care Association
- The Center to Advance Palliative Care
- Coalition for Compassionate Care of California
- Get Palliative Care
- University of California Television, San Diego: Palliative Care: Who is it For, What Does it Do, Why Should I Want it and When?