CLINICAL COMMENTARY


Palliative Care -the \"Un-Care\" or the \"Best Care\"?

Gerard W. Frank, M. D., Ph. D.

Palliative care as a concept is gaining increasing foothold in medical practice.
However, some confu-sion about its relation to hospice care may create the
perception that palliative care has little place in acute inpatient medicine.
Moreover, practitioners may believe that palliative care is antithetical to
intensive care. UCLA now has a laboratory of sorts set to correct those misperceptions.
The Palliative Care Unit at UCLA-Santa Monica in a very short time has already
proven its effectiveness in terms of patient satisfaction and acceptance by
physicians and staff. It is a \"unit without walls\" in the sense that its census
frequently exceeds the number of designated beds in the Santa Monica facility.
It also embraces a Palliative Care consultation service, available at both
Santa Monica and Westwood campuses.

The heart of providing palliative care
is the inter-disciplinary team, which follows all patients on the service
and meets at least weekly to review problems and progress. This team includes
a nurse practitioner dedicated to the Unit, several physicians, social workers,
dietitians, physical therapists and chaplains. The dedicated nurse practitioner
plays a central role in assessment of patients and coordination of the interdisciplinary
response. In addition to dealing with the problems of current patients, the
team maintains close follow up with discharged patients and bereaving families.

What is the vision of palliative care at UCLA? Most physicians think of
palliation in terms of terminal cancer treatment. This is its most narrow
definition. In a wider sense, palliative care refers to symptom management,
something physicians start learning the first day (or night) of internship,
but which is seldom taught in a systematic manner. Our vision of palliative
care, however, is that it is a response to the total needs of patients,
their families and their caregivers-clearly a tall order, but the ideal
to which we feel healthcare should aspire.

How then, does a Palliative
Care Service work? At Santa Monica it has been publicized to the Medical
Staff. For patients already in the hospital, the physi-cian can simply
write an order in the chart for a pallia-tive care consult. Seven days
a week, someone is on call to answer the request, either a physician
or nurse practitioner. Patients are evaluated in the same way as for any
specialty consultation, with recommenda-tions, and orders, if the referring
physician is comfortable with that. The consultant assesses all the patient\'s
needs and ensures that appropriate persons become involved: social worker,
chaplain, dietitian, etc. The Palliative Care team reviews the patient\'s
problems and progress weekly.

Patients may also be admitted to the dedicated
palliative care beds from home or another facility. Physicians in the community
or at other hospitals may request admission to these beds and the requests
are reviewed by or discussed with the Medical Director of the unit. There
are many indications for such referrals, including pain or other symptom
management, nutri-tional support, weaning from parenteral narcotics, mobility
improvement. Referring physicians have the options of serving as primary
inpatient physician with a palliative care physician as consultant, or asking
the palliative care physician to admit and follow the patient as primary
attending. Some, but not all the patients at Santa Monica have been followed
by hous-estaff and the hope is to expand their role in the unit.

Up to now,
the majority of patients followed by the Palliative Care Team have had advanced
malignancies. Often these patients have had an intercurrent acute medical
problem which has interfered with the continu-ation of their therapy and
the unit has served to improve their performance status with the goal of
enabling their return to a treatment program. However, there are clearly
other classes of patient appropriate for this type of care: end-stage pulmonary
disease, advanced rheumatologic disease, cardiomyopathy, as examples.

While
the Palliative Care Unit is located on a Medical-Surgical ward without telemetry,
the patients have occasionally been moved to higher levels of care for management
of acute problems and then returned to the unit. Some have required close
monitoring for arrhythmias, surgery for bowel obstruction, or palliative
radiation. Some have been followed into the hospital\'s Skilled Nursing Unit
for more prolonged stays when necessary. In general it is expected that patient
lengths-of-stay on the unit will last no more than a week.

The Palliative Care Team is anxious to extend its service to the ICU. The
special problems of palliative care in this setting include greater difficulty
in assessing pain and discomfort, the need to perform many pain-provoking
procedures, and the stress of the ICU environment on families. The team hopes
to be innovative in this regard, introducing complementary techniques for
stress reduction, keeping patient journals as a joint effort of families
and care providers.

While palliative care needs to be distinguished from
hospice care, the close relationship is obvious. The Palliative Care Service
has often eased the transi-tion to and acceptance of hospice by patients
and families. It frequently becomes apparent while the patient is on the
Palliative Care Service that further therapy is probably futile and the
patient\'s needs would be better met by hospice care.

The Palliative Care
Service at Santa Monica Hospital in its first eight months has accepted
over 150 patients into the dedicated unit and followed approximately 100
additional patients in consultation. Most of these patients eventually transition
to hospice care. Almost one-third of the patients have been able to go home.
Many have died in the hospital\'s Skilled Nursing Unit with hospice. This
has actually had a positive impact on the cost management of these diffi-cult
patients. The majority of our patients are still being transferred directly
from UCLA Westwood. Happily, the service has enjoyed universally positive
patient and family feedback, clearly an important component of contemporary
hospital outcomes. It is hoped that such gratitude will eventually lead to
the sort of philanthropy that can sustain this endeavor. This group of patients
places great demands on care-givers and only a supportive team effort can
ensure its success and the well-being of the nurses, physicians and other
team members who dedicate themselves to the service. It is anticipated that
the activity of the Palliative Care Service will continue to expand as the
Westwood and Santa Monica facilities rebuild and evolve into a more \"seamless\" institution.
It is hoped that through resident and nurse training, more indi-viduals will
be motivated to become involved in the service.