Palliative care improves quality of life by relieving symptoms, providing psycho-social support, and by lowering costs by eliminating unwanted inventions, such as hospital readmissions.1,2 Because bundled payments approach episodes of care with the patient’s goals at the center of all care planning, bundled payments can help make palliative care available to patients by offering incentives that help avoid expensive care that may be at odds with the patient’s wishes. Further, effective January 2016, CMS reimburses physicians for “advance care planning” activities that support palliative care as part of the updated Physician Fee Schedule under two new CPT codes.
At Remedy’s National Collaborative in November and at the SNF Collaborative last month, Dr. Steve Pantilat, Director of Palliative Care Service at the University of California, San Francisco, shared his advice on when to initiate the conversation about palliative care. General practice supports utilization of palliative care for the critically ill, which Dr. Pantilat suggests can be determined by three criteria.
Determining when to talk about Palliative Care:
Diagnosis, Utilization and Function
The first criterion Dr. Pantilat suggests is the diagnosis itself. Advance care discussions should be initiated for patients who suffer from advanced chronic illness, for example, cancer, heart failure, COPD, stroke, end stage renal disease, and ALS.
Another consideration is healthcare utilization. If the patient has been admitted to the hospital more than twice in the past year, or had two ER visits, an advance care conversation is recommended.
The third criterion is decline in function. For example, when a person who had been relatively mobile now needs a bedside commode, it can suggest that in the future he or she would lack the capacity to advocate for their own care preferences.
Dr. Pantilat underscores that advance care planning conversations with the patient are crucial because family members don’t always know what patients would wish for themselves. Absent a conversation, individuals in the ICU or hospital will receive aggressive treatment, which may not be what they want.
And not all family members would make decisions in the same way. It is important for the patient to designate a surrogate decision-maker for when they can’t speak for themselves and to discuss the extent of treatment they would want to undergo.
The Palliative Care Conversation: The Golden Questions
Dr. Pantilat suggests asking the patient to provide instructions in case they are no longer able to express their wishes. The goal is to establish a surrogate and find out if the patient has discussed the care they would want if they were seriously ill. If they have not, he suggests encouraging the patient to do so. Not only will this ensure the patient’s wishes are met, it will make things easier for the surrogate to make decisions that are in keeping with those wishes.
To get at this level of care, Dr. Pantilat uses what he calls ‘the golden questions’. The first question is, "When you look to the future what do you hope for?" This allows the patient to talk about milestones – a family member’s graduation they want to attend or a grandchild’s birthday. This question allows practitioners to structure care and interventions that will help the patient achieve the things they hope for.
The second golden question is "When you look ahead, what worries you the most?” Patient responses such as "I’m worried that I’ll be in pain" or "I’m worried that I won’t be able to care for myself or recognize my family" can help clinicians structure the care conversation around values and goals, rather than ticking off a list of possible clinical interventions.
The values and goals that are surfaced from these questions are then used to guide the conversation about interventions. A patient who says "I just want to be at home and as comfortable as possible" will have a different course of care than the one who says “I’m going to fight this in every way I can."
By using the answers to these questions, palliative care becomes the framework for more nuanced conversations about appropriate levels of care and provides the foundation to support the best possible quality of life for patients and their families.
For more information on Palliative Care, explore these resources:
Access to Good Palliative Care: The Time is Now by Remedy Partners Chief Medical Officer Win Whitcomb, MD, MHM
Palliative Care in the Era of Value, by Remedy Partners Chief Medical Officer, Win Whitcomb, MD, MHM in The Hospitalist
Remedy’s partner organizations will find additional material on the practice of Palliative Care and the use of Advance Directives in the resources section of The Transitional Care Institute.
 Morrison RS, Penrod JD, Cassel JB, Caust-Ellenbogen M, Litke A, Spragens L, Meier DE. Cost savings associated with US hospital palliative care consultation programs. Palliative Care Leadership Centers' Outcomes Group. Arch Intern Med. 2008 Sep 8; 168(16): 1783-90
 Gade G, Venohr I, Conner D, et al. Impact of an inpatient palliative care team: a randomized control trial. J Palliat Med. 2008;11(2):180-190.