Monday, March 14, 2011

Palliative Care and Harvard Business Review

Interesting piece in Harvard Business Review by Susan Block on Palliative Care. The Palliative Medicine world was talking about this one on twitter last night, and Christian Sinclair at Pallimed blog has a good post on it. Some will probably say, 'oh gosh, not the Business Review' and be worried about the loss of something, but the fact that the Harvard Business Review is writing about Palliative Care (care that addresses symptoms of serious illness regardless of prognosis) shows that its time has arrived in the health care system. The need for better Palliative Care has been identified and the questions move to how to provide it.

Block sets up the cultural reality of her view of the place of Palliative Care in the health care system as follows:

"No one wants to think about the stuff I do — death, suffering, pain, heartache, grief, sorrow. Individual reluctance is mirrored in the health care system's belief that more care and technology can stave off death, and that what we don't talk about won't happen. And often that strategy works. But it always fails eventually, and when that occurs, our system, by and large, does a lousy job."

Block's post succinctly captures several realities of end-of-life care.
  • It exists because everyone dies, it is only a matter of when and from what. This means that eventually interventions designed to forestall death will fail.
  • It is hard to prognosticate death, and hence when you might begin to make different treatment decisions.
  • There are financial incentives for providers (physicians and hospitals) to over-provide care.
  • There is a little coordination of care across the many different providers who are likely to care for chronically ill patients.
She focuses on the humanity of physicians--their own fear of death as well as of professional failure--that prevents honest communication with patients who are fearful as the primary barrier to better Palliative Care. She calls this a "misguided collusion of optimism between physicians and patients" that prevents better communication that would lead to better care that focused on patient goals of maximizing quality of life. And this means that Palliative Care tends to enter the picture too late to provide maximum benefit to patients.

Block then suggests several things that would be true of a system that did a better job of dealing with these issues. The most interesting one to me is the use of checklists in Palliative Care. This is reminiscent of my asking a few days back what the difference was between Palliative Care and Disease Management? A few folks emailed me and were irritated by this question and said that the essence of the difference was that Palliative Care was a professional intervention that was best provided in a manner that can't be easily taught or transmitted. That would be bad news if true, because the problems noted above are widespread. I think the essence of the rub is that when people suggest checklists or disease management it implies non-personalized robotic care that misses a fundamental essence of what Palliative Medicine does.

Christian Sinclair in the HBR post comments puts the (reasonable) worry like this:

"I would imagine we have to make sure they do not make very delicate discussions into unemotional robotic programming. Having worked with you, i am sure there is a lot of concern about finding that right balance between the science and the humanity of health care. Obviously they can be complimentary, but we have to make sure we are not blinded by the checklist."

There is quite a lot of room between Palliative Care being best as a highly idiosyncratic 'I know it when I see it' endeavor and mass producing 1 page checklists and calling it Palliative Care. That the field now needs to work this out shows that prime time for Palliative Care has arrived.

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