The field of hospice and palliative care is rapidly growing and becoming increasingly integrated into the US health system, opening the door to a variety of training opportunities for medical students, as well as practicing oncologists who often find this area of medicine to be crucial to caring for patients.
The palliative care system in the United States recently doubled, growing from fewer than 600 facilities offering this type of service to more than 1,200 in about a five-year period, according to a 2005 national data set from the American Hospital Association, the most recent information available.
In this survey, nearly 30% of US hospitals reported having a palliative care program, noted Diane Meier, MD, Director of the Center to Advance Palliative Care (CAPC) and the Hertzberg Palliative Care Institute and Professor of Geriatrics and Internal Medicine at Mount Sinai School of Medicine in New York City. If the data are cut differently, she said, then 70% of teaching hospitals, as well as 70% of hospitals with at least 250 beds, reported palliative care programs.
In the US, palliative care has been provided by hospices for the last 25 years, while institution-based palliative care began about 15 years ago, said Russell Portenoy, MD, President-Elect of the American Academy of Hospice and Palliative Medicine (AAHPM) and Chairman of the Department of Pain Medicine and Palliative Care at Beth Israel Medical Center in New York City.
The number of these programs has risen rapidly during the past seven to eight years, he added. Physicians with specialist-level skills seem to be driving this process, helping to spur new hospice and institutional palliative care programs.
Overall, the increased interest in palliative care has been due to a combination of demographic and societal influences, as well as private sector investment, Dr. Meier explained.
People are now living into their 80s and 90s with chronic heart, lung, and kidney disease; dementia; and other illnesses. “Most individuals turning to the health care system are old, have multiple illness, and live for years, not months, with serious disease,” she said. “Palliative care programs are a response to these people's needs.”
Another contributing factor, Dr. Meier continued, is the ascendancy of baby boomers in positions of power and authority. The drive for health care reform is part of an early response to addressing this population's future palliative care needs and to helping relieve the current burden on caregivers.
Also influential has been public attention on the issue of physician-assisted suicide, she said. For example, Jack Kevorkian brought to the forefront the problem of patients sometimes feeling that they weren't able to rely on the medical profession to relieve suffering or to have their concerns listened to in a profound way. Additionally, the Oregon Death with Dignity Act, which legalized physician-assisted suicide, has also brought attention to end of life care, she said.
Funding of Palliative Care Programs
The funding of palliative care programs has also been critical to their growth, said Dr. Meier. For example, since the 1980s, the Robert Wood Johnson Foundation's work through the Center to Advance Palliative Care and the Open Society Institute's Project on Death in America has generated more than $300 million to help build palliative care infrastructure in the US.
“We're well past the tipping point for the establishment of these programs,” said Dr. Meier, adding that one of the main objectives now is to increase the number of health care facilities that adhere to best practices and quality guidelines. “What does it mean when a hospital says, ‘Yes, we have a program’? Does it mean it adheres to palliative care guidelines of the National Quality Forum?”
Hospice & Palliative Medicine as a Subspecialty: HPM
One critical development that is helping to integrate this form of care into the US health system is the agreement last year to establish hospice and palliative medicine (HPM) as a subspecialty of 10 participating boards of the American Board of Medical Specialties (ABMS). The first ABMS-recognized HPM certification exam is scheduled for October 29, 2008.
“This is considered by us in the field as a watershed event that has been more than 10 years in the making,” said Dr. Portenoy. Bringing HPM as a subspecialty to fruition has involved a huge amount of work and could contribute to the rapid growth of this discipline not just for cancer patients but also in a variety of other areas of medicine, he said.
Additionally, the American Osteopathic Association (AOA) Bureau of Osteopathic Specialties approved the creation of a Certificate of Added Qualification in Hospice and Palliative Medicine. Final approval by the AOA Board of Trustees is expected in February.
The recognition of Hospice and Palliative Care as a subspecialty helps ensure the future of the field, noted Dale Lupu, PhD, now Vice President for Professional Development at the American Board of Hospice and Palliative Medicine (ABHPM) and formerly the organization's CEO.
In the American health system, recognizing a specialty is a way that knowledge, practice, and skills get codified in the medical school curriculum, residency, and fellowships, Dr. Lupu explained. “Students can say, ‘Here are the mentors I can learn from, here are the textbooks, here are the clinical experiences I can gain from a fellowship,’” she said.
In June 2006, the Accreditation Council for Graduate Medical Education (ACGME) began the process of accreditation for HPM fellowship programs. Starting in 2013, only applicants who have completed an ACGME-accredited HPM fellowship will be eligible to take the certification exam.
“This field has now become real and is recognized in the academic teaching world,” said Dr. Lupu. “Hopefully this translates at the patient level, with people getting care from skilled and well-trained professionals.”
Overall, the HPM subspecialty will have an impact on raising the consciousness of this field, leading to review articles and generating scientific studies, Dr. Portenoy said. The subspecialty will also require evidence-based medicine as part of best practice as with other medical specialties.
Hospitals will also be better able to identify specialists in hospice and palliative care medicine who can help establish or further develop institution-based palliative care programs. At the hospice level, the new subspecialty will also help drive a best-practice model, he said, adding that most current hospice medical directors are not board certified.
Charles von Gunten, MD, PhD, Provost of the Center for Palliative Studies at San Diego Hospice & Palliative Care, a teaching affiliate of the University of California, San Diego and co-principal of the Education for Physicians in End-of-Life Care (EPEC) Project, also made the point that the designation of hospice and palliative care medicine as a new subspecialty will mean that when oncologists are faced with patients whose challenges exceed the oncologists' time or ability they can now more readily access physicians who are certified in palliative care.
Upcoming Joint Commission Certification
Further lending credibility to the palliative care field is that sometime in April, the Joint Commission will launch a Health Care Services Certification in Palliative Care. The certification cuts across all diagnoses and conditions, cancer being one among many, said Laure L. Dudley, the Joint Commission's Executive Director of Marketing & Product Development.
The program will be complementary to the ABMS establishing HPM as a new subspecialty, Ms. Dudley explained. “Our program provides another tool to support the delivery of medical care.”
To help create the program, the Joint Commission will review the available literature on palliative care and consider guidelines from the National Consensus Project for Quality Palliative Care (NCP). The commission is also working with stakeholders such as CAPC to establish program standards, she explained.
One of the program goals is to focus on individuals who are seriously ill and to ensure quality of care regardless of the setting, Ms. Dudley noted. Additionally, core standards of the certification program will support clinical microsystems, meaning the front-line medical team and support staff who directly deliver the most care to the patient and family. Core standards will also support patient-centered care concepts, she said.
“We'll put together the fundamental structure and standards of evaluating palliative care, and these standards will be further defined by a task force this fall.”
The organization is hoping that some of the mature palliative care programs will use these standards to conduct an assessment of their services. The Joint Commission also envisions newer palliative care programs looking to the certification program to assist in their own development.
In 2004, a survey by the Joint Commission found that 95% of hospital palliative care programs, 75% of hospices, and 71% of home care programs thought that third-party evaluation would benefit their programs. Ms. Dudley noted that insurers have also expressed an interest in assessing quality of palliative care.
“I think this [program] is but one mark of how palliative care is becoming integrated into the health care system broadly in the US,” said David Weissman, MD, Professor of Medicine and Director of the Medical College of Wisconsin Palliative Care Center.
With time, the Joint Commission might want to look more closely at oncology because that is the area where the integration of palliative care from diagnosis to death is best described and there are model programs demonstrating value, he added.
Palliative Care Already Integral to Oncology
Palliative medicine is already an integral part of caring for patients with cancer, the oncologists and palliative care experts interviewed for this article agreed.
James Cleary, MD, a past president of the American Academy of Hospice and Palliative Medicine, who is Associate Professor of Medicine (Hematology Oncology Section) at the University of Wisconsin School of Medicine and Public Health and Director of Palliative Medicine at UW Hospital and Clinics, said that even with all the advances in oncology, some 50% of patients are still dying, making palliative care a critical part of cancer medicine.
By nature, much of what good oncologists do is in fact palliative care, he said. “They probably spend 30 to 50 percent of their time on it.”
True, every radiation, surgical, and medical oncologist would say that palliative care is an important part of cancer treatment, Dr. von Gunten said, “but all would also agree that it wasn't taught to them in training as residents or fellows.”
Dr. Cleary noted that he and his colleagues are now starting to see staff come on board with combined fellowships in oncology and palliative medicine. Moreover, oncology fellows are also coming through and showing great interest in the palliative care aspect of clinical practice.
Dr. Lupu noted that while palliative care may already be a part of their clinical practice, oncologists are also realizing that the support of colleagues trained in hospice and palliative medicine is also key. This may be especially true as the demand for oncology care rises in the next 10 to 15 years, she said referring to the recent ASCO report that predicted a shortage of oncologists (OT, 4/10/07 issue).
Comprehensive cancer centers will want to have specialists in palliative medicine working with the oncology team to bring expert care to patients and families, Dr. von Gunten said.
Programs at the UCSD already offer this type of specialized palliative care. “We see patients who have challenging symptom-control needs, as well as family and psychosocial issues, that exceed the cancer team's management abilities,” he said. “Their needs do, however, fall within the skill set of specialists in palliative care.”
For example, patients being treated aggressively for cure with bone marrow transplants have many symptoms, as well as psychosocial and spiritual issues, that are best addressed by palliative care experts, he said.
While palliation is needed for dying patients, this type of sophisticated care also needs to be applied to individuals at diagnosis and throughout their treatment to relieve discomfort, Dr. von Gunten said. Palliative care in oncology should be integrated from the day of diagnosis and throughout the course of the disease, whether or not a cure is expected.
Oncologists can also become involved in end-of-life care, he said, but they will generally want to transition patients to hospice when they have a life expectancy of about six months or less.
Dr. Portenoy said that oncologists recognize that palliative medicine is often needed while patients are being treated and that referring to specialist services or making early referrals to “open access” hospice services can be a valuable tool.
However, the oncology community will need to identify what its own abilities or limitations are in providing HPM and what additional skills certified HPM specialists can provide, Dr. Portenoy added. Oncologists are beginning to understand what kinds of clinical scenarios require specialized palliative care. Overall, he concluded, the oncology community is primed for developing a good relationship with institution-based palliative care and hospice programs.
Palliative Care Education & Training
Several opportunities exist for physicians who want to learn more about palliative care:
- ▪ Palliative Care Training: For example, Northwestern University's Feinberg School of Medicine and the American Society for Clinical Oncology offer a palliative care program, Education on Palliative and End-of-Life Care for Oncology (EPEC-O), for new oncologists and those already in the field. (www.epec.net and www.cancer.gov/aboutnci/epeco).
- In addition, The American Academy of Hospice and Palliative Medicine has developed a Clinical Scholars Program to give practicing physicians who don't have time to pursue a year-long fellowship the opportunity to learn more about palliative care, which will become available sometime this fall: www.aahpm.org/education/clinicaltraining.html. “The [AAHPM] training will mean nothing for board certification because it's not a substitution for a year's worth of fellowship,” said David Weissman, MD, Director of the Medical College of Wisconsin's Palliative Care Center. “Instead it's to bootstrap up the field for those doctors in practice who want to start providing palliative care.”
- ▪ Supporting Medical Educators: Medical school training in palliative care is also being addressed, said Dr. Weismann. Schools started requiring end-of-life education in 2000, but have been slow to adopt rigorous programs, he said. To help address this problem, the Medical College of Wisconsin has established a Web site called End of Life/Palliative Education Resource Center (EPERC), which provides educational resource materials for end-of-life physician educators (www.eperc.mcw.edu).
- ▪ Learning How to Establish Programs: Educational resources also exist for hospitals that want to start their own palliative care programs. For example, the Center to Advance Palliative Care offers training on how to draft financial and business plans, create organizational models, and market the advantages of such a program. Information on the program is available at www.capc.org/palliative-care-professional-development/Training