Monday, December 7, 2009

The Down Side of Palliative Care Growth.

From GeriPal:

My worry: We may be deskilling other doctors. Unfortunately, if the patient is viewed as dying, the primary teams feel that they should back off and ask palliative care to "take over". So house staff and junior internal medicine house staff do not have the opportunity to have these conversations and receive feedback. And as concerning, rather than integrating palliative care into the mainstream of medicine, we ghetto-size it.

Now some caveats. My experience is that of a mature palliative care program and thus may not reflect others experience. Second, from a patient point of view, it may well be better that we are consulted and have these conversations. Third, my whining is probably no different than any other consult service (I can imaging the cardiologist complaining about "silly" consults for afib that they believe that the internist should be able to handle).

Still, I think this should remind those of us who do palliative care at academic centers that our role is as much educational as clinical care. Thus doing more consults is not the only metric by which we should measure our success. We should ask that the residents who consult us come to the meetings and - as much as their skills allow - participate. We should debrief with them after the meeting so that they know what were were trying to do and can learn the communication tasks. And we should think about innovative ways to support teams and promote their skill sets.

As I've often said, the medical profession already ghetto-izes end of life care. If it didn't, hospices wouldn't have to hold bake sales for funds and palliative medicine wouldn't just now be growing. This lack of attention in general medicine to end of life, dying, and pain cessation is an old saw. The profession would much rather find cures for disease and be heros for saving lives. Help the dying? Where's the glory in that. Isn't a dying patient a sign of a doctor's failure??

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