Attending to patients’ emotional needs as well as their physical symptoms // Eliminating the choice between living longer or living better.
Palliative Care: More Than Hand-Holding
When Diane E. Meier met the 24-year-old patient, the young woman was curled on her side in a hospital bed, in too much pain to open her eyes. Her bloodstream was clogged with leukemia cells, making her gasp for breath if she tried to sit up. She hadn’t slept in a week and couldn’t keep down food or the drugs needed to ready her body for a bone marrow transplant.
The woman’s hematologist had prescribed ibuprofen and Tylenol (her parents had told the hematologist about their son, a former substance abuser, and insisted that she not be given anything potentially addictive), but neither helped much, and the patient kept pressing the call button, pleading for something stronger. Exasperated, the hematologist brought in Meier, a physician-specialist in palliative care, to help manage the symptoms, which also included depression and spiritual angst.
Meier knew that it would take an opioid to relieve the pain, but first she had to explain to the woman’s parents that her symptoms were severe enough to cause real harm. During the six weeks the patient was in the hospital, members of a large palliative care team—Meier, the hospital chaplain, a nurse practitioner, a social worker, a massage therapist, a therapeutic yoga instructor and a psychologist—visited her several times a day to monitor symptoms, provide emotional and spiritual support, and control pain and anxiety with massage and breathing techniques as well as medication. “There’s no way her hematologist and other physicians could have spent the time we did with this patient and her family,” says Meier, director of the Center to Advance Palliative Care at Mount Sinai School of Medicine in New York City.
Though the patient recovered after her bone marrow transplant and is healthy today, the majority of those treated by palliative care physicians are chronically ill. The goal, Meier says, is “to make sure you live as well as possible with whatever life-threatening disease you have while getting treatment meant to cure you or prolong your life.” Palliative care specialists help patients control symptoms and address their nonmedical needs in a relationship that may last indefinitely.
When patients opt for palliative treatments, many fewer dollars are likely to be spent on their care, and that’s one reason hospitals and insurers have been quick to embrace this specialty. The 5% or so of Medicare patients who die each year account for almost 30% of the government program’s outlays, and costs are highest when deaths occur in the hospital—particularly in intensive care. But in a recent study of New York hospitals that have palliative care programs, per-admission expenditures for people who received palliative care were $6,900 lower than outlays for seriously ill patients who got more aggressive treatments. Those who had the benefit of palliative care spent less time in intensive care, underwent fewer expensive imaging studies and other tests, and had fewer drugs and other therapies that had little effect during the patients’ last days.
Perhaps the most stunning—and surprising—benefit: In a randomized, controlled trial at Massachusetts General Hospital, people with metastatic lung cancer who received palliative care in addition to oncologic treatment not only saw their quality of life improve but also lived almost a third longer than those who received only chemotherapy and radiation. That result was contrary to what almost everyone had expected, and it was particularly notable in that many of those who received palliative care ultimately decided to end chemotherapy. So the presumed dilemma for patients—whether to live longer or better—may turn out not to be an either-or proposition.