Navigating Tensions: Integrating Palliative Care Consultation Services Into an Academic Medical Center Setting

Abstract

Context Despite rapid proliferation of hospital-based palliative care consultation services (PCCS) across the country, there is little description of the dynamic processes that the PCCS and the non-PCCS hospital cultures experience during the institutionalization of a successful PCCS. Objectives To describe the institutionalization of a new PCCS in a quaternary care academic medical center (AMC) and highlight two themes, cost and quality, that pervaded the dynamics involved from the inception to the successful integration of the service. Methods Ethnography using longitudinal field observations, in-depth interviews, and the collection of artifacts. The study was performed in a 750-bed quaternary care ACM in the northeastern region of the U.S. Participants were a purposefully selected sample (n = 79) of (a) senior-level institutional administrators, including clinical leaders in nursing, medicine, and social work, (b) clinicians who used the PCCS, either commonly or rarely, and (c) members of the PCCS core and extended teams. Results Key infrastructure components that contributed to the successful integration of the PCCS included: top level interprofessional administrative buy-in to the quality and cost arguments for PCCS, PCCS leadership selection, robust data collection strategies emphasizing quality outcome data, the adoption of the “physician referral only” rule, and incremental and sustainable growth. The PCCS service has grown an average of 23% per year from 2003–2009. Conclusion An in-depth understanding of the dynamic interaction of the infrastructures and processes of a successful institutionalization, in their unique complexity, may help other PCCSs identify and negotiate attributes of their own circumstances that will increase their chances for successful and sustainable implementation.

Growth of an Academic Palliative Medicine Program: Patient Encounters and Clinical Burden

“…Information regarding the challenges of clinical growth [16–18] and staffing allocation [19–21] of palliative care programs is limited. Here we describe the growth and staffing structure of an integrated palliative care program comprising an inpatient PCU, a mobile consult service, and an outpatient supportive care clinic at a comprehensive cancer center over a 10-year period.…”

Overcoming Barriers to Palliative Care Consultation

“…15 This anxiety may make them uncomfortable or unwilling to broach the idea of a palliative care consultation with a patient or a patient's family. 11 Aslakson et al 13 found that when surgeons attempted to open discussions about palliative care with patients, the discussions were often quick, inadequate, and ineffective. A variety of strategies have been suggested to overcome the reluctance of health care providers to initiate discussions about palliative care.…”

“…11 Some physicians think that introducing palliative care means that they must "give up" trying to cure their patients, something that they are unwilling to do because their patients might die sooner. physicians that they alone should provide total care to their patients, 5,13 that they already provide good palliative care themselves, 11 and a lack of knowledge among many health care providers about the extent and variety of palliative care services available at their institutions. 13 These barriers can be overcome with education about and experience with palliative care.…”

“…Families may be confused and see the "small steps" the patient makes as real progress, and therefore develop false hope. 11 They may be unwilling to acknowledge that the illness is life threatening and may not want to communicate with health care providers who mention that possibility. Or, a patient or the patient's family may not be able to formulate questions because of a lack of knowledge (including medical terms and jargon), cultural misunderstandings, or the overwhelming number of professionals from various multidisciplinary teams who speak with them.…”

Short-stay, specialist beds in a UK teaching hospital as a model to integrate palliative care into the acute hospital culture

“…20 Challenges or 'barriers' to delivering palliative care in hospital persist, including delays in recognising the need for palliative care and in referral for specialist advice. 21,22 In cancer centres there are additional challenges to referrals: 23 it may be perceived as an end to cancer treatment, synonymous with a loss of hope for the patients as well as a concern that they will feel abandoned by oncology services. Only through rigorous evaluation of outcomes and joint research will evidence be provided to support the continuation of palliative care in an era of figure 1 Conception of an Acute Palliative Care Unit.…”