The Hidden Power Of Palliative Care

Susan is 98 years old. She’s been diagnosed with hypertension and memory loss. She experiences frequent pain spells and, like many people her age, she’s at risk of falling, especially when she becomes tired. Five years ago, Susan fell, fractured her pelvis and spent an unhappy month in a skilled nursing facility. Physicians like myself often see patients like Susan in hospitals across the country. Typically, we treat them and send them on their way. And just as typically, patients like Susan often reappear in the hospital, either with new ailments or when the old ones show up again.

But not Susan. She has not been inside a hospital in more than a year. In fact, these days you’ll find her drinking coffee with her daughter in the comfort of her San Fernando Valley home, completely unaware that she represents the future of palliative care.

November is National Hospice and Palliative Care Month — the perfect occasion to reflect on what practices the medical profession should adopt as we guide our patients down the common path we all face at the end of life.

When I was a medical student, I believed in the infinite power of medical interventions to save lives. Lately, however, my thoughts have changed somewhat. As I watch my patients, my parents, and some of my close friends age, I’ve begun to think that, when it comes to people nearing the end of their lives, perhaps we put too much emphasis on curing diseases — and not enough on humanely helping our patients accept their diagnoses, counseling them on how to find enjoyment in their remaining days, and providing them with the knowledge they need to make informed end-of-life care decisions.

Truth be told, if you look back at the history of medicine, the profession was always more concerned with symptom management than curing disease. Hippocrates is known as the “father of medicine,” but perhaps a better title for him would be the “father of palliative care.” Though his belief in balancing the body’s four “humors” was off the mark, he nevertheless understood the primal importance of comforting patients by alleviating their symptoms, which in his case usually involved the use of herbal medicines

In the modern world, our focus has shifted primarily to curative medicine. In many cases, this is the correct approach. From plague to heart disease to many forms of cancer to cystic fibrosis, we can now cure an astonishing array of illnesses, allowing people to live longer, healthier lives than ever before.

And yet, for many seniors, no medicine or treatment of any kind can effectively stave off the inevitable. TV shows about hospitals have burned images into our brains of heroic doctors helping their patients outwit death. But in reality, it rarely works this way. As seniors age and experience deteriorating health, many bounce in and out of emergency departments, general and geriatric wards, and intensive care units. The time they spend in hospitals, hooked up to a myriad of tubes and subjected to a litany of tests, is rarely pleasant for them or their families — or even in accordance with their wishes. Eighty percent of Americans say they would like to die at home. And yet, about 60% of Americans ultimately pass away in hospitals, with 20% spending their final days in an ICU.

This presents a problem not just for patients and their families, but for the health system as a whole. One-quarter of Medicare spending goes toward caring for people in their final year of life. Moreover, a study of family members of patients who died from cancer found that only half felt their loved one had received excellent end-of-life care. Altogether, this suggests that we as a whole are directing valuable health care resources toward hospital-based end-of-life care that few people want — and that many people say is inadequate.

But there is an alternative. Physicians could put less emphasis on trying to cure late-stage illnesses in hospital settings and instead focus on the avoidance of suffering, and helping our patients make informed decisions about how they want to spend their final days. This, in a nutshell, is the goal of quality palliative care. Unfortunately, palliative care has often been seen as a hospital-based transition to hospice care. But an increasing body of evidence suggests that, when provided in the patient's home, good palliative care can lead people to live a high-quality end-of-life.

Which brings us back to Susan. She’s a patient of Aspire Health, a company I lead. Under Aspire’s care model, people like Susan receive home-based care from a specialized team of clinicians whose goals are to provide their patients with quality medical care, keep them out of the hospital, and offer them counsel in their final years. Seventy-one percent of Aspire patients engage in advance care planning discussions, allowing them and their families to make informed choices before they end up in the hospital, connected to tubes.

On a recent afternoon, Susan sat at her kitchen table with her daughter, Jenny, and Liz Garcia, an Aspire nurse practitioner who visits Susan in her home every four to six weeks. Susan sipped coffee, nibbled a muffin and gazed at the view of the valley while Liz took her blood pressure. Nearby, Rufus, Susan’s  dog, slept in the sun. Susan told Liz that she fell the night before, so she checked her legs for signs of bruising and offered to connect her with a service to evaluate her home for safety. “The goal is for you to be here at home, to be taken care of,” Liz explained.

Care models like Aspire’s not only provide patients like Susan with a dignified experience, they reduce costs. Aspire patients are two-thirds less likely than other people to experience expensive hospitalizations, which results in significant cost savings.

Of course, I recognize that there’s a tension here. Our job as physicians, I believe, is to offer our patients hope. Nevertheless, that isn’t our only job. It is also incumbent upon us to be honest comforters, to help our patients avoid suffering, and to have difficult discussions with them about the most delicate of subjects.

After Liz updated Susan’s’s medical record, she closed her laptop and got up to leave. But first, Susan wanted to show her the two Oscars her late husband won for set design. As Liz held the gold statuettes, Susan pointed out the Christmas tree she keeps year-round in the living room to remind her of her husband, who loved Christmas and died in late December.

 “He’s still with me,” Susan said adding, “I have my dog. I have my view. And I have my neighbors. I’m happy to be home.”