The downside of the growth of palliative care

As palliative care matures, I become increasingly concerned about the downside of our growth.

Let me say more.

A couple of stories from the last few months: One of my faculty told me that she got a consult for patient who was made “comfort measures only” and did not have any issues but “they thought we would be mad if we were not consulted”. Conversely, I have had many consults for patients where the primary team feels like the patient is dying so they should be transferred to our service. And consults by medical house staff to give bad news or talk about resuscitation preferences (cause we are better and more experienced at it).

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.

So does this resonate for others? Let me know