by: Alex Smith, @AlexSmithMD
Each July we post something about an introductory topic for the new fellows. See our prior posts on:
- How to explain hospice
- How to explain palliative care
- How to have a code status conversation
- How to talk about imminent death and dying
- How to talk to patients when you first meet them (hint: More like a cab driver, less like a doctor)
This year we’re going to discuss how to field a palliative care consult. I’d like to focus specifically on the moment you call back the intern who paged you to request an inpatient palliative care consult. Other articles have addressed the comprehensive role of the consultant in general, or in palliative care in particular. This post will focus specifically on that initial phone call. Some features may apply to outpatient care, and to geriatrics.
Here are 7 questions I usually ask the referring clinician on the initial call:
- “What’s the story?” Why was the patient admitted to the hospital? What treatments has the patient received, and what treatments are planned? This is what most people get from interns when they field a consult. This is the normal “minimum” level of information
- “Is the patient making decisions?” This is an important data point. DO NOT take it as fact that the patient has capacity to make decisions if the intern says they are making decisions. This question is important because it tells you if the primary team thinks the patient has capacity to make decisions, but you need to make your own assessment.
- “How can we be helpful?” I prefer to phrase it this way, rather than, “What is the consult question?” This is in contrast to other fields, say GI for example, where consultants like to have a very specific consult question. But sometimes the consultant has a general sense that they need help, rather than a specific question. Now think about all of the evidence we have for palliative care – palliative care for lung cancer, for GI cancer, for heart failure, for bone marrow transplant – do you recall these studies specifying “palliative care was initiated for patient’s whose physicians had a specific consult question.” NO! These studies were initiated for all patients with that specific serious illness, regardless of whether the referring physician had a specific consult issue at hand. We should probe generally in a non-judmental way about the primary team’s objectives in calling a consult, but not judge if they do not have a specific question. We can almost always find a way to be helpful. Sometimes palliative care is called when the team (not the patient) is distressed. Don’t block palliative care consults.
- “What do you think about the patient’s prognosis?” I ask this question primarily to get the interns thinking about prognosis and the importance of prognosis for decision making.
- “Are there family or friends involved?” Often interns who are well trained to attend primarily to the medical history neglect to mention the social circumstances in which their patients lives are embedded. Who is visiting? Where does this patient live? What kind of housing arrangement?
- “How long will he/she be in the hospital?” People forget to ask this question. I can’t tell you how many times we’ve fielded a long consult request, only to discover the intern intends to discharge the patient this afternoon, and can we please address pain, goals of care, and a discharge plan the day we meet the patient? Yeah right. Good to know what you’re getting into and set expectations right off the bat (“We can’t do all that, but we’re happy to meet them and get to know them so we are familiar with them for the next visit.”)
- “Does the patient know we’ve been consulted?” Ideally the patient will have heard and agree that palliative care is going to consult. Like psychiatry, there are some patients who strongly do not want to see palliative care because of the associations they have with the field. Asking the intern to introduce the idea of a consult primes the patient for our visit.
What do you think? Am I too lenient in #3? Do you require referring clinicians who are not clear about the answer go back, think about it as a team, and formulate a specific consult request? Do you lack the resources in your hospital to not block palliative care consults? Do you worry about violating the bounds of the consultant role without a clearly defined question? What other questions do you ask? Respond in the comments.
Thanks to Olivia Gamboa, Lynn Flint, and Eric Widera for thoughts on this post.