What’s Involved in Palliative Care and Hospice?

Session 104

Dr. Bruce Chamberlain tells me why he sees palliative medicine as more of a calling than a specialty. We discuss empathy, communication, and avoiding burnout. Bruce has been out of his training now for 29 years and has been practicing hospice and palliative care medicine all around the country.

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Going back to the episode today, palliative and hospice medicine is a specialty that is important. But not a lot of people know about this and not a lot of people actually consult palliative medicine early enough.

Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:50] Interested in Palliative and Hospice Care

Bruce got into this specialty without a plan, in fact, he had never heard of it before. He was board-certified in internal medicine and practicing in a clinic doing internal medicine.

Seeing that the majority of his patients were elderly, he began to notice a trend in his patients. They often had a functional limitation as a result of pain, whether they had osteoarthritis or low back pain.

'Even today, chronic nonmalignant pain is not near as sexy as cancer pain even though it's just as painful. Hence, there wasn't much attention being paid to it.'Click To Tweet

Bruce started self-educating in noninvasive pain management as well as some low-level injections. He partnered with a physical therapist. They started to become more aggressive with pain management and saw great success.

As a result, a fair part of his clinic was devoted to geriatric pain management. Through the course of time, one of his patients ended up in the hospice. The hospice called him and asked to help them with pain management. So during his day off, he’d work at the hospice.

'Most people who work or have worked in hospice and/or palliative care for any period of time will tell you that it ends up being more of a calling than a job.'Click To Tweet

Bruce considers working in hospice or palliative care as more of a calling than a job. You just feel like this is where you belong and what you’re supposed to be doing. 

And this happened to him. He began looking forward to half-day of the week going to the hospice. It was when he felt it was being the kind of doctor that he wanted to be.

Because of this, he slowly increased his hospice time and decreased his clinic time. Until finally, the clinic asked for his commitment and asked him to fish or cut bait. While at that time, the hospice offered him a full-time position so he cut bait.

From then on, he never looked back. He has done hospice and palliative care full-time or part-time for over 20 years now.

[Related episode: Palliative Care – There is Always Something You Can Provide]

[05:20] On Being Around Death All The Time

Bruce explains that in hospice, you have to change your mindset in that you have to accept the reality that people die.

Physicians are trained in the combat mode, fighting disease. And they are taking it as a personal and professional failure when a patient dies even though that’s going to happen to all of us.

'We accept the reality that people die.'Click To Tweet

When you accept the reality of death, then success becomes – was the patient comfortable?

Were they able to have closure on outstanding emotional issues? Was the family able to be there? Were they able to die at home as opposed to being plugged into 15 different tubes and monitors in the ICU?

Yes, it’s sad that they died. But it’s great that they died in a way they wanted to and they were comfortable. 

Moreover, usually at the very end of hospice care, there would be months before death takes places where you just manage their symptoms.

It’s about improving their quality of life for the time they have left because they were able to aggressively manage their symptoms. And oftentimes, they get positive feedback before the death as well as after the death with family comes up to thank them.

[Related episode: This Physician Wants to Change The Narrative Around Death]

[08:35] Traits that Make a Great Hospice and Palliative Care Physician

You have to be patient and have empathy. But you also have to have the ability to draw that fine line between empathy and getting too emotionally involved with what’s going on.

You have to be able to relate and have the patients feel like you actually understand them or you’re there for them. 

'If you get too far drawn into it, then you are on the road to burning out because it can be very emotionally stressful.'Click To Tweet

A good hospice and palliative care doctor is very skilled at pain and symptom management. In geriatrics, you would usually review the patient’s medication list.

[10:25] Hospice vs. Palliative Care

Hospice has been defined by Medicare – a patient with a medical condition that if it continues as anticipated, we expect the patient to die within six months.

Bruce doesn’t actually like this definition because nobody is that good at prognostication. But Medicare is looking to change that definition to allow for earlier care.

'The problem is that because we're so bad at prognosticating, a high percentage of patients aren't good on hospice until they're actively dying.'Click To Tweet

Bruce defines hospice as the point of the sphere of palliative care which is an aggressive end of life care. Palliative care refers to aggressive quality of life interventions, symptom management, and communication with the patients and their families.

It’s important the patient’s family knows what’s going as you can’t have informed consent if you’re not informed.

They also ask the hard questions such as the resuscitation status that people are often reluctant to do or do incredibly badly.

Aggressive symptom management includes pain management with patients who are post-op.

Palliative care is a broader spectrum of quality of life interventions and symptom management that includes, but is not limited to, end of life care. Whereas hospice is end-of-life care. It’s part of palliative care but palliative care is much more.

[13:22] Diagnosing Patients

Bruce explains that palliative care is not called upon to be expert diagnosticians. Usually, they already know what’s happening. And they work in conjunction with other doctors. For instance, the surgeons are still taking care of the surgical issues while Bruce does symptom management.

'Often, it's not a diagnostic conundrum, it is a 'in light of this disease' process and what's going on. What can we do to improve this patient's quality of life?'Click To Tweet

[14:30] Typical Day

Bruce is currently working as an inpatient palliative care doctor. He comes in the morning and works with the nurse practitioner and two nurses who are liaisons with the hospice system.

First, they review consults that have come in from yesterday afternoon and after the shop has closed down and through the next morning. Then they make up a list of all their patients for review. They look at the plans and look at whether some other interventions are needed.

They then split up the consults. Bruce would usually attend to the multidisciplinary ICU rounds.

The rest of the day is spent doing new consults and doing follow-up visits. They also educate them on what their discharge options are from facility rehab to long-term care facility to hospice.

They would often have to explain what hospice is as what they have in their minds is the 1960s setting. 

'Go home and stop buy your medicines. We're now going to hold your hand and sing kumbaya and wait for you to die – that's the mental image that many people have of hospice.'Click To Tweet

They have to explain that modern hospice involves aggressive management. You could stay on your medications. They will talk to you about risks and benefits but it’s your choice. They try to keep you out of the hospital and go through the benefits involved. Most people are very surprised to hear that this is what hospice is.

During family meetings, they would usually discuss the patient’s condition, the current treatment plan of care, and then options going forward. Then together they make decisions when the patient is unable to participate in that decision-making process.

[17:55] What He Loves About Being a Palliative Care Doctor

What Bruce loves about being a palliative care doctor is having enough time. As a hospitalist, you’re in and out. You have to see all these patients. You get them admitted and discharged. It’s a constant rush.

'What I love about being a palliative care doctor is I have time... for me, I love that I have the time to make sure people know what's going on.'Click To Tweet

In palliative care, he just spends an hour and a half in a family meeting with a patient in the ICU. There was no rush. He was able to spend all the time that the family needed to answer the questions and give them the information and help them come to a decision. Bruce says there’s nobody else in the hospital that can do this.

Both in hospice and palliative care, they have a strong emphasis on engaging a multi-disciplinary team. They often bring in a social worker or a chaplain or a spiritual care worker.

As a palliative care doctor, he would assess the needs of the patient and access the other resources. And to be able to relieve that by providing information is incredibly rewarding for Bruce.

'People are so overwhelmed in the hospital. This is just a scary environment especially if you're elderly.'Click To Tweet

[21:18] Taking Calls

In the hospice he’s working in, there are only two of them and they provide an 8am-5pm service. They’re a very new service to be doing the more aggressive types of interventions they’re doing now.

That being said, they still have to prove themselves before they can grow and get JCAHO-certified. (JCAHO stands for Joint Commission Accreditation for Hospice Organizations) And to get certified, you have to have 24/7 coverage, which can’t be done as of the moment with only two of them.

[22:20] The Training Path

When hospice and palliative care became an ACGME one-year fellowship, it had more boards that endorsed it than he believes any other subspecialty has. 

In almost all of the boards you could think of, as you go through your residency, you can then apply for a 12-month fellowship. In short, there are a lot of different paths that you can take to get there.

'There's really a two-tiered system here. We believe that primary care doctors should be able to provide basic palliative care.'Click To Tweet

In line with this, they believe that primary care physicians should have basic knowledge of palliative care. They should have basic pain management skills. They should be able to talk through advanced directives.

They want to see primary care doctors educate themselves enough to get the basics and know when to defer to a palliative care specialist. So they want more of them trained. Part of this is because there is a growing demand for doctors doing palliative care due to the increasing aging population.

'Almost every hospital of over 300 beds in the country has inpatient palliative care and there's a need for outpatient palliative care.'Click To Tweet

Bruce says this is a field in medicine that is in high demand and will continue to be based on just population demographics.

[26:00] The Challenge in a Lot of Hospitals

In smaller hospitals, full-time palliative care is somewhat limited that it becomes an extra duty for the hospitalist.

Previously, Bruce implemented inpatient palliative care as part of his hospitalist practice. The hospital paid him a stipend to manage it. However, it doesn’t pay for itself in a silo. Instead, they save a lot of money by getting patients out of the ICU sooner and getting them discharged sooner.

'The problem we face is that in a hospital environment, palliative care doesn't pay for itself in a silo.'Click To Tweet

In the big picture, every study that has been done has shown that inpatient palliative care saves the hospital money. Unfortunately, hospitals just look at the cost. This becomes challenging for smaller hospitals to want to go out and bring in a full-time palliative care doctor.

In this regard, hospitals are using nurse practitioners in that role. And the issue is they don’t make tons of money with what they do.

[27:44] Working with Primary Care Doctors

The first thing Bruce wishes that primary care doctors knew is that they don’t have to wait until their patient is actively dying to get palliative care involved. 

'Many of the national oncology organizations are now suggesting in their policy guidelines that palliative care be involved at the time of diagnosis and going forward.'Click To Tweet

If you have an elderly patient with multiple chronic medical problems, those are patients that palliative care can help with. They can help with symptom management. They can take the time that primary care doctors don’t have in the clinic. They can provide this service.

Don’t wait until end of life and don’t let their patients suffer. If they’re having trouble managing pain, they can help with this. In fact, this is an increasing problem, with opioids not being prescribed by a lot of doctors anymore because they’re so nervous about it.

[29:50] Special Opportunities Outside of Clinical Medicine

There a lot of academic opportunities for palliative care doctors. Many of them actually move up into administration. Other opportunities include research and teaching.

On another note, what Bruce likes the least about being a hospice and palliative care doctor is the fact that most people don’t understand what they do. They just see him as the “death doctor” without really understanding the broader picture. He also doesn’t like the current financial picture.

[31:50] Major Changes in the Field

With the workforce shortage and the aging population, Bruce thinks that there has got to be a change in the Medicare regulations for the hospice benefit.

Hopefully, there’s more involvement in palliative care in residencies and medical schools. This way, there’s more exposure and a better understanding of what they do.

Ultimately, if he had to do it all over again, Bruce thinks this actually is a hard question. Where he came from, there were very few full-time jobs in hospice and palliative care medicine. So he had multiple job changes and each time, there was significant stress.

All those being said, in terms of his personal path, he wouldn’t mind doing something more stable and consistent. But in terms of the work he does, he feels this is more of a ministry. He loves what he does.

[33:50] Final Words of Wisdom

If you’re a student doing rotation, go spend some elective time. It’s a great way to see what they do. Volunteer with a hospice. They always need volunteers. Go shadow a hospice doctor. 

Bruce also draws the difference between inpatient palliative care, outpatient palliative care, and hospice. Each has a very special skill set and special population. So go out there and get exposed to it!

[34:50] Interview with Dr. BJ Miller

I had a previous interview with Dr. BJ Miller, a triple amputee from an accident he had while in college He went on to medical school and became a hospice and palliative care medicine specialist. He has made it his life’s mission to help people die in a better way. Check out that interview on The Premed Years Podcast Episode 301.

Links:

Board Rounds podcast

BoardVitals

The Premed Years Podcast Episode 301 with Dr. BJ Miller: Near-Death Experience Led This Physician to Help People Die

Listen to Other Episodes

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