The number of Palliative Care Programs (PCP) in large and
not-for-profit U.S. hospitals has increased 125.8 percent over
the last eight years according to a recent study by the Center to
Advance Palliative Care (CAPC) and the National Palliative
Care Research Center (NPCRC), but for profit hospitals are lagging.¹ Even with these improved numbers, there are still gaps in
providing palliative care for cancer patients. PCPs enhance the
quality of care for patients experiencing serious, chronic illnesses.
Palliative care (PC) for cancer patients can be integrated
into the therapy regimen without sacrificing curative intent,
while hospice care is clearly focused on the dying patient who no
longer benefits from therapy. Dr. Diane Meier, the director of
CAPC, says that the PCP “addresses the fragmentation of the
healthcare system and puts the focus back on communication
with the patient and family.”² Hospitals and physicians working
together can develop a PCP or enhance an existing program to
better serve the needs of their cancer population.
What is Palliative Care?
PC for the cancer patient focuses on living with a chronic
cancer diagnosis, and preparing for the process of dying. While
more attention has been given to palliative care over the past
few years, referrals to PCPs still occur late in the trajectory of
the disease.3 Hospice care is widely available but also suffers
from late referrals, even as more institutions implement palliative
care programs which should improve timeliness of referrals
to hospice. Private physician practices are slow to adopt palliative
care initiatives for a variety of reasons,
including time and staff constraints
and reimbursement. Fadul, et al., found
in their study conducted at M. D.
Anderson Cancer Center that physicians
and other providers were more likely to
refer patients to a service called supportive
care than to one called palliative care,
which was perceived as distressing and
In order for PC to be successful, it
must be timely and interdisciplinary. The
goal of palliative care, according to the
Center to Advance Palliative Care, is to “relieve suffering and
improve quality of life for patients with advanced illness and
their families.”4 The World Health Organization (WHO) supports
palliative care as the total active care of patients whose disease
is not responsive to curative treatments.5 While recent press
surrounding health reform inaccurately references “death panels,”
6 the WHO states that PC affirms life and regards dying as
a natural process, neither hastens nor postpones death, provides
relief from pain and suffering, and offers a support system
including support in bereavement. Consideration of palliative
care intervention should begin soon after diagnosis and grow in
increasing importance throughout the disease (Figure 1).
Who Should Provide Palliative Care?
PCP’s require a variety of care sites, a multidisciplinary
team, and appropriate medical intervention that provides
optimal quality of care as the disease progresses. It also should
begin far in advance of the need for hospice, when the patient
is chronically ill and requiring ongoing medical care. The
Institute of Medicine’s National Cancer Policy Board and The
Center to Advance Palliative Care both emphasize the importance
of PC beginning at initial diagnosis with increasing
levels of support through the disease until death.4,7 While hospice
care removes all therapeutic interventions and focuses
on relief of pain and suffering, palliative care continues therapeutic
interventions until the intervention is outweighed by
Involving the medical and radiation oncologists in palliative
care provision is critical to success. The National Comprehensive
Cancer Network (NCCN) recommends that oncologists integrate
PC into their practice for patients who meet screening criteria,
and consult and collaborate with a palliative care specialist
for more complex cases.
Organizations writing palliative care guidelines provide
invaluable guidance to hospitals and physicians committed to
the concept of PC. NCCN provides a guideline for Palliative
Care from the physician perspective that addresses the need for
a plan of care developed by an interdisciplinary team.8 CAPC
provides guidelines for hospitals interested in developing a
PCP.4 Both the American Society of Clinical Oncology
(ASCO) and the American Society of Radiation Oncology
(ASTRO) address the need for palliative care. The ASCO position
statement on palliative care states “that it is the oncologists’
responsibility to care for their patients in a continuum
that extends from the moment of diagnosis throughout the
course of the illness. In addition to appropriate anticancer
treatment, this includes symptom control and psychosocial
support during all phases of care, including those during the
last phase of life.”9 ASTRO supports the use of the NCCN
guidelines and the National Consensus Project for Quality
Palliative Care guidelines.10-11
How to Provide Palliative Care?
Cancer care is inherently fragmented as patients move from
physician offices to freestanding radiology and laboratory centers
to hospitals to radiation therapy centers and to a myriad of
other sites from diagnosis to the end point of their care. The
questions of who provides palliative care and where this care is
provided must be addressed. The cost of cancer care is high
and the minimal reimbursement for PC only compounds the
problem. Developing a program requires interdisciplinary cooperation
and coordination, while determining financing methodologies.12 Utilizing cost aversion is an excellent strategy for
hospitals, while medical and radiation oncologists receive their
usual fees for providing the ongoing therapeutic care the patient
normally needs in cancer care.13
The first step in providing a PCP is determining interest and
knowledge in the facility and among the medical staff. Asking
questions of physicians and staff, providing the NCCN guidelines
for review as a component of quality assessment projects,
or perhaps conducting a review of palliative care offerings during
the annual assessment of services and care required by the
American College of Surgeons (ACoS) Commission on Cancer
as part of the accreditation process are all strategies to determine
the extent of available services and the interest in providing
more.14 Implementing a palliative care program or developing
strategies to improve an existing program may also meet
Standard 8.2 of the ACoS requirements stating that the Cancer
Committee or other appropriate leadership implements two
improvements that directly affect patient care.
To begin a PCP requires a commitment from the hospital
provider and physicians to work together, including a commitment
of resources and a time commitment of staff involved.
Using the CAPC resources is highly recommended as is working
with individuals who have established and maintained quality
programs. Using a team approach of volunteers is ideal as it establishes
early buy-in for the program efforts. Identifying the interdisciplinary
team needed to drive the process is critical. A medical
staff leader, a nursing leader, a medical social worker, a pain management
specialist, a pastoral care member, and an administrator
are the minimum needed to begin the process. Others with an
interest in PCP development are encouraged, including a family
member or Hospice representative, but if the minimum team can
not be identified, the program may not succeed.
Developing an initial action plan, including a draft statement
of medical leadership support, patient volumes anticipated,
financial implications, and administrative and clinical expertise,
begins the initial steps of program development. From the initial
action plan will flow the business case that must be developed
that calculates the financial impacts of the program. Cost avoidance
in the hospital setting is more difficult to quantify but there
are tools, resources and consultants available that assist facilities
in determining the actual costs and dollars saved by implementing
a program. Edens, et al., reported that one facility freed up
costly ICU beds and averted unnecessary resuscitations to more
than pay for the program.12-13 Physician offices must determine
if additional time is required to counsel patients about palliative
care options or if a greater involvement with the hospital program
is the best avenue to provide this service.
While the focus of this discussion is on the cancer patient,
one analysis of more than 700 admissions with 6,600 plus
patient days in three different facilities revealed that only 14 percent
of the deaths in the hospitals had a cancer diagnosis.12
Palliative care serves an older population, many with a cardiopulmonary,
neurological or other non-cancer diagnosis so
including other specialties in the discussion of program development
After a comprehensive assessment of knowledge about palliative
care provision and a clinical analysis of admissions are
complete, a financial analysis is needed. Reviewing deaths in the
facility for cause of death, site of care, cost to deliver care and
reimbursements received, and the potential to avert unneeded
care provides the financial data for the hospital provider. In the
physician office, compliance with nationally recognized palliative
care guidelines such as the NCCN guidelines, determining
time spent in counseling patients and families about treatment
and non-treatment outcomes, the percent of patients in late
stage or futile care protocols, the number and timeliness of referrals
to hospice care and other factors are important to understand. While medical and radiation oncologists continue the
active therapy of their patients and receive reimbursements for
that care even in the presence of patients’ participation in a palliative
care program, the potential to relieve suffering and support
the best possible quality of life for patients and families is
crucial. There may be uncompensated care that is provided in
the physician office setting that needs to be captured in a financial
assessment of the practice.
What Model of Palliative Care?
Once the educational, clinical and financial analyses are
complete and support for the program development is evident,
determining the model of care to provide is the next
step. There are several models that may be adopted, and three
options are presented here.4,12 The Consultative Service Model
uses either a single individual (Sole Practitioner Model) or a
team (Full Team Model) that follows the patient regardless of
site of care. This model functions in an advisory role to physicians
providing therapeutic care to the patient, including recommending
when the patient may verbalize a readiness for
hospice care. A Geographic Inpatient Model uses a dedicated
bed model and congregates patients in a unit for inpatient
admissions. This may be a difficult model to implement when
patients have a variety of diagnoses. Designating beds on the
medical oncology unit and providing additional education
and training for staff is one way to support a geographic
model. Patients are generally symptomatic when admitted to
the hospital and are continuing to receive active therapy, so
geographic locale and billing is usually disease-based and
reflects the acute care model.
The leader of the PCP may be a Board Certified Palliative
Care Physician, an Advanced Practice Nurse, or other clinical
leaders with additional training in palliative care. The leader
should be identified early in the process of developing a program
and incorporated into the planning as soon as possible. Staff
should also receive additional education about providing palliative
care through both formal and informal means.
The hospital and physician practice environments for the
patient and family participating in a PCP should be modified
regardless of the model chosen. Patient and family involvement
in decision making regarding treatments and care planning,
using private rooms, minimizing restrictions on visiting even in
the ICU, and providing a more patient centric care experience
are vital to a healthy PC effort.
Palliative care may be outsourced, and many community
hospice agencies are beginning to provide this service to
patients, facilities and physician practices.12 Outsourcing may be
provided through staff, leased services and beds, or contract
management. Home care agencies are also involved in palliative
care provision in some markets. If services are provided outside
the domain of the hospital and physician office, the patient
must clearly understand that there may be an additional bill for
the services provided through another agency.
So Should We Offer Palliative Care?
Providing access to palliative care is the right thing to do for
patients, and is an integral part of quality patient care. Even
before reimbursement is determined, consumers and payors
becoming more knowledgeable of the benefits provided by the
program may demand access. While no one argues that palliative
care provides a measurable benefit to quality of life, developing
a program without an easily identifiable revenue stream is
challenging. Understanding clearly the benefits of a PCP, developing
a cost aversion financial model to support the cost of the
program, and gaining the support of physicians, administrators,
interested staff and patients will assist your facility or practice in
determining how to provide palliative care. Providing a smooth
transition from diagnosis to either cure or a good death is one of
the best gifts a patient and family can receive from their
providers. It is the right thing to do.
Pat Stanfill Edens, PhD, RN, FAAMA, FACHE, is Senior Consultant, The Oncology Group, LLC. Prior to joining TOG, she was
Assistant Vice President, Hospital Corporation of American (HCA), with corporate responsibility for strategic and operational
direction, and financial performance of the $3.5 billion Oncology, Solid Organ and Bone Marrow Transplant Service Lines and
was the Responsible Business Executive for Clinical Research for the company. She presents internationally on topics related
to cancer, biotechnology, healthcare economics, clinical research and quality, with over 100 publications in a variety of content
Marsha Fountain, MSN, RN, is a Founder of The Oncology Group, a national oncology consulting firm. Marsha began consulting
to cancer programs in 1996 following a 20-year career as a cancer program Administrator. As a consultant to hospitals, she
has been influential in the development and planning of cancer programs throughout the United States. She assists hospitals
in providing and improving the continuum of cancer care services patients require through the development of strategic plans
and business plans that are specific to the hospital, physician and community. Marsha is a frequent speaker at national symposia
and author of numerous articles.
- Analysis of U.S. Hospital Palliative Care Programs 2010 Snapshot.
Center to Advance Palliative Care. Available at: http://www.capc.org/
news-and-events/releases/04-05-10. Accessed on April 7, 2010.
- Palliative Care Programs Continue Rapid Growth in U.S. Hospitals
Becoming Standard Practice throughout the Country. Press Release on
April 7, 2010 from Center to Advance Palliative Care. Available at:
http://www.capc.org/news-and-events/releases/04-05-10. Accessed on
April 7, 2010.
- Fadul N, Elsayem A, Palmer JL, Del Fabbro E, Swint k, Li Z, Poulter V,
Bruera E. Supportive versus palliative care: what’s in a name? a survey of
medical oncologists and midlevel providers at a comprehensive cancer
center. Cancer, 2009 May 1;115(9):2013-21.
- Palliative Care. The Center to Advance Palliative Care. Available for order
at: www.capc.org. 2008.
- What is Palliative Care. World Health Organization. Available at:
www.who.int/entity/hiv/topics/palliative/PalliativeCare/en. Accessed on
April 4, 2010.
- False ‘Death Panel” Rumor Has Some Familiar Roots. The New York
Times. Available at: http://www.nytimes.com/2009/08/14/health/
policy/14panel.html. Accessed on April 4, 2010.
- Improving Palliative Care for Cancer, Summary and Recommendations.
Institute of Medicine. Available at: www.iom.edu. Accessed on April 7, 2010.
- Palliative Care Practice Guidelines in Oncology v.1.2010. National
Comprehensive Cancer Network. Available at: http://www.nccn.org/pro
fessionals/physician_gls/PDF/palliative.pdf Accessed on April 5, 2010.
- Position Statement on Palliative Care. American Society of Clinical
Palliative+Care. Accessed on April 7, 2010.
- Consensus Based Clinical Practice Tools. American Society of Therapeutic
Radiation Oncology. http://www.astro.org/Research/ClinicalPracticeTool/
Consensus-based/. Accessed on April 7, 2010.
- National Consensus Project on Quality Palliative Care. http://www.national
consensusproject.org/. Accessed on April 7, 2010.
- Edens PS, Harvey CD, Gilden KM. Developing and Financing a Palliative
Care Program. American Journal of Hospice and Palliative Medicine.
2008 Oct/Nov 25(5):379-384.
- Edens PS and Harvey CD. Utilizing cost aversion in a business case to justify
palliative care programs in for-profit community hospitals. Journal of
Clinical Oncology, 2005 ASCO Annual Meeting Proceedings. Vol 23, No
16S (June 1 Supplement), 2005: 8084.
- Commission on Cancer: Cancer Program Standards 2009. American
College of Surgeons. Available at: http://www.facs.org/cancer/coc/
cocprogramstandards.pdf. Accessed on April 7, 2010.