If there are such things as universal truths, then one of them is almost certainly this: nobody likes to be in pain (okay, maybe masochists). This simple assumption is the key principle behind palliative care, which focuses on reducing the severity of pain and managing symptoms of patients with advanced illness—instead of relentlessly concentrating on trying to cure a condition. As many have put it before, palliative care is about caring, not curing—helping patients feel better, sometimes through medication and sometimes through communication and personal support.

Palliative care seems like a practice that would be somewhat at odds with American-style medicine, which centers on maxing out detection efforts and treatment interventions. The reasons for this tendency are two-fold: in our warped reimbursement system, doctors get paid more to do more procedures, and our medical culture is very much focused on ‘beating’ sickness instead of treating people.

Yet palliative care has been on the upswing in American medicine over the past few years. According to the American Hospital Association, as of 2005, 30 percent of U.S. hospitals and 70 percent of hospitals with more than 250 beds had a palliative care program—an increase of 96 percent from 2000. What’s behind this surge?

One hopes that hospitals are increasingly recognizing the value of
palliative care to patients. Palliative care is not just about hospice
care—that is, care for the dying—though it’s a big part of helping sick
patients pass on in comfort. It’s also, as Dr. Diane Meier, the
Director of the Center to Advance Palliative Care and member of The
Century Foundation’s Medicare Working Group,
has noted, an important part of helping all people with advanced
illness have a higher quality of life. If we ignore palliative care, we
end up with patients who might be getting ‘treatment,’ but who are
miserable and in pain during the process. “Forcing a choice between
cure and comfort until the end-of-life predictably results in
preventable suffering during all other stages of a serious illness,”
Meier pointed out in a 2007 commentary for Medscape.

But it would be foolish to ignore the elephant in the room when it comes health care: money. In the newest Archives of Internal Medicine, Meier and a collection of co-authors from the Palliative Care Leadership Center offer another possible explanation as to why palliative care is catching on: it saves hospitals money.

Meier and co. looked at more than 5,000 palliative care patients and
20,551 patients who only received “usual care” (i.e. care focused on
curing rather than caring) across eight hospitals. After controlling
for age, gender, condition, and even insurance coverage within the
sample group, the research team found that, for patients discharged
alive, “palliative care consultation was associated with adjusted net
savings in total costs of $2,642 per admission compared with usual
care.” For patients who died in the hospital, “palliative care
consultation was associated with adjusted net savings in total costs of
$6,896 per admission and $549 per day.”  In other words: “hospital
palliative care consultation teams are associated with significant
hospital cost savings.”

This is important stuff, because any and all savings make a difference
to hospitals. The authors point out that hospitals have a median
operating margin—that is, the profit made on patient care—of just 2
percent, which breaks down to about $27-$40 per day. That’s not a lot.
So why does palliative care save money? Simple: “discontinuing costly
non-beneficial interventions among seriously ill patients reduces
hospital costs.” In other words, consultation from palliative care
teams appears to make patients and doctors think twice about undergoing
costly, unproven treatments intended to “prolong life and avert death
at all costs.”

It’s hard to over-estimate the importance of any sort of consultation
that influences this decision-making process surrounding issues of what
kind, and how much, intensive or invasive care seriously ill patients
receive, particularly for end-of-life care. As the famous annual Dartmouth Atlas
research project has shown again and again, spending more time and
money on severely ill patients doesn’t necessarily make them healthier.
In fact, regions of the U.S. that spend more on Medicare patients over
the course of their last two years of life have slightly worse
mortality outcomes.

Unfortunately, it’s generally difficult to get physicians to rethink
the do-everything-you-can-because-you-can-do-it logic that results in
bombarding patients with painful, and sometimes inhumane, care. In May,
Maggie reported
on a harrowing story that Meier recounted to an audience of medical
students about a man who was literally tied to his bed so that doctors
could install a feeding tube he didn’t want in order to ‘save’ him. A
1995 JAMA study
confirms that such stubbornness amongst doctors isn’t as rare as you
might hope. This study looked at 9,105 patients over two years who had
life-threatening illnesses, and split the sample roughly evenly into
two groups. Patients in the first group had access to a specifically
trained nurse to have “multiple contacts with the patient, family,
physician, and hospital staff to elicit preferences, improve
understanding of outcomes, encourage attention to pain control, and
facilitate advance care planning and patient-physician communication.”
In other words, these patients had a special go-between representing
their preferences and palliative care priorities to doctors. The second
group did not, and received usual care. 

Unfortunately, the JAMA found that the addition of a specialized
nurse didn’t make much of a difference. Patients in the first group
“continue[ed] to receive low-yield, burdensome, and high-cost tests and
treatments including prolonged ICU stays—a probable result of highly
ingrained physician and hospital practice patterns and prevailing
hospital culture.” Sadly, according to the JAMA authors, it
seems that “enhancing opportunities for more patient-physician
communication, although advocated as the major method for improving
patient outcomes, may be inadequate to change established practices.”

It’s tough to convince doctors that they should be prioritizing
palliative care—at least when it’s only a nurse and a patient
discussing things. But it seems that full-on palliative care
consultation—intervention by an interdisciplinary consultation team
that can include any range of medical experts from fields like
oncology, internal medicine, psychiatry, and other disciplines as
needed—does make a difference. Maybe doctors will only listen to
other doctors, or maybe there’s strength in numbers; whatever the
reason, it seems that “palliative care consultation fundamentally
shifts the course of care off the usual hospital pathway and in doing
so, significantly reduces costs.” It looks like a lot fewer patients
want to be poked, prodded, cut open, or irradiated than the medical
establishment usually assumes—they just need a critical mass of experts
valuing their comfort in order for these preferences to be made
reality.

As palliative care becomes more common in the U.S., it will undoubtedly
face many of the same difficulties that surround so many other health
care issues, such as compensation and equity. As Meier told Maggie
earlier this year, reimbursement for palliative care consultations is
abysmally low: “When a three-person palliative care team made up of a
doctor, a nurse and a psychologist spends 90 minutes in a meeting with
a family, Medicare would probably pay $130 to $140—for all three
people.” Just as concerning is the fact that hospice care, which is a
large part of palliative care, is also unevenly distributed in the
U.S.: though African-Americans make up 13 percent of the total U.S.
population, the Robert Wood Johnson Foundation reports that they make
up only 8 percent of hospice patients—while whites make up 83 percent
of patients who receive end-of-life hospice care.

Still, whatever challenges may lie ahead for efforts to better
integrate palliative care with American health care, evidence that it
saves money—and helps to divert doctors from a medical methodology that
has proven to be much more expensive than its benefits warrant—is an
important start.