The Rise of Palliative Subspecialty Care

Within each specialty, there will arise a palliative care focus, with a physician (especially in the larger medical groups) who will become the palliative specialist for that specialty. We are beginning to see this develop rapidly in our hospitals with hospitalists that focus on palliative care or separate palliative teams.

Let us take the oncologists for example. A patient will be followed by an oncology group and when a patient requires a different approach to the treatment of their cancer (comfort over cure), the palliative specialist will take over the care. What will that look like?

 A patient has metastatic disease that involves the pleural lining (the lining surrounding the lung). Fluid is building up in the space between the rib cage and the lung tissue, pushing and squeezing the lung tissue making it difficult to breathe. Traditionally, the patient with this condition gets admitted to the hospital through the emergency room, multiple studies are completed, consultants are gathered, a procedure is completed to remove the fluid, more recovery and tests, then discharged in a weakened condition days later. Still with the cancer and now with additional complications (weakness, pressure sores, Clostridium difficile diarrhea, fluid overload, black and blue marks from multiple needle sticks, etc.) from treating the complication (pleural fluid).

 The alternative here is a planned admission with the palliative care pulmonologist directly to a palliative unit in the hospital. Only testing related to a safe procedure is completed, the procedure is accomplished, and then the patient is discharged shortly after. And we can even improve on that step further. Create a focus in an outpatient center for intensive palliative care procedures like the one described, with direct discharge to the home setting with intensive home health using modalities like telemediobservation (one form of telemedicine) and home health nursing.

 As a physician that focuses on wound care, I utilize my palliative skills every day. Patients with wounds often develop those wounds as an end-stage process of chronic illness: venous ulcerations from chronic venous insufficiency; pressure ulcers from general debility and nutritional compromise; diabetic ulcerations from a poorly-controlled, long-standing diabetic condition. I suggest hospice to my patients more often that I did when I was in a full-time internal medicine practice. Much of the care that we deliver in our wound center is palliative.

If you identify a patient that has palliative needs, please advocate for them. Many healthcare systems are designed around test, treat and cure rather than comfort over cure.

Scott Matthew Bolhack, MD, MBA, CMD, CWS, FACP, FAAP