Article Archive
November/December 2015

Palliative Care: Its Role in Improving Health Care
By Timothy G. Ihrig, MD, MA
Today's Geriatric Medicine
Vol. 8 No. 6 P. 20

Palliative care reduces hospitalization rates and 30-day readmission rates while decreasing per capita health care expenditures.

It is a most interesting phenomenon to be a resident of Iowa during a presidential election cycle. A little before 6:30 AM, I stumble into my neighborhood coffee shop. Through the haze of drowsiness cast by a sleepless night from a succession of my children awakened by thunder and lightning, I find myself standing next to a CNN regular, recognizing him as a candidate seeking the nomination for the presidency. Sipping coffee, offering ideas on how to save America, the individual preaches to an audience of more reporters than locals. This is not an infrequent occurrence.

Nearly a year before the presidential election, Iowa is awash with appearances, handshakes, and stump speeches of would-be leaders of these United States. While not unique to this go-round, the commentary on what threatens this great nation of ours is always intense. Flavors of the week, in no particular order, include the war in Afghanistan, ISIS, immigration reform, gay marriage, and the US economy. Individually and collectively, these stand to undermine the integrity and stability of life as we know it here in America—or so they say.

While waiting for my light roast, I find myself flashing back to a birthday party I attended as a child. A magician performed as we sat in a semicircle, mesmerized by flash and flair. Where did that coin go? How did all the colorful scarves suddenly appear from his hat? Magnificent sleight-of-hand maneuvers distracted us from the reality of his art, much like this and all candidates for the Oval Office stumping across the state. What is it we citizens, consumers, and voters need to know? What is it we don't know? What aren't they showing us? What really jeopardizes our way of life? I believe the real problem hasn't been discussed or even alluded to over the thousands of cups of coffee throughout dozens of towns across this state or any other.

The truth is that health care spending is the No. 1 threat to the United States economy and our way of life. The significant expense of doing things to the elderly, the sickest and most vulnerable individuals in our society, stands to change how we practice medicine and may determine whether we will even have the opportunity to continue practicing medicine over the next several decades. It also dramatically influences every aspect of our culture and economy. True palliative care is the solution to this crisis.

Spending Concerns
So, what do we know with certainty? We know the United States spends nearly 10 times more than any other industrialized countries for health care.1 We know the United States is ranked worst among the 11 wealthiest countries in the world with respect to health care efficiency, equity, and outcomes and is not even among the top 35 of all countries on the planet.2 We know the sickest and most vulnerable 5% of our population is responsible for nearly 50% of health care expenditures.3 We know the sickest, most vulnerable 20% of our population is responsible for upward of 85% of health care expenditures.4 Currently this equates to nearly 20% of the gross domestic product (GDP) of the United States, nearly $3.5 trillion in 2014.5 Via taxes, the government brings in roughly 12% to 15% of the GDP in revenue to support all social services.6 In addition, in this country there are approximately 10,000 individuals per day reaching the age of 65 and approximately 14% of them can be classified as rising-risk, high-risk sick and vulnerable individuals falling into the aforementioned category. This increase is projected to continue for the next two decades, according to the Dartmouth Atlas of Health Care.

Simply following the slope of the line of per capita expenditure vs attributable population, we stand to exceed 60% of the GDP for health care expenditures for only 15% of the population by 2035. If this comes to fruition, the conversation ceases to be about health care for the most vulnerable individuals. Health care and health care systems will no longer exist. Nor will much of anything else with which we're familiar today. And as the United States is the largest economy in the world, and presuming it maintains a prominent position in the global markets, such a change would have implications extending far beyond our free-market, capitalistic society.

To be certain, this is not merely a primary care crisis. It is not just a medicine crisis. It is not specific to one side of the political aisle or another. It is our crisis—a human crisis. To the fee-for-service specialists who fail to understand the economic reality, there will be no cardiac catheterization suite, oncology transfusion center, or orthopedics clinics when the system within which we operate ceases to exist. We can't be foolish enough to think the revenue we generate today or in the future can compensate for the lack of value equal to 60% of the GDP. It is the responsibility of every health care provider to understand this issue and its economic realities. It is the responsibility of every business in the country to understand this issue and its economic realities. An individual may not care about an elderly and frail demented grandparent, but the company inherited from him is in jeopardy if this issue is not addressed. And it would behoove every politician to understand this issue and address it.

An argument could be made for such expenditures if the country, a health care system, or even an individual derived value from these dollars, with value translated as an enhancement in the quality of life or a prolonging of that life. However, a majority of the time, this is not the case. Recognizing that the average life expectancy of the sickest, most vulnerable individuals is less than two years, all of the things done to them do not potentiate a longer life or one of higher quality. This has been proven many times. Nearly one-third of expenditures occur within the last 30 days of life.7

Realistic Treatment
We cannot curb the trajectory of decline, debility, and death despite the $3.5 trillion spent annually. In addition, we have failed to honor those we are sworn to serve by not empowering them to know the truth about their ailments—progressive, irreversible fatal disease—such as widely metastatic cancer, congestive heart failure, or dementia. Nothing we do to them will change their outcome. Efforts to change the inevitable often make their journey more difficult. We can, however, change the journey for the better and add value to patients' lives by doing things for and with them. We need to tell the truth. Recognizing medicine's limitations and the inability to defeat Mother Nature, we need to transition as a culture (of medicine and beyond) toward focusing on a broader context of the human condition than pathology.

Rarely are people asked how they want to live. This is antithetical to the question asked on a regular basis: "Do you want to die?" No, of course not. I've yet to meet someone who wants to die. The sense of losing control or suffering is often inconsistent with the quality of life patients desire regardless of disease, but this is very different from wanting to die. The answer to the question is the carte blanche for perpetuation of diagnostics, procedures, pharmacologic agents, and false hope.

We rarely give people the option of choosing their own treatment path regardless of the medical malady. Why? We fail time and time again, some more frequently than others, to care for the individual. And again, a majority of suffering and feelings of loss of control are iatrogenic. Myopically focused on disease rather than the whole person, and what additional bells and whistles we can bring to the table in spite of evidence contrary to our verbiage of "survival," we steal from fellow human beings the opportunity to live, laugh, love, learn, cry, dance, and sing based on what is sacred to them in the final days, weeks, months, and years of their lives.

People want the truth, good or bad. Most people want to decide how they live regardless of life expectancy. Public opinion polls demonstrate this time and again. Rather than connect with another human, we often focus our attention on linear algorithms, which are the foundations of medicine, and true choice is rarely offered. The pen with which patients can write the last chapters of their lives is set aside because they don't know the crescendo is upon them. We instill false hope and preserve unrealistic expectations due to our ignorance and fear.

My experience is that most patients and families traversing these last chapters of their lives too often reflect upon their health care journey with remorse and with feelings of abandonment, grief, and loss. Feelings emanate from what we long-white-coat providers fail to tell them, as well as what we do to them. Those whom they are supposed to trust most, those to whom they reveal their most vulnerable aspects often close the book by saying, "There is nothing more we can do." That's wrong. We can care. Caring, however, must be our starting place rather than "doing" because caring transcends medicine.

It is time to embrace an algorithm and philosophy placing every patient at the center of care. That's true palliative care. True palliative care promotes the connectivity between physician and patient. Reaching far beyond a service line for hospice—and not synonymous with hospice—true palliative care provides comprehensive interdisciplinary care for patients with life-limiting or potentially life-limiting illnesses through an expertise in symptom management, communication, and prognostication. The emphasis of palliative care is on quality of life and the relief of suffering.

Palliative Care as a Solution
Palliative care is provided throughout the trajectory of a disease process without regard to prognosis and can be provided in concert with curative care, as well as end-of-life care. The palliative care team works with patients in conjunction with their primary care physician and other specialists to address any physical, psychosocial, emotional, or spiritual issues patients and their families and/or caregivers may experience. It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment. Offered across the entire health care continuum, it promotes the greatest opportunity to support patients and their caregivers.

One of the greatest challenges in providing palliative care is overcoming the assumptions and misgivings of others who define palliative care based on antiquated beliefs, political rhetoric, or an inability to acknowledge and accept that palliative care's true definition can come only from the subspecialty itself. There are many who bastardize, demonize, and degrade palliative care based on their own prejudices, fears, ignorance, and historical meanings given to the words by other nonpalliative care practitioners. Just as I, a palliative care physician, would never ascribe a definition to any other subspecialty outside of my own, it is egregious for anyone outside of the palliative field to define it.

When, for example, an oncologist defines palliative care based on historical definitions from his or her field rather than those put forth by the accredited palliative care organization under the Board of Medicine, he or she is not only promoting falsities, biasing patients and other caregivers, and demoting the potential quality and longevity of a patient's life, but he or she is also wrong. That a majority refuse to engage in conversation with palliative care providers in an effort to truly understand the scope and power of palliative care is antithetical to one of the fundamental tenets of medicine: nonmaleficence.

With respect to true palliative care, here is what we know with certainty. All evidence-based medicine studies demonstrate that, regardless of diagnosis, individuals who receive palliative care concurrently with treatment experience a higher quality of life, less symptom burden, and often a longer life expectancy. As a palliative care physician, I strive to meet each individual where he or she is. I work hard to develop relationships with other providers and work with them to support an individual's understanding of his or her illness and elucidate what goals, clinical and other, they desire. Serving thousands of the most ill and vulnerable patients, my team has seen a 93% zero-hospitalization rate over the last three years for palliative care outpatients, a reduction in 30-day readmissions upward of 40%, and up to a 70% reduction in per capita expenditures. In addition, our program consistently has the highest patient satisfaction scores throughout our entire system and is a program that patients judge to be "most likely to recommend to others." Such feedback repudiates the myth that palliative care is "giving up" or "stealing hope."

My coffee is ready. With steam streaming through the lid, I sip while slowly walking toward the door. Thinking about my morning encounter, I realize we have the opportunity to change the world—our world, our future. While there is value in tending to other issues around the country and the world, if we fail to address our health care challenges, we will lose the opportunity to do anything else. A health care delivery paradigm predicated upon informed consent and eliciting a patient's goals regardless of clinical situation is the answer to overcoming the present and future cost burdens of our health care systems. True palliative care is the answer to procuring a future not only for our profession but also for everything we as a society value and hold sacred. Only then can we embrace risk and each other to enhance value to an individual's life. Collectively we can change and we must change. This is no stump speech.

— Timothy G. Ihrig, MD, MA, is medical director of palliative care at the Trinity Regional Medical Center and director of Ihrig MD & Associates and Medhava Media, whose focus is innovation in the space of advancing palliative care. He is nationally recognized for his expertise and success with community-based palliative care program development and innovation.

1. US health system ranks last among eleven countries on measures of access, equity, quality, efficiency, and healthy lives. The Commonwealth Fund website. Published June 16, 2014.

2. World Health Organization's ranking of the world's health systems. The Patient Factor website.

3. Fischbeck P. US-Europe comparisons of health risk for specific gender-age groups. Carnegie Mellon University; September 2009.

4. Commonwealth Fund national scorecard on U.S. health system performance, 2011. Commonwealth Fund website.

5. Medicare Payment Advisory Commission. Report to the Congress — Medicare payment policy. Published March 2009.

6. What is the total US government revenue? US Government Revenue website.

7. Barnato AE, McClellan MB, Kagay CR, Garber AM. Trends in inpatient treatment intensity among Medicare beneficiaries at the end of life. Health Serv Res. 2004;39(2):363-375.

1. Anderson GF, Hussey PS, Frogner BK, Waters HR. Health spending in the United States and the rest of the industrialized world. Health Aff (Millwood). 2005;24(4):903-914.

2. Congressional Budget Office. High-cost Medicare beneficiaries. Published May 2005.