Introduction   Palliative care consultative services are becoming commonplace in academic and community hospitals and clinics. Patients and families may have negative perceptions of palliative care and hospice – viewing such a discussion as signaling that the physician is “giving up on the patient” and that the reality of impending death must be faced.   For the attending physician, the decision to convey to a patient and family that a consultation is needed can provoke anxiety.  Physicians may fear such a discussion will provoke anxiety, anger or a sense of hopelessness.  This Fast Fact provides tips for beginning a discussion leading to a visit by a palliative care consultation team.

First, decide why you want assistance from the palliative care team. Typically, physicians seek assistance in four domains: 1) pain and non-pain symptom assessment and management; 2) assistance in making difficult decisions, usually about continued use or withdrawal of potentially life-prolonging treatments such as feeding tubes, antibiotics, dialysis, or ventilators; 3) assistance in planning for the most appropriate care setting to meet patient/family goals for end-of-life care; and 4) providing psychological support to patients, families and the health care team.

Second, contact the palliative care team.  Discuss your reason(s) for consultation along with pertinent details of the patient’s history and family support structure.   Describe both what your goals are for the consultation, as well as what the family’s/patient’s goals may be.  This is a good time to discuss any concerns you have about using the term palliative care with the patient or family.

Third, engage the patient/family in a discussion of the current medical condition and goals of care. Introduce the topic of a consultation by saying: To best meet some of the goals we’ve been discussing (fill in with the goals mentioned by the family/patient) I’d like to have some consultants from the Palliative Care Team visit with you.  You can follow this by saying, They are experts in treating the symptoms you are experiencing (fill in symptom). They are also good at helping your family deal with all the changes brought on by your illness; they can answer your questions about (fill in previously discussed patient questions).

You should not say that the reason you are asking Palliative care to be involved is “that there is nothing more to do” or because “I have nothing more to offer.”  Talk about the positive goals Palliative Care can help you and the patient achieve. 

Finally, emphasize your continued involvement: You and I will talk about the recommendations of the palliative care experts.  I’ll make sure all your questions are answered.  This can help relieve fears of abandonment.  If a patient or family reacts negatively to the suggestion for a consultation, explore their concerns.  Someone may have mentioned palliative care and this may have negative connotations to them.  Ask, What experience do you have with hospice/palliative care?  What are your concerns?   It may be important to discuss that palliative care is compatible with aggressively treating the underlying disease.  Emphasize the positive aspects of what palliative care can do, rather than focusing on how the palliative care team will help them accept death and dying.  After all, the goal of palliative care is to achieve the best possible quality of life through relief of suffering, control of symptoms and restoration of functional capacity, while remaining sensitive to the patient and family’s values. Palliative Care guides the patient and family as they face disease progression and changing goals of care, and helps those who wish to address issues of life completion and life closure. 

References

1. Weissman DE.  Consultation in Palliative Medicine. Arch Int Med. 1997; 157:733-737.
2. Last Acts Campaign Task Force on Palliative Care. Precepts of Palliative Care. J Pall Med. 1998; 1:109-115.

Version History:  This Fast Fact was originally edited by David E Weissman MD.  2nd Edition published July 2005; 3rd Edition May 2015. Current version re-copy-edited April 2009; then again May 2015.