America, your bluff has been called…the verdict is in, and the old adage remains true: you cannot have your cake and eat it too (shocking news, I know). Clichéd as it may sound, that message rang true this morning as the annual assembly opened in a blaze of introspection and criticism of the status quo. The target? Rising healthcare costs. Even current levels of U.S. healthcare spending are unsustainable, yet we continue on a path of rising costs without adequate thought regarding the value of care provided.
The panel discussion featured Thomas Smith, Brad Stuart, and Rebecca Kirch, each presenting perspectives on the problem and fielding questions. Smith hit the nail on the head, pointing out that “value is missing, care is not optimal, and costs are rising unsustainably.” He highlighted some staggering statistics from a sample of cancer patients at a major academic medical center (Dy, et al, 2011). Roughly 1/3rd received chemotherapy within 2 weeks of death, ~25% ended up on a ventilator, less than 1/4th were discharged to hospice care, and ~1/3rd died in the hospital. Quite a sad state of affairs! Yet insurance premiums are rising quickly, having doubled between 2000 and 2010; herein lies the “missing value.” What are we buying with all this money spent? What’s a society to do?
At this point someone usually drops the “R-bomb,” which can curtail any meaningful debate. Imposing limits on healthcare is such a charged and seemingly un-American idea. Must rationing be the only solution though? Per Brad Stuart, the answer to this question is a resounding “no!” Stuart described a program called AIM (Advanced Illness Management), which effectively turns this debate on its head. Rather than focusing on imposing limits, AIM emphasizes the importance of eliciting and defining patient preferences early (and often), and facilitates doing this in the community rather than just the hospital. AIM data show how this approach can yield improved outcomes, higher quality of care, and even decreased costs!
This sounds like what many of us in palliative care already think we do; we’re communicators, goals elicitors, and compassionate caregivers. But we are handcuffed by a system that often views us as the alternative to aggressive treatments, especially in cancer care, and we’re often involved too late in the process. Thankfully, this too is changing. A recent guideline from the American Society of Clinical Oncology recommends early palliative care for all patients with advanced cancers (link). Palliative care is increasingly viewed as a part of the solution and a part of quality cancer care, rather than an adversary.
In this climate, 2012 is a time of enormous excitement for our field! How we brand and conduct ourselves though, is crucial. We must be partners in cancer care, not antagonists. As Kirch taught us in reviewing the CAPC report, how we talk about palliative care truly matters; if we do it “correctly,” patients are overwhelmingly interested in what we do, and would want it for their loved ones (link).
As a trainee in both oncology and palliative medicine, I cannot imagine a more exciting time to be working at the intersection of these fields. Let’s continue to work together to blaze a trail towards increasing quality of life and quality of cancer care. In line with the AIM program, and those like it, let’s be champions of patient choice, rather than reapers of grim. Palliate early, and often!Thomas W. LeBlanc, MD, MA Fellow, Medical Oncology and Palliative Medicine Duke University