There’s a lot of confusion about palliative care. If you’ve read my blog post about comfort care, you’ll know it’s the palliative care team that drives comfort care. However, the palliative care team’s main focus is on pain management. They don’t focus on curative measures (measures to stop diseases). So just because palliative care is involved, does not mean curative treatments are being stopped. It just means we want you to be as comfortable as possible while we’re pursuing those curative treatments.
So, in a way, palliative care = pain care.
Curative measures are managed by other teams and just because palliative care is there, doesn’t mean those other teams are giving up.
In the ICU, it’s very common to see palliative care involved in a case. That’s not necessarily true in other units. I was helping out on an oncology unit once and had a patient with stage 4 cancer. The patient was in a great deal of pain that was not being helped by the current medicine being prescribed. I said as much to the attending physician (the physician that oversees the patient’s case as a whole without having a speciality) and I recommended getting palliative care involved. The attending thought it appropriate and put the orders in.
When the palliative care provider approached, she had the look of someone who had just been banging their head against a wall. She came up to me to talk about the patient before going in and meeting them. She started with a sigh and said, “This is Dr. X’s patient, yeah?” (Dr. X was the oncologist and obviously not the doctor’s real name.) I said yes. She said, “I’m going to go in there and talk to this patient and I’m going to try to help them be more comfortable. You may see that the orders I put in are quickly discontinued by Dr. X. When that happens, please let our service know. We go through this a lot with him.”
Sure enough, the Palliative Care provider went in with the patient, adjusted the patient’s pain management to something, in her expertise, was more appropriate. Shortly thereafter Dr. X canceled those orders. I followed through as requested and let the Palliative Care provider know.
Some time went by and Dr. X came by the patient’s room to do his rounds. He addressed pain management with the patient and then, in my opinion, he crossed a line. He told the patient that they don’t need palliative care, because he’s not ready to give up on them yet…
Most of us tend to look at doctors through a lens akin to that of a child to their parents. If they say so it must be true because they have our best interest at heart. Now I’m not suggesting that they don’t have our best interest at heart. That is to say that I believe they have the best of intentions. But just like we all figured out at some point that our parents are human, make mistakes, and have fears, worries, and egos that sometimes block them from making the best decisions for us, doctors are the same. I doubt this doctor had anything nefarious in mind like, “Sh*t! Palliative is on the case. They’re going to tell this patient to give up and then there goes my paycheck!” I also doubt this doctor was so ill informed that he believed palliative care meant giving up on curative measures. I think it possible he equates palliative care to hospice, and as an oncologist, has probably seen many patients take that road before he felt they should. He’s being defensive for the sake of his patient. Shows he cares. But still a line was crossed: he negated the palliative teams orders and in the process negated the attending’s preferences.
He told the patient he wasn’t ready to give up on them yet, equating the pain medications provided by palliative care with the patient giving up. In his human defensiveness, in my opinion, he could have caused the patient harm.
After he told them he wasn’t ready to give up on them, I made sure to confirm with him that he knew palliative care was only consulted to manage the break-through pain the patient had been experiencing. I clarified that they were not consulted for comfort care or hospice and that no one had any conversations about giving up. I also made sure I did this in front of the patient. The Doc looked at me for a moment and then back to the patient. Then, for the first time in his conversation with them, he asked if they were experiencing breakthrough pain. Afterward he reinstated the palliative care team’s orders. That was a definite win for me, if I do say so myself. But I was only able to intervene because I was there. Often, when teams visit on those lower acuity floors (non-ICU) where the nurse has 5-6 patients, the nurse cannot be present for all of the doctor visits.Palliative care can be confusing. Not only because of its dual purposes, but because of the implications of those purposes. Make sure that if you’re being referred to palliative care, you understand why. Ask the team if it’s for pain management only, or if there are intentions of pulling curative treatments. Don’t just assume the latter
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