C O L L A B O R A T I V E C A S E M A N A G E M E N T
A Medical Director’s Perspective
Making the Transition to Palliative Care
By Ann Allegre, MD, FACP
Medical education, training, certification and practice develop physicians competent in treating and managing sick and injured patients. However,
medical training often leaves doctors less prepared to manage end-of-life issues – specifically, managing the transition from aggressive curative
care to a palliative or comfort course of treatment. The decision to provide palliative rather than restorative care and the transition in care
delivery bring multilayered challenges. Managing the challenges – emotional, medical and financial – can be a difficult process for not only the
patients and their families, but often for the physicians and care team as well.
Achieving a level of efficiency in this difficult transition to palliative
care is in the best interest of all parties – the patient, family and
hospital. When this transition is not efficient, hospital outcomes will
degrade and delays in care will likely result, extending length of stay
(LOS) and risking denied days. Patient and family outcomes are also
less optimal, as inefficiency produces or prolongs physical and
emotional suffering.
Inefficiencies in this transition will become obvious to case
managers as a plan of care that is vaguely defined, not progressing
appropriately, or the patient’s treatment may not be, in the case
manager’s opinion, consistent with their condition. However, the
potential and common causes of transitional inefficiencies are
multilayered and complex, involving family psychodynamics, clinical
and emotional elements. Case managers will often face difficulty
improving the plan of care or its progression, and may request a
medical director’s intervention. Medical Director involvement may also
be driven by the outlier or long-stay nature of such cases or a medical
director may already be involved in the case based on LOS or the high
intensity of the patient’s needs.
For medical director intervention to be effective in these complex
cases, it is important to have a clear understanding of the role of
palliative care. Specifically, the medical director should be familiar
with indicators for when palliative care is appropriate, the potential
barriers to transitioning to palliative care, and he or she should have
a plan for effective physician-to-physician communication designed
to influence the care to produce positive outcomes for patient, family
and hospital.
Providence Health Palliative Care Consult Team (PCCT) was
developed at Providence Medical Center in Kansas City, KS, and has
demonstrated interventions to efficiently manage the complex
transition from curative to palliative care. The service began seeing
consults in March of 2000, and currently serves two system hospitals
and a skilled nursing facility. The service sees about 500 consults
annually, with an average daily census of 10 patients.
THE ROLE OF PALLIATIVE CARE IN THE ACUTE CARE SETTING
Development and implementation of palliative care services in
acute care hospitals is increasing rapidly. The Center to Advance
Palliative Care (CAPC) analyzed data collected in 2007 by the
American Hospital Association (AHA) Annual Survey of Hospitals
13
which shows 1240 hospitals nationwide provide palliative care
programs, compared with 632 programs in 2000. Of all hospitals
appropriate for palliative care programs,1 30% currently have a
program, and 70% of these hospitals with over 250 beds have a
program.2 This increase reflects the fact that palliative care teams
have demonstrated the ability to improve outcomes by bridging the
transition from curative to end-of-life care.
Hospital palliative care services like PCCT share key similarities
with case management. The nurses and other non-physician staff on
the service are often employed by the hospital, and do not create
revenue directly. (In some institutions, physicians and nurse
Involving palliative care when
and where it is appropriate is
critical to a hospital’s efficient
management of the transition from
curative to palliative care.
practitioners are employed by another corporation and may bill for
their clinical services.) In all cases, palliative care services produce
value through cost avoidance, particularly in reducing daily charges,
and, more importantly, improved patient care. Figure A (page 14)
shows cost reduction outcomes produced by PCCT. This data was
collected from chart reviews of cases in which PCCT was involved in
2004. Whether patients and families chose to continue to seek
aggressive goals (non-palliative) or were ready for palliative goals only,
the charges for care were reduced significantly after interventions by
the team. Like case managers, palliative care teams advocate for both
the patient and the hospital, seeking the situation that is most
appropriate for both. Palliative care’s objective is to produce a
reasonable outcome based on the medical realities of the patient’s
condition(s). By clarifying the goals of care and focusing on a patient
and family’s concerns, efforts can be targeted to reduce suffering and
produce more cost-effective care that increases patient and family
satisfaction in the stressful setting of serious illness.
continued on page 14
 w w w . a c m a w e b . o r g

physician, and palliative care team. The objective of the family

Financial Impact of Consult meeting is to facilitate communication and develop a plan of care
appropriate for the patient’s condition and facilitate its progression.
by Palliative Care Team The agenda for this initial meeting will include:
• Clarify clinical information about patient’s illness and
5000
options for care
• Allow all decision-makers to hear the same clinical information
4500
• Allow patient and family to hear from each other about goals
4000 and values
3500 • Understand the sources of suffering
• Clarify goals, which may be curative or palliative
3000
• Discuss advance care planning
2500
• Begin conversation about discharge planning
2000 While this meeting faces difficult issues, it allows the patient
and family to face these difficult issues in a structured setting, with
1500
professional facilitation. Patients and families are often relieved to
1000 be able to address the topics that concern them the most, such as
whether their loved one will survive, what kind of life he or she will
500
have going forward, and how the family will manage their care.
0 The family meeting forum allows all involved with the case to
Daily Charge Pre Daily Charge Post Savings communicate openly regarding the patient’s medical realities,
■ PALLIATIVE GOAL ■ NONPALLIATIVE prognosis and treatment options, and individuals can jointly come
to a realistic appraisal of the situation. Additional meetings can be
FIGURE A held to facilitate the progression of the plan of care.
The PCCT’s palliative care team is led by physicians who are
In spite of the increased prevalence of palliative care services in board certified in hospice and palliative medicine, and includes two
the acute care setting, many clinicians and healthcare professionals advanced practice nurses with certification in palliative care, a social
misperceive their role. Three common misperceptions are: worker and chaplain. This interdisciplinary team affords the critical
• Palliative care serves the hospital’s interest rather than advocate ability to immediately address whatever challenges arise during the
for the patient – For example, some think palliative care teams family meeting so that decisions can be completed rather than
are “out to get the DNR.” To maintain medical credibility, postponed. For example, questions regarding Medicare coverage,
palliative care professionals must never attempt to force or clinical questions about prognosis or potential outcomes, or a
manipulate patients and/or families into a decision for which family’s request for prayer commonly arise in these meetings, and the
they are not prepared. palliative care team includes professionals to address each effectively.

• Palliative care is an extension of social work or chaplaincy

counseling services for terminal patients – An effective
palliative care team includes medical expertise specific to
terminal illness and symptom management, as well as
psychodynamic and communication expertise related to
end-of-life decisions and planning.
• Palliative care takes over a patient’s care – The attending
physician does not hand off the patient, but utilizes the
palliative care team as a consultative service. The team
collaborates with the attending physician, who remains
primary in the case, to develop and facilitate the most
appropriate plan of care and setting.
CASE INDICATORS FOR PALLIATIVE CARE INVOLVEMENT
Involving palliative care when and where it is appropriate is
critical to a hospital’s efficient management of the transition from
curative to palliative care. Indicators that a patient may be
appropriate for palliative care involve both the dynamics of the case
and the patient’s clinical condition. Clinical indicators include:
• Advanced chronic disease without significant
hope of improvement
• Functional decline
• Frequent need for hospitalization – defined as three or
more hospital visits in one year

The PCCT’s foundational intervention is an initial family • Frequent infections

meeting. This meeting will include the patient, family, attending • Unintentional weight loss

14
 C O L L A B O R A T I V E C A S E M A N A G E M E N T

While these clinical indicators can be predictive that a patient is nearing the
end of life, predicting future outcomes in such cases is difficult and influenced by
several non-clinical factors. Indicators that may become apparent in the dynamics Key Benefits
of the case include:
of Palliative
• Development of conflicting goals for patient care, either within the family,
between the patient and family, or between the patient/family and the Care Involvement
attending physician
• When a patient or family is overwhelmed by a severe/terminal diagnosis
1 Improved assessment
• A patient/family request for a palliative approach
and management
Defining when to discuss the transition to palliative care involves considering of physical symptoms
the clinical and psychodynamic factors, as well as the patient/family values, beliefs
and goals. However, the PCCT team prefers to be consulted and involved in a case as 2 Increased psychosocial
early as possible when factors in the case indicate that a preliminary discussion of
and spiritual support
palliative care is appropriate. As Figure A demonstrates, not all cases in which the
for patient and family
PCCT is consulted transition to a palliative care goal. The team’s intervention
provides both patient and hospital benefits whether a transition is made to palliative
3 Increased awareness
care or the patient continues to pursue a curative course of care. Early involvement
in a case also allows time for the team to develop a relationship with the patient and
of patient/family
family, build trust, and work through end-of-life planning and decisions. preferences and priority

COMMUNICATION AND EXPECTATIONS 4 Comprehensive

When a patient’s condition and history indicate for palliative care, a physician discharge planning
order is required to involve PCCT’s team. The team will hold the initial family
meeting the same business day, or the next business day if necessary. The 5 Cost savings due to reduced
attending physician should be prepared to review and discuss the patient’s use of laboratory, procedures,
condition, history and prognosis, and work through potentially difficult case ICU days and unnecessary
dynamics to develop a clear plan of care, and is encouraged to participate in this acute care hospital days
meeting. If the attending physician is not able to attend the family meeting, the
palliative care physician or nurse practitioner will obtain the above information 6 Risk avoidance by helping
from the attending and will facilitate the family meeting. If a direct transition to a patients/families cope with
palliative course of care can not be developed or is not appropriate, the team will anger which is often directed
strive to develop an interim goal with specific time parameters, reevaluation at the healthcare system
points and criteria.
After the initial meeting, the palliative care team will collaborate with the 7 Improved quality of life
attending physician to facilitate the progression of the defined plan of care and
discharge arrangements. The team will remain involved in the case until the 8 Improved satisfaction
patient is either discharged or reaches the end of his or her life. by patient/family and
staff due to increased
BARRIERS TO PALLIATIVE CARE
Properly utilizing a palliative care service manages the complex transition
support and resources to
from restorative to end-of-life care and improves care outcomes for patients and manage emotionally difficult
families, such as improved symptom management, communication, planning for and draining cases and
future care, and addressing of family concerns. Accurately understanding the role decision support
and interventional methodology of palliative care will help physicians more
effectively utilize this service. However, significant potential barriers to efficiency 9 Better acceptance of the
remain, and can prevent or delay the involvement and efficacy of the palliative reality of death
care team. Barriers arise from two primary sources: The patients and families or
the attending physicians. 10 Bereavement support
Families involved in severe or terminal cases face numerous difficult decisions
with life-altering ramifications. Common barriers to patients and families making

continued on page 16
15
 w w w . a c m a w e b . o r g
decisions about the nature of the care provided and the goals of that
care include:
• Unclear messages about prognosis and expected treatment
outcomes, especially when they are hearing conflicting
messages from various physicians involved in the patient’s care
• Lack of information on patient’s wishes
• Financial distress
• Family conflicts, including conflicts over who has the power to
make decisions
• Inability to accept a patient’s decline
• Difficulty coping with feelings of grief, anger, and guilt
• Unwillingness to accept moral responsibility for making
decisions to limit aggressiveness of care
Patients and families may become stuck in their feelings and
unable or unwilling to discuss or make difficult decisions. In
addition, practical issues may be involved, such as a family’s
financial dependence on the patient, lack of financial resources to
fund different levels of care, or the inability to care for the patient at
home. Because of such fears, patients and families rarely initiate
questions of prognosis or broach the subject of palliative care.
An attending physician, like a patient’s family, may struggle
with the reality of the patient’s prognosis, and delay the transition to
a palliative course of care even when indicated. Common physician
barriers include:
• Discomfort with giving bad news – The communication
required to help a patient and family make the transition to
palliative care can be time-consuming, uncomfortable, and
psychosocially complex
• Fear of or discomfort with emotional reactions from patients
and families
• Emotional attachment – The physician may have a bond with
the patient and be reluctant to face the patient’s prognosis
• Fear of taking away hope – Concern that discussing a change
from curative care goals may take away the patient’s hope and
shorten their survival
EFFECTIVE MEDICAL DIRECTOR INTERVENTION
AND COMMUNICATION
When these barriers negatively impact patient and hospital
outcomes by preventing or delaying the transition to palliative care
or involvement of the palliative care team, physician-to-physician
counseling may be required for the case to progress. Medical
director intervention with the attending physician may be
necessary to help the attending physician confront the medical
realities of the case, manage their own emotional involvement, and
make effective use of the resources available, including a palliative
care team. The necessary conversation may, in many ways, parallel
the discussion by the palliative care team with a patient and family.
Some key elements of effective medical director
communication with an attending physician in this situation are:
• Clear presentation of the clinical realities of the case –
especially where the patient’s history demonstrates a
progressive decline. The medical director can add a broadened
perspective, and raise what the patient’s care is actually
achieving, or hopes to achieve.
• Present opinions of other physicians involved in the case
– other consulting physicians may be in favor of discussing
palliative care, and can be used to help influence a reluctant
attending physician.
• Discuss the wishes of the patient and family – often medical
professionals assume the patient and family are in favor of
aggressive care, without presenting other options or asking the
patient and family to clarify their wishes.
• Define a clear plan of care – attending physicians may become
fixated on a future test result or evaluation, effectively using this
to delay facing difficult issues or presenting bad news to the
patient or family. The medical director can encourage an
outlook beyond the next test or evaluation and push for a
longer-term plan of care.
• Present palliative care team intervention as a valuable resource
– the medical director can educate the attending physician on
how to utilize this resource to progress the plan of care and
improve outcomes.
While difficult, the transition to end–of-life care is ever-present
in the acute care setting. As the population ages, effectively bridging
the transition from curative to palliative care will become
increasingly important to both patient and hospital outcomes.
Interdisciplinary palliative care teams are able to guide this
transition and manage the inevitable psychosocial and medical
complexities. As stewards of hospital resources and advocates for
patient care, case managers and medical directors are responsible
to ensure palliative care is utilized and implemented effectively in
care delivery.
Ann Allegre
Allegre, MD, FACP, is Director of Medical Programs with
Kansas City Hospice and Palliative Care, a position she has held for
12 years. Dr. Allegre is also a Clinical Associate Professor at the
University Of Kansas School Of Medicine. She earned her MD
from the University Of Kansas School Of Medicine, and is board
certified in Hospice, Palliative Medicine and Internal Medicine.
Dr. Allegre has over 30 years of healthcare experience.
1
Hospitals appropriate for palliative care programs excludes psychiatric
and rehabilitation facilities.
2
Center to Advance Palliative Care (CAPC). “Hospital Palliative
Care Programs Continue Rapid Growth.” Released December 7, 2006.
http://www.capc.org/news-and-events/releases/december-2006-release.
16