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Palliative Care Perspectives : Chapter 10: Palliative Care Consults : Models for a Palliative Care Consult

"She says, if you please, sir, she only wants to be let die in peace." "What! And the whole class to be disappointed, impossible! Tell her she can't be allowed to die in peace; it is against the rules of the hospital!"

John Fisher Murray (1811-1865)
The World of London

Palliative care consults are a relatively new phenomenon, at least in American hospitals. A handful of articles have been published to document the tasks to be performed and some outcome measures of the consultation process.1-6 Very little has been written on how to actually do a palliative care consult.

In performing consults we face an interesting challenge - how do we incorporate the principles and practices of palliative care into a highly ritualized form of interaction that has evolved within the world of traditional medicine? That the consultation process is so ritualized is a mixed blessing. On the one hand, consults as a method of interaction are very familiar to clinicians; assuming the role of a consultant may make it easier for others to accept what we have to offer. On the other hand, palliative care clinicians may feel like "strangers in a strange land," constrained by some rituals that seem quite alien to good palliative care practices. Understanding the implicit rules (and tensions) in the consultative process and how they may affect our work is a necessary first step.

In the hospitals within which I have worked, a major tension exists between two different models of consultation. One model stresses giving advice to the primary physician or ward team, and the other stresses taking over some aspect of care. The latter approach appears to be more frequent in tertiary academic hospitals and where discrete technical skills (such as the ability to perform endoscopy) are required. General internists and family medicine physicians tend to prefer the advisory role, when possible, which keeps them in the loop. Many subspecialists, at least in academic medical centers, prefer the take-over role, even when working at a nontechnical discussion phase of consultation. For example, most oncologists I know, when consulting in hospital on a patient with a new diagnosis of cancer, minimally involve the ward team in decisions regarding options, such as chemotherapy and radiation therapy. After all, what does a general internist know about these options? This frequently gives rise to resentment on the part of primary care physicians, who will readily admit that they are not experts in oncology but who may think they have something to contribute in terms of understanding the totality of the patient. Similarly, many cardiology consultants, when asked their opinions about whether cardiac catheterization is advisable, will go ahead and schedule catheterization, if thought appropriate, without discussing this with the primary care team.

My experience is that neither model is ideal for palliative care consults; a good consult requires a delicate blend of approaches. For example, ward teams may wish for us to take over certain tasks, such as talking with patients and families about care options, but would be offended if we discussed certain medical treatment options with which they might not feel comfortable. For example, I have recommended dexamethasone for a patient with pain due to a compression neuropathy. However, the primary care team, worried about immunosuppressive side effects, did not want to take this recommendation. Had I mentioned the medication to the patient, this would have put the primary care team in an awkward position. An additional problem for palliative care consult teams is to figure out to what extent education of other clinicians is a task they wish to undertake. Educating clinicians can add time to the consultation process and cut down on efficiency. However, a major objective in performing consults should be to educate clinicians in what palliative care has to offer and help them to incorporate palliative care into their own practices.

Modeling certain skills to primary care team members, such as discussing preferences, can be an efficient and effective way of teaching skills. Of course, this requires coordination in the timing of meetings with patients and families, and it is time consuming for the observing team members. When possible, however, this is a superb way to help other clinicians understand what we do, and skill development is promoted.

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Palliative Care Perspectives

James L. Hallenbeck, M.D.

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Copyright 2003 by Oxford University Press, Inc.

The online version of this book is used with permission of the publisher and author on web sites affiliated with the Inter-Institutional Collaborating Network on End-of-life Care (IICN), sponsored by Growth House, Inc.