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Palliative Care Perspectives : Chapter 10: Palliative Care Consults : Barriers To Palliative Care Consults

Because palliative care consults are a relatively new phenomenon in most hospitals, many referring clinicians will be unfamiliar with what we have to offer. Some clinicians will be opposed to the whole idea of such consults. Nave unfamiliarity is apparent when clinicians do not know when it would be appropriate to request a palliative care consult. Thus, many patients who could benefit from a consult do not receive it, or they receive it later than would be ideal. Because our consult team is associated with an inpatient hospice unit, most of the "consults" we obtained in the months following the establishment of our team were merely requests for transfer to our hospice ward. Although not bad per se, such consults reflected a mind-set in which consultation was solely about placement at a time when the primary care team had decided this was appropriate. Such requests do not acknowledge a helping role for the consult team, other than by getting the patient "off the service." Clinicians often mistakenly believe that palliative care consults are restricted to patients who are overtly terminally ill, if not imminently dying, and who have decided on comfort care only. "Active therapy" with life-prolonging agents is too often understood as a contraindication to a consult. Thus, for example, when a patient had a completely obstructed esophagus due to cancer that resulted in a distressing build-up and overflow of saliva, his team initially thought that the fact that he was to receive chemotherapy and radiation therapy contraindicated a palliative care consult. (At least they called us, asking if it was appropriate to obtain a consult. We assured them that it was. We advised a slurry of glycopyrrolate to dry up salivary secretions followed by artificial saliva. This was very helpful to the patient.)

Notably, cholestatic pruritus is not mediated via histamine receptors. Thus, the clinicians, who tried antihistamines, had no success in treating his itching. This form of pruritus involves pain fibers and responds best (if opioids are not being used, as was the case here) to naloxone. Naloxone administration in this case resulted in instant and near complete relief of his itching. A slow naloxone infusion was maintained until the stone was removed, which resolved the underlying problem.

The rarest type of palliative care consult we receive is for nonterminal patients who have difficult symptoms the primary care team cannot adequately address. An example was a consult for a patient with pruritus (itching) secondary to an impacted gallstone in the common bile duct pending endoscopic removal. Based on our experience, there is no easy fix for such unfamiliarity. Distributing flyers and giving presentations on "what palliative care consults can do" can help, but gaining trust and understanding is a long, slow process.

More difficult is dealing with frank hostility to palliative care consults. Hostility can come both from clinicians and from patients and families. Nave hostility often arises from simple misunderstandings. Well-intended clinicians may inform a patient or family that the "hospice group is coming to talk about stopping therapy and going to a very nice place to die." As one patient who had received such advanced billing put it when we first met, "So you're guys who are going to pull the plug on me!" Clinicians (and patients and families) may resist consults because they may come to symbolize evidence of the patient's deteriorating, often terminal, clinical course, which may be difficult to face. Some will be actively hostile to consults if and when they believe the consult will result in a negation of their current or proposed care plan. At times palliative care consult teams are drawn into a battle without even knowing it. For example, it is not rare in my experience for primary care clinicians to argue with oncologists over whether a patient should receive aggressive chemotherapy. Without even knowing it, a consult may represent an invitation to engage in ritual battle with oncologists. To the extent we are viewed as "reinforcements" in such a battle, we should not be surprised to encounter hostility. A little advance scouting can usually determine if and when we are being set up for such a battle.

More subtly, we may encounter resistance from groups with whom the discipline of palliative care overlaps. A consult request to palliative care may be considered unnecessary because specialists believe they ought to be able to handle the issues at hand. In being identified as specialists in a particular domain of care, physicians come to believe they should know everything about patient care that in any way relates to that domain. The sad fact that most such specialists have received little training in palliative care as it relates to their particular disciplines does not assuage their belief that they ought to be competent in all aspects of care related to their specialty. Thus, the oncologist believes that he or she ought to be able to provide all care related to a cancer patient. The pulmonologist thinks that he or she ought to know how to treat all forms of dyspnea, and the cardiologist is of the opinion that he or she must be an expert on everything related to congestive heart failure. Our involvement in the care of their patients may be seen as an affront to their expertise.

The greater the overlap between palliative care and other specialties, the stronger yet less obvious this resistance can become. For example, geriatricians, who overlap greatly with palliative care in their work with chronically ill and dying elders, may overtly view palliative care practitioners as allies in a cause serving such patients (as we are). However, they may be slow to recognize the need for palliative care services for geriatric patients distinct from the care they provide, thinking that they ought to be able to provide such care for elders based on their credentialing, even if their training was deficient in specific palliative care skills. Similar resistance can be found among pain management specialists, who may view palliative care consults as competition. Early in our process of establishing a consult team, we found, somewhat to our surprise, that some general medicine attending physicians became quite irate at finding us talking with their patients. We would inform them that their resident team had requested the consult. "Well, I was not informed of this!" was the reply. Although one would think this was an intraward team problem of miscommunication, I doubt the same attending physicians would have been offended to find an infectious disease consultant at the bedside of a patient with an exotic infection, as they would readily acknowledge the specialist's expertise. At least in our hospital, residents often request consults without first informing the attending physician. So what was going on? I think these very good physicians felt that in discussing certain things such as goals of care and preferences we were infringing on their areas of expertise (working with the whole patient) and thus felt an affront. We have since built in the step of ensuring that the attending physician is aware of the consult before we perform it.

In summary, palliative care consults exist in a politically charged environment. Consults must address these political concerns if they are to be accepted and the team is to be successful.

Many consult requests also are emotionally charged. Except for very straightforward consults such as for a hospice referral or for treatment of an isolated physical symptom, most consults occur in an atmosphere of desperation. Commonly, a major disagreement arises between some involved parties, and help is needed to resolve such conflict. These emotionally charged issues usually exist in the subtext of a consult request. The consult may state, "Instruct patient and family about the dying process," when what is really going on is, "The patient and family are driving us crazy. They keep requesting therapies that will not work. We've tried to explain to them that the patient is dying, but they just don't get it. I hope you palliative care people have some magic tricks up your sleeves so that you can get through to them." Identifying this emotional subtext as it applies to clinicians, patients, and families is usually a key task in the consultation process.

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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.