What do you guys do?

[SleepIsGood]

So what do hospice/palliative care docs do?

I'm assuming you take care of end of life patients that are in LOTS of pain. What do you guys do different from the anesthesia service that writes PCAs etc? Couldnt any physician write for opiods in high doses to take care of these patients as long as they were closely monitored?

I'm thinking of getting certified in Hospice/Pall Care after I finish my pain fellowship..just trying to figure out if it's worth it,etc Does anyone know of any Pain Medicine Physicians that went into Hospice/Pall care. What do they do that's different? What's their practice like?

---

Members don't see this ad.

 

[Prof Moriarty]

Sleep, I hope someone with more experience comes to answer your questions, but this forum is not that well-frequented, so I'll offer you my opinion after having done a couple of electives in palliative care.

Pain is a major issue. Opioids are commonly used in dosages and combinations that I find most attendings in other specialties are not comfortable with. This wouldn't be the case for a pain guy such as yourself obviously. But I have routinely seen med/ICU personnel balk at the prescriptions suggested by the palliative consult. As you know, there is no upper physiologic limit of opioid dosage. There's a fair amount of titration to pain control, including long-acting and break-through pain agents, patches, PCA's, etc, with multiple agents. I did one rotation @ a center that had both an active pain service and an active palliative care service. I saw very little overlap. All month, I think we shared <5 patients in a very busy consult service. The one that comes to mind was where the pain fellow managed the intrathecal device, whereas the palliative team took care of everything else related to the patient's pain and end of life (EOL) issues.

Of course, palliative is not always EOL. Palliative can be brought in on any life-threatening diagnosis - from what I've seen, the earlier the better. And on the far end of the spectrum, there's hospice - with a prognosis of < 6 months. Although in reality, palliative is often consulted very late in the course of illness, and it's not uncommon to get them in their final days.

But as significant as the pain control component is to palliative care, it is probably one of the more straightforward aspects. Other symptom management includes: nausea, anorexia, anxiety, insomnia, dyspnea, depression, delirium, constipation, fatigue, et al. Nausea is a big one. In some cases, patients are still receiving potentially life-saving treatments, in others they're not.

And then there's the psychodynamic stuff - learning how to talk about these issues with the patient and/or their family. Having family meetings and dealing with those dynamics. Understanding the course of illness, the likelihood of recovery, what type of recovery, the various options given the patient's condition. Advanced directives. Health care proxy. Being able to explain all this and offer meaningful medical opinion. Listening without judgment or agenda is huge. This is the main thing I've seen the palliative people do, and it may be the most helpful. Understanding the legal and ethical stuff is a key component of practice too.

Top diagnoses in palliative care are cancer, COPD, CHF, and dementia. Of course there are plenty of cases of anoxic brain injury too, where the patient was "successfully" resuscitated but remains in a coma on life support indefinitely. Needless to say, these illnesses have different types of trajectories. And of course there are other known and unknown illnesses too.

How to navigate the system to ensure appropriate follow-through care for patients is important. A good social worker cognizant of these issues would handle this for you, but I think you've got to be aware.

From what I've seen, it's a time-consuming practice that requires a lot of patience and presence. I think you need to have an upbeat, optimistic personality, or it could get depressing real fast. You often spend a fair amount of time getting to know a patient and their family when the outcome is never in doubt (to you).

I would think this would not fit great with an interventional pain practice, which also places significant demands on your time and is probably more financially rewarding right now. It would be hard to give up the Benjamins after all that training, I would think.

But in my limited experience, this is a special branch of medicine with its own unique kind of rewards.

As to your question about getting certified in both, I asked around at a program that offers both fellowships if anyone had ever done both, and they said they knew only one person who did.

Keep in mind, I'm an MS-3 (almost -4), with limited experience in both palliative and pain management, but with an interest in both.

 

[markglt]

awesome response.

 

[brimcmike]

Remember too that by their very physiologic nature, patients at end-of-life are actually very dynamic, and their management, towards as soft a landing as possible, if conscientiously attended to, requires a degree of thought, planning and finèsse that managing acute-on-chronic patients to discharge home does not.

I would add that many attendings at large, and often academic, institutions do more than one thing, i.e., several things part-time. So, if what the bad Professor described sounds interesting and rewarding, and/or you need a break from Pain, or just need variety in your weeks and months, from clinic-procedures/procedures-clinic, and you're not drawn to the OR so much for that break, I see the combo of Anesthesia-Pain-HPM as very strong because besides knowing your way around an ICU, you could perform and manage the pain interventions that some of these patients wind up needing.

By its nature HPM itself is interdisciplinary. I think if any folk would know specifically where these two specialties come together nicely and diverge sharply, it would be at the Department of Pain Medicine and Palliative Care at Beth Israel Medical Center (BIMC) in New York. http://www.stoppain.org/

BIMC offers an ACGME-accredited Fellowship in Pain Medicine sponsored by the Department of Anesthesiology, Albert Einstein College of Medicine, and an ACGME-accredited Fellowship in Hospice and Palliative Medicine sponsored by the Department of Family Medicine, Beth Israel Medical Center.
http://www.stoppain.org/for_professionals/content/information/training.asp

FYI, while HPM is co-sponsored by 10 separate specialty boards (IM, FM, Anesthesia, PM&R, Neuro & Psych, Rads, Surg, Peds, EM and Ob-Gyn) the oversight of fellowship training at ACGME is administered by the Family Medicine RRC.

Cheers!