Jean S. Kutner, MD, MSPH

All new legislation concerning advance care planning was removed from the Affordable Care Act, signed into law in March 2010. However, through a Medicare payment regulation, Centers for Medicare and Medicaid Services (CMS) was able to add a provision allowing compensation to physicians for advance directive (AD) discussions as part of the annual Medicare wellness exam. Previously, under President George W. Bush, funding for AD discussions was already part of the Welcome to Medicare visit. Once again, the provision was misrepresented and distorted in the media, talk radio shows, and social networking sites. Within days of the announcement, the White House removed the regulation stating that the controversy surrounding the provision was distracting from the overall debate about healthcare. The term death panels has now entered our national lexicon and serves to undermine the efforts of the palliative care field which, through discussions with patients and families, attempts to provide care consistent with patients' goals.

In fact, ADs have been a cornerstone of ethical decision making, by supporting patient autonomy and allowing patient wishes to be respected when decisional capacity is lacking. Advance directives may include a living will, a Medical Durable Power of Attorney, or may be a broader more comprehensive document outlining goals, values, and preferences for care in the event of decisional incapacity. ADs allow patients to express preferences that incorporate both quantity and quality of life, as there are times when interventions at the end of life may increase length of life to the detriment of quality of life. In this context, patients may chose to value quality of life and request the interventions be withdrawn that focus on maintaining life without hope for quality of life. ADs also permit patients who prefer quantity over quality of life to communicate these wishes. These conversations are complex and time‐consuming. Patients may have profound misperceptions about the benefits offered by interventions at the end of life. Having detailed conversations with healthcare providers about actual benefits, risks, and alternatives has been shown to impact that decision‐making process.1 In our current payment system, these time‐consuming conversations are not compensated by private or public insurers, and are incompatible with 20‐minute appointments, so they rarely occur.24 While Nancy Cruzan and Terri Schiavo brought national attention to the issue for a brief time, recent data suggest that only 30% of adults have completed an AD,57 however, 93% of adults would like to discuss ADs with their physician.8 Furthermore, Silveira et al. showed that older adults with ADs are more likely than those without ADs to receive care that is consistent with their preferences at the end of life.9 ADs were the sole predictor of concordance between preferred and actual site of death in a cohort of seriously ill, hospitalized patients.10 Patients with advanced cancer who discussed their end of life wishes with their physician were more likely to receive care consistent with their preferences.11

Advance directives are based on the ethical principle of autonomy and, with the growing evidence that ADs may improve care at the end of life, public understanding of the issue is critical. We had presented early preliminary data in a letter to the editor showing that having had an advance directive discussion or an AD in the medical record was not associated with an increased risk of death.12 This research, along with the work of Silveira and colleagues,9 was cited by the Obama administration when they decided to add the regulation for including advance care planning as part of the annual Medicare wellness exams. This brief report presents a more comprehensive examination of the relationship of AD discussions and AD documentation with survival in a group of hospitalized patients.

METHODS

RESULTS

Characteristics of the 356 study subjects are listed in Table 1. Overall, the sample population was ethnically diverse, slightly above middle‐aged, mostly male, and of lower socioeconomic status, reflecting the hospitals' populations. Using the CARING criteria, 297 subjects were found to be at low risk, and 59 subjects at medium risk, of death at 1 year.

Overall, 206 (45%) reported a discussion about ADs with a healthcare provider. However, we found that only 56 (10%) had an AD document on their chart. Twenty‐eight (6%) had a living will, 43 (9%) had a durable power of attorney, and 30 (7%) had a broader AD document. Between 2003 and 2009, 121 (26%) patients died. Unadjusted mortality rates for those with and without documentation and discussions of ADs are displayed in Figure 1.

Figure 1

Kaplan‐Meier survival curves showed that, for subjects with a low or medium risk of death at 1 year, having had an AD discussion or having an AD in the medical record did not affect survival in subjects (Figures 2 and 3). Cox proportional hazards models adjusting for other covariates confirmed the results of the survival analysis (data not shown). Minimal intraclass correlation coefficients (0.005) were observed for the outcomes. Therefore, no models accounting for clustering within hospitals were developed.

Figure 2

Figure 3

DISCUSSION

We found no decrease in survival for patients at low and medium 1‐year risk of death who reported having discussed ADs or who had an AD in their medical record, providing important evidence that having advance care planning discussions do not hasten death in this group of adults. However, it is possible that ADs, when implemented properly, may dictate withdrawal or withholding of interventions that may extend quantity of life at a quality unacceptable for the person executing the directive. For example, a feeding tube delivering artificial nutrition and hydration may grant years to someone in a persistent vegetative state, but those years, without the ability to be aware or interact with surroundings and loved ones, may not be a life worth living for some individuals. One explanation for our negative findings may be that the circumstances in which an AD may have an effect on outcomes may not yet have occurred among this lower risk population.

Opposition to the process of advance care planning may be considered unethical, by removing the opportunity for individuals to express their desires in the event of decisional incapacity, therefore disregarding patient autonomy. Furthermore, with the growing evidence that AD discussions and documentation help patients achieve care consistent with their wishes at the end of life,9, 11, 17 preventing advance care planning may worsen end of life outcomes.

Another important finding in our study was that only about 10% of the patients interviewed had completed an AD document, although nearly half reported they had discussed ADs with a healthcare provider. The patients we interviewed in this study had been admitted to the hospital in the previous 24 hours. As part of the Patient Self‐Determination Act, all patients admitted to a healthcare facility should receive information and counseling on AD. Less than half of our cohort reported any discussions about ADs and only 10% had completed an AD, suggesting that huge opportunities exist for improvement in advance care planning. As this study demonstrates, there was no increased mortality from advance care planning among those at low and medium risk of death, and others have shown benefits from the process. AD discussions and documentation should be fostered, especially as the burden of chronic disease increases and the population ages. In targeted studies to improve advance care planning, completion rates of up to 85% have been achieved.17

Our decision to focus solely on patients at low or medium risk of death, and exclude those at a high risk of death, is based on both clinical and methodological judgment. First, it is important to note that ADs are important even for those at lower risk of deaththe 3 critical cases that have shaped AD policy in this country, Karen Ann Quinlan, Nancy Cruzan, and Terry Schiavo, were all otherwise healthy young women.

Our study does have limitations. First, the sample size is small and not powered to detect small differences in survival. In addition, we only examined Vital Records within Colorado, although all participants had either a date of death or recent date of last contact. It is also conceivable that some patients discussed or completed ADs at a later time in their illness trajectory. However, the generalizability of this study is a major strength, by including a population and healthcare settings that are ethnically and socioeconomically diverse. Generalization of results beyond the three types of hospitals should be limited even with the low intraclass correlation. The major limitation of this research is that we do not have data on participant quality of life or whether completing an AD led to increased use of palliative care. During the time the research was conducted, 2 of the 3 hospitals involved had small palliative care services and the third remains without a palliative care service.

In conclusion, our study provides limited data to counteract the misleading claims of those opposed to the advance care planning process. Our results underscore the importance of educating the public on the importance of ADs and cast doubt on the death myth surrounding advance care planning. However, further, preferably longitudinal, study is needed to prospectively understand both the benefits and risks of advance care planning.

All new legislation concerning advance care planning was removed from the Affordable Care Act, signed into law in March 2010. However, through a Medicare payment regulation, Centers for Medicare and Medicaid Services (CMS) was able to add a provision allowing compensation to physicians for advance directive (AD) discussions as part of the annual Medicare wellness exam. Previously, under President George W. Bush, funding for AD discussions was already part of the Welcome to Medicare visit. Once again, the provision was misrepresented and distorted in the media, talk radio shows, and social networking sites. Within days of the announcement, the White House removed the regulation stating that the controversy surrounding the provision was distracting from the overall debate about healthcare. The term death panels has now entered our national lexicon and serves to undermine the efforts of the palliative care field which, through discussions with patients and families, attempts to provide care consistent with patients' goals.

In fact, ADs have been a cornerstone of ethical decision making, by supporting patient autonomy and allowing patient wishes to be respected when decisional capacity is lacking. Advance directives may include a living will, a Medical Durable Power of Attorney, or may be a broader more comprehensive document outlining goals, values, and preferences for care in the event of decisional incapacity. ADs allow patients to express preferences that incorporate both quantity and quality of life, as there are times when interventions at the end of life may increase length of life to the detriment of quality of life. In this context, patients may chose to value quality of life and request the interventions be withdrawn that focus on maintaining life without hope for quality of life. ADs also permit patients who prefer quantity over quality of life to communicate these wishes. These conversations are complex and time‐consuming. Patients may have profound misperceptions about the benefits offered by interventions at the end of life. Having detailed conversations with healthcare providers about actual benefits, risks, and alternatives has been shown to impact that decision‐making process.1 In our current payment system, these time‐consuming conversations are not compensated by private or public insurers, and are incompatible with 20‐minute appointments, so they rarely occur.24 While Nancy Cruzan and Terri Schiavo brought national attention to the issue for a brief time, recent data suggest that only 30% of adults have completed an AD,57 however, 93% of adults would like to discuss ADs with their physician.8 Furthermore, Silveira et al. showed that older adults with ADs are more likely than those without ADs to receive care that is consistent with their preferences at the end of life.9 ADs were the sole predictor of concordance between preferred and actual site of death in a cohort of seriously ill, hospitalized patients.10 Patients with advanced cancer who discussed their end of life wishes with their physician were more likely to receive care consistent with their preferences.11

Advance directives are based on the ethical principle of autonomy and, with the growing evidence that ADs may improve care at the end of life, public understanding of the issue is critical. We had presented early preliminary data in a letter to the editor showing that having had an advance directive discussion or an AD in the medical record was not associated with an increased risk of death.12 This research, along with the work of Silveira and colleagues,9 was cited by the Obama administration when they decided to add the regulation for including advance care planning as part of the annual Medicare wellness exams. This brief report presents a more comprehensive examination of the relationship of AD discussions and AD documentation with survival in a group of hospitalized patients.

METHODS

RESULTS

Characteristics of the 356 study subjects are listed in Table 1. Overall, the sample population was ethnically diverse, slightly above middle‐aged, mostly male, and of lower socioeconomic status, reflecting the hospitals' populations. Using the CARING criteria, 297 subjects were found to be at low risk, and 59 subjects at medium risk, of death at 1 year.

Overall, 206 (45%) reported a discussion about ADs with a healthcare provider. However, we found that only 56 (10%) had an AD document on their chart. Twenty‐eight (6%) had a living will, 43 (9%) had a durable power of attorney, and 30 (7%) had a broader AD document. Between 2003 and 2009, 121 (26%) patients died. Unadjusted mortality rates for those with and without documentation and discussions of ADs are displayed in Figure 1.

Figure 1

Kaplan‐Meier survival curves showed that, for subjects with a low or medium risk of death at 1 year, having had an AD discussion or having an AD in the medical record did not affect survival in subjects (Figures 2 and 3). Cox proportional hazards models adjusting for other covariates confirmed the results of the survival analysis (data not shown). Minimal intraclass correlation coefficients (0.005) were observed for the outcomes. Therefore, no models accounting for clustering within hospitals were developed.

Figure 2

Figure 3

DISCUSSION

We found no decrease in survival for patients at low and medium 1‐year risk of death who reported having discussed ADs or who had an AD in their medical record, providing important evidence that having advance care planning discussions do not hasten death in this group of adults. However, it is possible that ADs, when implemented properly, may dictate withdrawal or withholding of interventions that may extend quantity of life at a quality unacceptable for the person executing the directive. For example, a feeding tube delivering artificial nutrition and hydration may grant years to someone in a persistent vegetative state, but those years, without the ability to be aware or interact with surroundings and loved ones, may not be a life worth living for some individuals. One explanation for our negative findings may be that the circumstances in which an AD may have an effect on outcomes may not yet have occurred among this lower risk population.

Opposition to the process of advance care planning may be considered unethical, by removing the opportunity for individuals to express their desires in the event of decisional incapacity, therefore disregarding patient autonomy. Furthermore, with the growing evidence that AD discussions and documentation help patients achieve care consistent with their wishes at the end of life,9, 11, 17 preventing advance care planning may worsen end of life outcomes.

Another important finding in our study was that only about 10% of the patients interviewed had completed an AD document, although nearly half reported they had discussed ADs with a healthcare provider. The patients we interviewed in this study had been admitted to the hospital in the previous 24 hours. As part of the Patient Self‐Determination Act, all patients admitted to a healthcare facility should receive information and counseling on AD. Less than half of our cohort reported any discussions about ADs and only 10% had completed an AD, suggesting that huge opportunities exist for improvement in advance care planning. As this study demonstrates, there was no increased mortality from advance care planning among those at low and medium risk of death, and others have shown benefits from the process. AD discussions and documentation should be fostered, especially as the burden of chronic disease increases and the population ages. In targeted studies to improve advance care planning, completion rates of up to 85% have been achieved.17

Our decision to focus solely on patients at low or medium risk of death, and exclude those at a high risk of death, is based on both clinical and methodological judgment. First, it is important to note that ADs are important even for those at lower risk of deaththe 3 critical cases that have shaped AD policy in this country, Karen Ann Quinlan, Nancy Cruzan, and Terry Schiavo, were all otherwise healthy young women.

Our study does have limitations. First, the sample size is small and not powered to detect small differences in survival. In addition, we only examined Vital Records within Colorado, although all participants had either a date of death or recent date of last contact. It is also conceivable that some patients discussed or completed ADs at a later time in their illness trajectory. However, the generalizability of this study is a major strength, by including a population and healthcare settings that are ethnically and socioeconomically diverse. Generalization of results beyond the three types of hospitals should be limited even with the low intraclass correlation. The major limitation of this research is that we do not have data on participant quality of life or whether completing an AD led to increased use of palliative care. During the time the research was conducted, 2 of the 3 hospitals involved had small palliative care services and the third remains without a palliative care service.

In conclusion, our study provides limited data to counteract the misleading claims of those opposed to the advance care planning process. Our results underscore the importance of educating the public on the importance of ADs and cast doubt on the death myth surrounding advance care planning. However, further, preferably longitudinal, study is needed to prospectively understand both the benefits and risks of advance care planning.

All new legislation concerning advance care planning was removed from the Affordable Care Act, signed into law in March 2010. However, through a Medicare payment regulation, Centers for Medicare and Medicaid Services (CMS) was able to add a provision allowing compensation to physicians for advance directive (AD) discussions as part of the annual Medicare wellness exam. Previously, under President George W. Bush, funding for AD discussions was already part of the Welcome to Medicare visit. Once again, the provision was misrepresented and distorted in the media, talk radio shows, and social networking sites. Within days of the announcement, the White House removed the regulation stating that the controversy surrounding the provision was distracting from the overall debate about healthcare. The term death panels has now entered our national lexicon and serves to undermine the efforts of the palliative care field which, through discussions with patients and families, attempts to provide care consistent with patients' goals.

In fact, ADs have been a cornerstone of ethical decision making, by supporting patient autonomy and allowing patient wishes to be respected when decisional capacity is lacking. Advance directives may include a living will, a Medical Durable Power of Attorney, or may be a broader more comprehensive document outlining goals, values, and preferences for care in the event of decisional incapacity. ADs allow patients to express preferences that incorporate both quantity and quality of life, as there are times when interventions at the end of life may increase length of life to the detriment of quality of life. In this context, patients may chose to value quality of life and request the interventions be withdrawn that focus on maintaining life without hope for quality of life. ADs also permit patients who prefer quantity over quality of life to communicate these wishes. These conversations are complex and time‐consuming. Patients may have profound misperceptions about the benefits offered by interventions at the end of life. Having detailed conversations with healthcare providers about actual benefits, risks, and alternatives has been shown to impact that decision‐making process.1 In our current payment system, these time‐consuming conversations are not compensated by private or public insurers, and are incompatible with 20‐minute appointments, so they rarely occur.24 While Nancy Cruzan and Terri Schiavo brought national attention to the issue for a brief time, recent data suggest that only 30% of adults have completed an AD,57 however, 93% of adults would like to discuss ADs with their physician.8 Furthermore, Silveira et al. showed that older adults with ADs are more likely than those without ADs to receive care that is consistent with their preferences at the end of life.9 ADs were the sole predictor of concordance between preferred and actual site of death in a cohort of seriously ill, hospitalized patients.10 Patients with advanced cancer who discussed their end of life wishes with their physician were more likely to receive care consistent with their preferences.11

Advance directives are based on the ethical principle of autonomy and, with the growing evidence that ADs may improve care at the end of life, public understanding of the issue is critical. We had presented early preliminary data in a letter to the editor showing that having had an advance directive discussion or an AD in the medical record was not associated with an increased risk of death.12 This research, along with the work of Silveira and colleagues,9 was cited by the Obama administration when they decided to add the regulation for including advance care planning as part of the annual Medicare wellness exams. This brief report presents a more comprehensive examination of the relationship of AD discussions and AD documentation with survival in a group of hospitalized patients.

METHODS

RESULTS

Characteristics of the 356 study subjects are listed in Table 1. Overall, the sample population was ethnically diverse, slightly above middle‐aged, mostly male, and of lower socioeconomic status, reflecting the hospitals' populations. Using the CARING criteria, 297 subjects were found to be at low risk, and 59 subjects at medium risk, of death at 1 year.

Overall, 206 (45%) reported a discussion about ADs with a healthcare provider. However, we found that only 56 (10%) had an AD document on their chart. Twenty‐eight (6%) had a living will, 43 (9%) had a durable power of attorney, and 30 (7%) had a broader AD document. Between 2003 and 2009, 121 (26%) patients died. Unadjusted mortality rates for those with and without documentation and discussions of ADs are displayed in Figure 1.

Figure 1

Kaplan‐Meier survival curves showed that, for subjects with a low or medium risk of death at 1 year, having had an AD discussion or having an AD in the medical record did not affect survival in subjects (Figures 2 and 3). Cox proportional hazards models adjusting for other covariates confirmed the results of the survival analysis (data not shown). Minimal intraclass correlation coefficients (0.005) were observed for the outcomes. Therefore, no models accounting for clustering within hospitals were developed.

Figure 2

Figure 3

DISCUSSION

We found no decrease in survival for patients at low and medium 1‐year risk of death who reported having discussed ADs or who had an AD in their medical record, providing important evidence that having advance care planning discussions do not hasten death in this group of adults. However, it is possible that ADs, when implemented properly, may dictate withdrawal or withholding of interventions that may extend quantity of life at a quality unacceptable for the person executing the directive. For example, a feeding tube delivering artificial nutrition and hydration may grant years to someone in a persistent vegetative state, but those years, without the ability to be aware or interact with surroundings and loved ones, may not be a life worth living for some individuals. One explanation for our negative findings may be that the circumstances in which an AD may have an effect on outcomes may not yet have occurred among this lower risk population.

Opposition to the process of advance care planning may be considered unethical, by removing the opportunity for individuals to express their desires in the event of decisional incapacity, therefore disregarding patient autonomy. Furthermore, with the growing evidence that AD discussions and documentation help patients achieve care consistent with their wishes at the end of life,9, 11, 17 preventing advance care planning may worsen end of life outcomes.

Another important finding in our study was that only about 10% of the patients interviewed had completed an AD document, although nearly half reported they had discussed ADs with a healthcare provider. The patients we interviewed in this study had been admitted to the hospital in the previous 24 hours. As part of the Patient Self‐Determination Act, all patients admitted to a healthcare facility should receive information and counseling on AD. Less than half of our cohort reported any discussions about ADs and only 10% had completed an AD, suggesting that huge opportunities exist for improvement in advance care planning. As this study demonstrates, there was no increased mortality from advance care planning among those at low and medium risk of death, and others have shown benefits from the process. AD discussions and documentation should be fostered, especially as the burden of chronic disease increases and the population ages. In targeted studies to improve advance care planning, completion rates of up to 85% have been achieved.17

Our decision to focus solely on patients at low or medium risk of death, and exclude those at a high risk of death, is based on both clinical and methodological judgment. First, it is important to note that ADs are important even for those at lower risk of deaththe 3 critical cases that have shaped AD policy in this country, Karen Ann Quinlan, Nancy Cruzan, and Terry Schiavo, were all otherwise healthy young women.

Our study does have limitations. First, the sample size is small and not powered to detect small differences in survival. In addition, we only examined Vital Records within Colorado, although all participants had either a date of death or recent date of last contact. It is also conceivable that some patients discussed or completed ADs at a later time in their illness trajectory. However, the generalizability of this study is a major strength, by including a population and healthcare settings that are ethnically and socioeconomically diverse. Generalization of results beyond the three types of hospitals should be limited even with the low intraclass correlation. The major limitation of this research is that we do not have data on participant quality of life or whether completing an AD led to increased use of palliative care. During the time the research was conducted, 2 of the 3 hospitals involved had small palliative care services and the third remains without a palliative care service.

In conclusion, our study provides limited data to counteract the misleading claims of those opposed to the advance care planning process. Our results underscore the importance of educating the public on the importance of ADs and cast doubt on the death myth surrounding advance care planning. However, further, preferably longitudinal, study is needed to prospectively understand both the benefits and risks of advance care planning.

Patients with advanced illness frequently do not receive care that meets their physical and emotional needs at the end of life,1 despite significant expenditures. Palliative care has been recommended as an approach to improve the quality of care for patients with advanced illness,26 while achieving hospital cost savings.7 Studies show that palliative care consults are associated with decreased hospitalization cost712 and length of stay13, 14 in the acute care setting.

Identifying which hospitalized patients are likely to benefit most from palliative care has not been well defined. The Hamilton Chart Audit tool was developed to estimate the number of patients that would benefit from a palliative care consult, in order to determine hospital palliative care staffing and financial needs.15 The CARING criteria identifies patients on admission to the hospital who are at high risk of death within one year and may, therefore, benefit from palliative care.16 The literature from the medical intensive care unit (MICU) identifies palliative care core competencies and quality measures, but does not describe patient factors that should trigger a palliative care consult.1719 Norton et al. studied proactive palliative care consultation in the MICU, finding that palliative care consultation in the high‐risk group (serious illness and high risk of dying) was associated with a shorter MICU length of stay without a significant difference in mortality rates.14

The most specific triggers for a palliative care consult comes from the surgical intensive care guidelines. The American College of Surgeons Surgical Palliative Care Task Force published a consensus guideline based on expert opinion identifying the top ten triggers for a palliative care consultation in the surgical intensive care unit (SICU).20 The top 10 criteria to identify SICU patients for palliative care consultation listed in order of priority were: 1) family request; 2) futility considered or declared by the medical team; 3) family disagreement with the team, advance directive, or each other lasting greater than seven days; 4) death expected during the same SICU stay; 5) SICU stay of greater than one month; 6) diagnosis with a median survival of less than six months; 7) greater than three SICU admissions during the same hospitalization; 8) Glasgow Coma Score of less than eight for greater than one week in a patient greater than 75 years old; 9) Glasgow Outcome Score of less than three (i.e., persistent vegetative state); and 10) multisystem organ failure of greater than three systems.

Studies are lacking that identify hospitalized patients who are more likely to have higher cost per day or length of stay, as these are patients who may benefit from palliative care. We sought to identify patient characteristics that are associated with higher cost per day or longer length of stay in hospitalized patients who died during the hospitalization or were discharged to hospicepatients likely to benefit from targeted palliative care services. We hypothesized that hospitalized patients with the following characteristics who died during the hospitalization or were discharged to hospice would have a higher cost per day or longer length of stay: older patients, lack of insurance, and patients receiving care from a critical care specialty.

METHODS

RESULTS

The study population comprised 1155 hospitalizations. Nine hospitalizations were excluded from analysis (five for organ donation, three were erroneousthe patients were not discharged to hospice or did not die during the hospitalization, and one was a pediatric patient), resulting in a study population of n = 1146 hospitalizations.

Table 1 depicts study population characteristics. The average patient age was 62 years (SD = 16), and 96% of patients were insured. The average length of stay was 10.7 days (SD = 14.1), with an average total cost per admission of $44,410 (SD = 76,355), as compared to an overall hospital admission (excluding obstetrics/neonatology) average length of stay of 5.7 days (SD = 8.5) and average total cost per admission of $17,410 (SD = 36,633) during the same time period. The average cost per day was $5095 (SD = $8546). About one‐third of patients were admitted to internal medicine, 20% to pulmonary critical care, and 18% to surgical specialties. The remaining 29% belonged to other specialties.

DISCUSSION

We found several characteristics that were significantly associated with higher cost per day or longer length of stay in patients who died during hospitalization or were discharged to hospice. Among this patient population, the surgical specialty services had overall higher cost per day and length of stay than other services. Patients cared for on the cardiothoracic surgery service had higher cost per day and length of stay; in contrast, internal medicine patients had lower cost per day and length of stay. Neurosurgery patients had higher cost per day, while surgical oncology patients had higher length of stay. Patients age 65 years and older had a significantly lower cost per day and shorter length of stay than those less than 65 years of age.

Higher cost per day for cardiothoracic surgery and neurosurgery patients may partially be explained by cardiothoracic surgery patients' usage of clinical services, including operating room services, which are higher in costs compared with those of nonsurgical specialties. Some patients may require repeat surgeries in the same hospitalization which further increases the cost per day. Longer length of stay in surgical oncology patients may be related to complex surgeries and possible postoperative complications that may take longer to recover from than standard surgeries.

Our findings that older patients have lower cost per day and shorter length of stay are corroborated by other studies. Lubitz and Riley21 found that in 1976 and 1988, Medicare payments per person year decreased with age. Levinsky et al.22 had similar findings in a review of Medicare data in 2001, but noted smaller reductions in total costabout $400 decrease for each year above 65. Their explanation of the lower cost is that older patients receive less aggressive care. Physicians, as well as patients and families, may continue to pursue expensive, invasive therapies for terminally ill patients who are younger for a longer period of time than with older patients, which would increase cost per day as well as length of stay.

The finding that patients on the surgical specialty services may be a focus for active palliative care intervention has many implications. The American College of Surgeons Surgical Palliative Care Task Force consensus guideline triggers for a palliative care consultation in SICU applied clinically did not result in a change in palliative care consultation rate.23 The use of triggers for palliative care consultation may be an ineffective approach because knowledge and application of the triggers did not change behavior. Focusing on integrating palliative care interventions or consultation for all high‐risk surgical patients, as opposed to relying upon triggers, may be a more effective approach to meeting these patients' palliative care needs while lowering cost per day and length of stay and warrants further study. For instance, palliative care consult teams may consider routine or daily rounds with the surgical specialty services in order to effectively integrate palliative care for these patients. Such an integrative approach may foster familiarity and comfort with palliative care approaches, facilitating access to palliative care services for those patients with palliative needs.

Our study is limited in that it is a retrospective, single‐center study. Our results may not be applicable to the general population. The experience of additional centers analyzed prospectively would provide additional context. The available administrative data limited the analyses to only a small number of predictors. In the subset population with the highest 10% total hospitalization costs, from which clinical information was gathered, the presence of respiratory failure was associated with shorter LOS (33 days vs 42 days; P = 0.03), but not associated with cost per day. Having sepsis at admission was associated with lower cost per day ($5783 vs $10,071; P = 0.04); however, this finding was based on only four patients with sepsis at admission. Patients who were evaluated by the palliative care service (n = 35) had a significantly lower cost per day ($4896 vs $12,210; P = 0.01) but longer LOS (46.5 vs 35.7 days; P = 0.03) than those who were not. These, and other, clinical characteristics need further testing in larger samples. An additional limitation is that we combined hospital decedents with patients discharged to hospice as our study population. These groups were combined since they are both at high risk of death in the near future; the median hospice length of stay in Colorado is 20 days.24 There may exist important differences in these populations that are not accounted for in our findings. Despite these unidentified differences, both populations are at high risk of death in the near future, making it likely that they would benefit from palliative care. Those who died during hospitalization did have a longer LOS (11.5 vs 9.2 days; P = 0.003) and higher cost per day ($6734 vs $2221; P < 0.0001) than those who were discharged to hospice.

Palliative care consultations can lead to improved quality of care for patients and families by addressing suffering and addressing quality of life measures (2, 4, 5, 6). We sought to identify characteristics associated with high cost and prolonged hospitalizations in patients who died during hospitalization, or were discharged to hospice, in order to inform targeting of palliative care services. Our data suggest that younger patients and those cared for by surgical specialty services may have the most palliative needs. Palliative care teams may consider focusing efforts at integrating palliative care with surgical specialty services to address these needs. These findings need to be corroborated in other centers, and include clinical outcomes.

Patients with advanced illness frequently do not receive care that meets their physical and emotional needs at the end of life,1 despite significant expenditures. Palliative care has been recommended as an approach to improve the quality of care for patients with advanced illness,26 while achieving hospital cost savings.7 Studies show that palliative care consults are associated with decreased hospitalization cost712 and length of stay13, 14 in the acute care setting.

Identifying which hospitalized patients are likely to benefit most from palliative care has not been well defined. The Hamilton Chart Audit tool was developed to estimate the number of patients that would benefit from a palliative care consult, in order to determine hospital palliative care staffing and financial needs.15 The CARING criteria identifies patients on admission to the hospital who are at high risk of death within one year and may, therefore, benefit from palliative care.16 The literature from the medical intensive care unit (MICU) identifies palliative care core competencies and quality measures, but does not describe patient factors that should trigger a palliative care consult.1719 Norton et al. studied proactive palliative care consultation in the MICU, finding that palliative care consultation in the high‐risk group (serious illness and high risk of dying) was associated with a shorter MICU length of stay without a significant difference in mortality rates.14

The most specific triggers for a palliative care consult comes from the surgical intensive care guidelines. The American College of Surgeons Surgical Palliative Care Task Force published a consensus guideline based on expert opinion identifying the top ten triggers for a palliative care consultation in the surgical intensive care unit (SICU).20 The top 10 criteria to identify SICU patients for palliative care consultation listed in order of priority were: 1) family request; 2) futility considered or declared by the medical team; 3) family disagreement with the team, advance directive, or each other lasting greater than seven days; 4) death expected during the same SICU stay; 5) SICU stay of greater than one month; 6) diagnosis with a median survival of less than six months; 7) greater than three SICU admissions during the same hospitalization; 8) Glasgow Coma Score of less than eight for greater than one week in a patient greater than 75 years old; 9) Glasgow Outcome Score of less than three (i.e., persistent vegetative state); and 10) multisystem organ failure of greater than three systems.

Studies are lacking that identify hospitalized patients who are more likely to have higher cost per day or length of stay, as these are patients who may benefit from palliative care. We sought to identify patient characteristics that are associated with higher cost per day or longer length of stay in hospitalized patients who died during the hospitalization or were discharged to hospicepatients likely to benefit from targeted palliative care services. We hypothesized that hospitalized patients with the following characteristics who died during the hospitalization or were discharged to hospice would have a higher cost per day or longer length of stay: older patients, lack of insurance, and patients receiving care from a critical care specialty.

METHODS

RESULTS

The study population comprised 1155 hospitalizations. Nine hospitalizations were excluded from analysis (five for organ donation, three were erroneousthe patients were not discharged to hospice or did not die during the hospitalization, and one was a pediatric patient), resulting in a study population of n = 1146 hospitalizations.

Table 1 depicts study population characteristics. The average patient age was 62 years (SD = 16), and 96% of patients were insured. The average length of stay was 10.7 days (SD = 14.1), with an average total cost per admission of $44,410 (SD = 76,355), as compared to an overall hospital admission (excluding obstetrics/neonatology) average length of stay of 5.7 days (SD = 8.5) and average total cost per admission of $17,410 (SD = 36,633) during the same time period. The average cost per day was $5095 (SD = $8546). About one‐third of patients were admitted to internal medicine, 20% to pulmonary critical care, and 18% to surgical specialties. The remaining 29% belonged to other specialties.

DISCUSSION

We found several characteristics that were significantly associated with higher cost per day or longer length of stay in patients who died during hospitalization or were discharged to hospice. Among this patient population, the surgical specialty services had overall higher cost per day and length of stay than other services. Patients cared for on the cardiothoracic surgery service had higher cost per day and length of stay; in contrast, internal medicine patients had lower cost per day and length of stay. Neurosurgery patients had higher cost per day, while surgical oncology patients had higher length of stay. Patients age 65 years and older had a significantly lower cost per day and shorter length of stay than those less than 65 years of age.

Higher cost per day for cardiothoracic surgery and neurosurgery patients may partially be explained by cardiothoracic surgery patients' usage of clinical services, including operating room services, which are higher in costs compared with those of nonsurgical specialties. Some patients may require repeat surgeries in the same hospitalization which further increases the cost per day. Longer length of stay in surgical oncology patients may be related to complex surgeries and possible postoperative complications that may take longer to recover from than standard surgeries.

Our findings that older patients have lower cost per day and shorter length of stay are corroborated by other studies. Lubitz and Riley21 found that in 1976 and 1988, Medicare payments per person year decreased with age. Levinsky et al.22 had similar findings in a review of Medicare data in 2001, but noted smaller reductions in total costabout $400 decrease for each year above 65. Their explanation of the lower cost is that older patients receive less aggressive care. Physicians, as well as patients and families, may continue to pursue expensive, invasive therapies for terminally ill patients who are younger for a longer period of time than with older patients, which would increase cost per day as well as length of stay.

The finding that patients on the surgical specialty services may be a focus for active palliative care intervention has many implications. The American College of Surgeons Surgical Palliative Care Task Force consensus guideline triggers for a palliative care consultation in SICU applied clinically did not result in a change in palliative care consultation rate.23 The use of triggers for palliative care consultation may be an ineffective approach because knowledge and application of the triggers did not change behavior. Focusing on integrating palliative care interventions or consultation for all high‐risk surgical patients, as opposed to relying upon triggers, may be a more effective approach to meeting these patients' palliative care needs while lowering cost per day and length of stay and warrants further study. For instance, palliative care consult teams may consider routine or daily rounds with the surgical specialty services in order to effectively integrate palliative care for these patients. Such an integrative approach may foster familiarity and comfort with palliative care approaches, facilitating access to palliative care services for those patients with palliative needs.

Our study is limited in that it is a retrospective, single‐center study. Our results may not be applicable to the general population. The experience of additional centers analyzed prospectively would provide additional context. The available administrative data limited the analyses to only a small number of predictors. In the subset population with the highest 10% total hospitalization costs, from which clinical information was gathered, the presence of respiratory failure was associated with shorter LOS (33 days vs 42 days; P = 0.03), but not associated with cost per day. Having sepsis at admission was associated with lower cost per day ($5783 vs $10,071; P = 0.04); however, this finding was based on only four patients with sepsis at admission. Patients who were evaluated by the palliative care service (n = 35) had a significantly lower cost per day ($4896 vs $12,210; P = 0.01) but longer LOS (46.5 vs 35.7 days; P = 0.03) than those who were not. These, and other, clinical characteristics need further testing in larger samples. An additional limitation is that we combined hospital decedents with patients discharged to hospice as our study population. These groups were combined since they are both at high risk of death in the near future; the median hospice length of stay in Colorado is 20 days.24 There may exist important differences in these populations that are not accounted for in our findings. Despite these unidentified differences, both populations are at high risk of death in the near future, making it likely that they would benefit from palliative care. Those who died during hospitalization did have a longer LOS (11.5 vs 9.2 days; P = 0.003) and higher cost per day ($6734 vs $2221; P < 0.0001) than those who were discharged to hospice.

Palliative care consultations can lead to improved quality of care for patients and families by addressing suffering and addressing quality of life measures (2, 4, 5, 6). We sought to identify characteristics associated with high cost and prolonged hospitalizations in patients who died during hospitalization, or were discharged to hospice, in order to inform targeting of palliative care services. Our data suggest that younger patients and those cared for by surgical specialty services may have the most palliative needs. Palliative care teams may consider focusing efforts at integrating palliative care with surgical specialty services to address these needs. These findings need to be corroborated in other centers, and include clinical outcomes.

Patients with advanced illness frequently do not receive care that meets their physical and emotional needs at the end of life,1 despite significant expenditures. Palliative care has been recommended as an approach to improve the quality of care for patients with advanced illness,26 while achieving hospital cost savings.7 Studies show that palliative care consults are associated with decreased hospitalization cost712 and length of stay13, 14 in the acute care setting.

Identifying which hospitalized patients are likely to benefit most from palliative care has not been well defined. The Hamilton Chart Audit tool was developed to estimate the number of patients that would benefit from a palliative care consult, in order to determine hospital palliative care staffing and financial needs.15 The CARING criteria identifies patients on admission to the hospital who are at high risk of death within one year and may, therefore, benefit from palliative care.16 The literature from the medical intensive care unit (MICU) identifies palliative care core competencies and quality measures, but does not describe patient factors that should trigger a palliative care consult.1719 Norton et al. studied proactive palliative care consultation in the MICU, finding that palliative care consultation in the high‐risk group (serious illness and high risk of dying) was associated with a shorter MICU length of stay without a significant difference in mortality rates.14

The most specific triggers for a palliative care consult comes from the surgical intensive care guidelines. The American College of Surgeons Surgical Palliative Care Task Force published a consensus guideline based on expert opinion identifying the top ten triggers for a palliative care consultation in the surgical intensive care unit (SICU).20 The top 10 criteria to identify SICU patients for palliative care consultation listed in order of priority were: 1) family request; 2) futility considered or declared by the medical team; 3) family disagreement with the team, advance directive, or each other lasting greater than seven days; 4) death expected during the same SICU stay; 5) SICU stay of greater than one month; 6) diagnosis with a median survival of less than six months; 7) greater than three SICU admissions during the same hospitalization; 8) Glasgow Coma Score of less than eight for greater than one week in a patient greater than 75 years old; 9) Glasgow Outcome Score of less than three (i.e., persistent vegetative state); and 10) multisystem organ failure of greater than three systems.

Studies are lacking that identify hospitalized patients who are more likely to have higher cost per day or length of stay, as these are patients who may benefit from palliative care. We sought to identify patient characteristics that are associated with higher cost per day or longer length of stay in hospitalized patients who died during the hospitalization or were discharged to hospicepatients likely to benefit from targeted palliative care services. We hypothesized that hospitalized patients with the following characteristics who died during the hospitalization or were discharged to hospice would have a higher cost per day or longer length of stay: older patients, lack of insurance, and patients receiving care from a critical care specialty.

METHODS

RESULTS

The study population comprised 1155 hospitalizations. Nine hospitalizations were excluded from analysis (five for organ donation, three were erroneousthe patients were not discharged to hospice or did not die during the hospitalization, and one was a pediatric patient), resulting in a study population of n = 1146 hospitalizations.

Table 1 depicts study population characteristics. The average patient age was 62 years (SD = 16), and 96% of patients were insured. The average length of stay was 10.7 days (SD = 14.1), with an average total cost per admission of $44,410 (SD = 76,355), as compared to an overall hospital admission (excluding obstetrics/neonatology) average length of stay of 5.7 days (SD = 8.5) and average total cost per admission of $17,410 (SD = 36,633) during the same time period. The average cost per day was $5095 (SD = $8546). About one‐third of patients were admitted to internal medicine, 20% to pulmonary critical care, and 18% to surgical specialties. The remaining 29% belonged to other specialties.

DISCUSSION

We found several characteristics that were significantly associated with higher cost per day or longer length of stay in patients who died during hospitalization or were discharged to hospice. Among this patient population, the surgical specialty services had overall higher cost per day and length of stay than other services. Patients cared for on the cardiothoracic surgery service had higher cost per day and length of stay; in contrast, internal medicine patients had lower cost per day and length of stay. Neurosurgery patients had higher cost per day, while surgical oncology patients had higher length of stay. Patients age 65 years and older had a significantly lower cost per day and shorter length of stay than those less than 65 years of age.

Higher cost per day for cardiothoracic surgery and neurosurgery patients may partially be explained by cardiothoracic surgery patients' usage of clinical services, including operating room services, which are higher in costs compared with those of nonsurgical specialties. Some patients may require repeat surgeries in the same hospitalization which further increases the cost per day. Longer length of stay in surgical oncology patients may be related to complex surgeries and possible postoperative complications that may take longer to recover from than standard surgeries.

Our findings that older patients have lower cost per day and shorter length of stay are corroborated by other studies. Lubitz and Riley21 found that in 1976 and 1988, Medicare payments per person year decreased with age. Levinsky et al.22 had similar findings in a review of Medicare data in 2001, but noted smaller reductions in total costabout $400 decrease for each year above 65. Their explanation of the lower cost is that older patients receive less aggressive care. Physicians, as well as patients and families, may continue to pursue expensive, invasive therapies for terminally ill patients who are younger for a longer period of time than with older patients, which would increase cost per day as well as length of stay.

The finding that patients on the surgical specialty services may be a focus for active palliative care intervention has many implications. The American College of Surgeons Surgical Palliative Care Task Force consensus guideline triggers for a palliative care consultation in SICU applied clinically did not result in a change in palliative care consultation rate.23 The use of triggers for palliative care consultation may be an ineffective approach because knowledge and application of the triggers did not change behavior. Focusing on integrating palliative care interventions or consultation for all high‐risk surgical patients, as opposed to relying upon triggers, may be a more effective approach to meeting these patients' palliative care needs while lowering cost per day and length of stay and warrants further study. For instance, palliative care consult teams may consider routine or daily rounds with the surgical specialty services in order to effectively integrate palliative care for these patients. Such an integrative approach may foster familiarity and comfort with palliative care approaches, facilitating access to palliative care services for those patients with palliative needs.

Our study is limited in that it is a retrospective, single‐center study. Our results may not be applicable to the general population. The experience of additional centers analyzed prospectively would provide additional context. The available administrative data limited the analyses to only a small number of predictors. In the subset population with the highest 10% total hospitalization costs, from which clinical information was gathered, the presence of respiratory failure was associated with shorter LOS (33 days vs 42 days; P = 0.03), but not associated with cost per day. Having sepsis at admission was associated with lower cost per day ($5783 vs $10,071; P = 0.04); however, this finding was based on only four patients with sepsis at admission. Patients who were evaluated by the palliative care service (n = 35) had a significantly lower cost per day ($4896 vs $12,210; P = 0.01) but longer LOS (46.5 vs 35.7 days; P = 0.03) than those who were not. These, and other, clinical characteristics need further testing in larger samples. An additional limitation is that we combined hospital decedents with patients discharged to hospice as our study population. These groups were combined since they are both at high risk of death in the near future; the median hospice length of stay in Colorado is 20 days.24 There may exist important differences in these populations that are not accounted for in our findings. Despite these unidentified differences, both populations are at high risk of death in the near future, making it likely that they would benefit from palliative care. Those who died during hospitalization did have a longer LOS (11.5 vs 9.2 days; P = 0.003) and higher cost per day ($6734 vs $2221; P < 0.0001) than those who were discharged to hospice.

Palliative care consultations can lead to improved quality of care for patients and families by addressing suffering and addressing quality of life measures (2, 4, 5, 6). We sought to identify characteristics associated with high cost and prolonged hospitalizations in patients who died during hospitalization, or were discharged to hospice, in order to inform targeting of palliative care services. Our data suggest that younger patients and those cared for by surgical specialty services may have the most palliative needs. Palliative care teams may consider focusing efforts at integrating palliative care with surgical specialty services to address these needs. These findings need to be corroborated in other centers, and include clinical outcomes.

Communication, palliative care, and patient safety have been identified by the Society of Hospital Medicine as core competencies in hospital medicine. Effective communication is recognized as being central to the role of the hospitalist to promote efficient, safe, and high quality care.1 Hospitalists are increasingly recognized as having a central role in initiatives to improve palliative care for hospitalized patients and their families24 and have a vital role in leading and participating in interventions to mitigate system and process failures that affect patient safety.1 The obligation of the hospitalist to assure safe, quality care for hospitalized people with advanced illness extends from direct patient care to advocacy for systems that facilitate the provision of such care.

Four articles in this issue of the Journal of Hospital Medicine provide complementary perspectives on these crucial roles of the hospitalist. Cherlin and colleagues describe findings from a survey of hospitalists and medical residents regarding their knowledge, attitudes, and practices relative to caring for patients with terminal illness. The article identifies misperceptions related to core components of quality palliative care: pain and symptom control, hospice eligibility, and communication about prognosis and hospice and palliative care.5 Although this study was conducted at only a single academic medical center and certainly deserves to be repeated in an expanded and more representative sample, it clearly identifies deficits in core components of quality care for persons with advanced illness. The article by Minichiello and colleagues provides practical guidance and resources for addressing one of the deficits identified: communicating a poor prognosis, or bad news.6

Pain and symptom management and communication are commonly recognized aspects of quality care for persons with advanced illness. Less often appreciated are the significant threats to patient safety and medical errors that occur in the care of this vulnerable population.79 Potential errors include failure of a planned action to be completed as intended (ie, not following advance directives) and failure to treat symptoms adequately. The original research article and accompanying images discussion by Sehgal and colleagues serve as a call to action to both recognize and address the potentially significant patient safety issue related to the use of color‐coded wristbands, particularly variation in color used by different hospitals to designate do not resuscitate status.10, 11 What is exciting about this sequence of articles is that they describe opportunities for improvement and provide potential solutions. We have to be aware that there is a problem in order to initiate change. Hospitalists are in an a prime position to both identify these potential critical issues and effect the necessary changes to facilitate our ability to provide safe, effective care to our patients with advanced illness.

Palliative care is increasingly being accepted as a means for improving care for persons with advanced illness. The National Consensus Project Clinical Practice Guidelines for Quality Palliative Care, released in 2004, was endorsed by the National Quality Forum and incorporated into its Framework for Hospice and Palliative Care in 2007.12, 13 The Joint Commission (TJC; previously known as JCAHO) is developing a Health Care Services Certification Program for palliative care services modeled on existing programs for diabetes and stroke care, to take effect in 2008.14 Newsweek featured palliative care in its August 2006 issue focused on Fixing America's Hospitals.15 US News and World Report has included hospice and palliative care indicators in its ranking of America's Best Hospitals since 2002.16 There has been significant recent growth in hospital‐based palliative care programs, with 1250 hospitals reporting palliative care programs in 2005, an increase of almost 100% over 2000. Seventy percent of U.S. hospitals with more than 250 beds report having a palliative care program.17

Although hospital‐based palliative care programs are increasing, it is the obligation of all hospitalists who care for an ill, often elderly population to assure that all hospitalized patients with advanced illness receive safe, quality care while hospitalized. This includes avoiding medical errors such as inappropriate resuscitation attempts because of miscommunication of do‐not‐resuscitate orders or advance directives, as well as minimizing distress, maximizing comfort, and addressing informational and psychosocial support needs. As evidenced by the 4 articles in this issue of the Journal of Hospital Medicine, we need to make safe, effective care for people with advanced illness a priority, then implement appropriate training and education and create systems that assure delivery of quality care.

Communication, palliative care, and patient safety have been identified by the Society of Hospital Medicine as core competencies in hospital medicine. Effective communication is recognized as being central to the role of the hospitalist to promote efficient, safe, and high quality care.1 Hospitalists are increasingly recognized as having a central role in initiatives to improve palliative care for hospitalized patients and their families24 and have a vital role in leading and participating in interventions to mitigate system and process failures that affect patient safety.1 The obligation of the hospitalist to assure safe, quality care for hospitalized people with advanced illness extends from direct patient care to advocacy for systems that facilitate the provision of such care.

Four articles in this issue of the Journal of Hospital Medicine provide complementary perspectives on these crucial roles of the hospitalist. Cherlin and colleagues describe findings from a survey of hospitalists and medical residents regarding their knowledge, attitudes, and practices relative to caring for patients with terminal illness. The article identifies misperceptions related to core components of quality palliative care: pain and symptom control, hospice eligibility, and communication about prognosis and hospice and palliative care.5 Although this study was conducted at only a single academic medical center and certainly deserves to be repeated in an expanded and more representative sample, it clearly identifies deficits in core components of quality care for persons with advanced illness. The article by Minichiello and colleagues provides practical guidance and resources for addressing one of the deficits identified: communicating a poor prognosis, or bad news.6

Pain and symptom management and communication are commonly recognized aspects of quality care for persons with advanced illness. Less often appreciated are the significant threats to patient safety and medical errors that occur in the care of this vulnerable population.79 Potential errors include failure of a planned action to be completed as intended (ie, not following advance directives) and failure to treat symptoms adequately. The original research article and accompanying images discussion by Sehgal and colleagues serve as a call to action to both recognize and address the potentially significant patient safety issue related to the use of color‐coded wristbands, particularly variation in color used by different hospitals to designate do not resuscitate status.10, 11 What is exciting about this sequence of articles is that they describe opportunities for improvement and provide potential solutions. We have to be aware that there is a problem in order to initiate change. Hospitalists are in an a prime position to both identify these potential critical issues and effect the necessary changes to facilitate our ability to provide safe, effective care to our patients with advanced illness.

Palliative care is increasingly being accepted as a means for improving care for persons with advanced illness. The National Consensus Project Clinical Practice Guidelines for Quality Palliative Care, released in 2004, was endorsed by the National Quality Forum and incorporated into its Framework for Hospice and Palliative Care in 2007.12, 13 The Joint Commission (TJC; previously known as JCAHO) is developing a Health Care Services Certification Program for palliative care services modeled on existing programs for diabetes and stroke care, to take effect in 2008.14 Newsweek featured palliative care in its August 2006 issue focused on Fixing America's Hospitals.15 US News and World Report has included hospice and palliative care indicators in its ranking of America's Best Hospitals since 2002.16 There has been significant recent growth in hospital‐based palliative care programs, with 1250 hospitals reporting palliative care programs in 2005, an increase of almost 100% over 2000. Seventy percent of U.S. hospitals with more than 250 beds report having a palliative care program.17

Although hospital‐based palliative care programs are increasing, it is the obligation of all hospitalists who care for an ill, often elderly population to assure that all hospitalized patients with advanced illness receive safe, quality care while hospitalized. This includes avoiding medical errors such as inappropriate resuscitation attempts because of miscommunication of do‐not‐resuscitate orders or advance directives, as well as minimizing distress, maximizing comfort, and addressing informational and psychosocial support needs. As evidenced by the 4 articles in this issue of the Journal of Hospital Medicine, we need to make safe, effective care for people with advanced illness a priority, then implement appropriate training and education and create systems that assure delivery of quality care.

Communication, palliative care, and patient safety have been identified by the Society of Hospital Medicine as core competencies in hospital medicine. Effective communication is recognized as being central to the role of the hospitalist to promote efficient, safe, and high quality care.1 Hospitalists are increasingly recognized as having a central role in initiatives to improve palliative care for hospitalized patients and their families24 and have a vital role in leading and participating in interventions to mitigate system and process failures that affect patient safety.1 The obligation of the hospitalist to assure safe, quality care for hospitalized people with advanced illness extends from direct patient care to advocacy for systems that facilitate the provision of such care.

Four articles in this issue of the Journal of Hospital Medicine provide complementary perspectives on these crucial roles of the hospitalist. Cherlin and colleagues describe findings from a survey of hospitalists and medical residents regarding their knowledge, attitudes, and practices relative to caring for patients with terminal illness. The article identifies misperceptions related to core components of quality palliative care: pain and symptom control, hospice eligibility, and communication about prognosis and hospice and palliative care.5 Although this study was conducted at only a single academic medical center and certainly deserves to be repeated in an expanded and more representative sample, it clearly identifies deficits in core components of quality care for persons with advanced illness. The article by Minichiello and colleagues provides practical guidance and resources for addressing one of the deficits identified: communicating a poor prognosis, or bad news.6

Pain and symptom management and communication are commonly recognized aspects of quality care for persons with advanced illness. Less often appreciated are the significant threats to patient safety and medical errors that occur in the care of this vulnerable population.79 Potential errors include failure of a planned action to be completed as intended (ie, not following advance directives) and failure to treat symptoms adequately. The original research article and accompanying images discussion by Sehgal and colleagues serve as a call to action to both recognize and address the potentially significant patient safety issue related to the use of color‐coded wristbands, particularly variation in color used by different hospitals to designate do not resuscitate status.10, 11 What is exciting about this sequence of articles is that they describe opportunities for improvement and provide potential solutions. We have to be aware that there is a problem in order to initiate change. Hospitalists are in an a prime position to both identify these potential critical issues and effect the necessary changes to facilitate our ability to provide safe, effective care to our patients with advanced illness.

Palliative care is increasingly being accepted as a means for improving care for persons with advanced illness. The National Consensus Project Clinical Practice Guidelines for Quality Palliative Care, released in 2004, was endorsed by the National Quality Forum and incorporated into its Framework for Hospice and Palliative Care in 2007.12, 13 The Joint Commission (TJC; previously known as JCAHO) is developing a Health Care Services Certification Program for palliative care services modeled on existing programs for diabetes and stroke care, to take effect in 2008.14 Newsweek featured palliative care in its August 2006 issue focused on Fixing America's Hospitals.15 US News and World Report has included hospice and palliative care indicators in its ranking of America's Best Hospitals since 2002.16 There has been significant recent growth in hospital‐based palliative care programs, with 1250 hospitals reporting palliative care programs in 2005, an increase of almost 100% over 2000. Seventy percent of U.S. hospitals with more than 250 beds report having a palliative care program.17

Although hospital‐based palliative care programs are increasing, it is the obligation of all hospitalists who care for an ill, often elderly population to assure that all hospitalized patients with advanced illness receive safe, quality care while hospitalized. This includes avoiding medical errors such as inappropriate resuscitation attempts because of miscommunication of do‐not‐resuscitate orders or advance directives, as well as minimizing distress, maximizing comfort, and addressing informational and psychosocial support needs. As evidenced by the 4 articles in this issue of the Journal of Hospital Medicine, we need to make safe, effective care for people with advanced illness a priority, then implement appropriate training and education and create systems that assure delivery of quality care.

This issue of the Journal of Hospital Medicine contains the inaugural article in a planned series addressing key palliative care topics relevant for the practice, teaching, and study of hospital medicine. As was noted by Diane Meier in her article Palliative Care in Hospitals1 and in Steve Pantilat's accompanying editorial, Palliative Care and Hospitalists: A Partnership for Hope,2 hospitalists are well positioned to increase access to palliative care for all hospitalized patients. Achieving this goal will require that hospitalists attain at least basic competence in the components of high‐quality, comprehensive palliative care (assessment and treatment of pain and other symptom distress, communication about goals of care, and provision of practical and psychosocial support, care coordination, continuity, and bereavement services). Palliative care is becoming more prominent in medical school and residency curricula, palliative care fellowship opportunities are proliferating, a number of palliative care resources are available on the Internet, and motivated hospital‐based providers may attain palliative care education via a variety of educational programs and faculty development courses (see Table 1 in the Meier article).1 Some hospital medicine programs have specifically targeted faculty development in palliative care competencies.4

Recognizing the salience of palliative care for the practice of hospital medicine, the Society of Hospital Medicine (SHM) created the Palliative Care Task Force specifically to raise awareness of the importance of palliative care to hospital medicine and charged it with developing relevant palliative care educational materials. The Palliative Care Task Force has selected the Journal of Hospital Medicine as a means of disseminating palliative care content through a series of peer‐reviewed articles on palliative care topics relevant to hospital medicine. The articles will address practical matters relevant to care at the bedside in addition to policy issues. The article in this issue, Discussing Resuscitation Preferences: Challenges and Rewards,3 addresses the common barriers to and provides practical advice for conducting these frequent, but often difficult, conversations. Planned topics, addressing some of the key domains of palliative care clinical practice, include: pain management, symptom control, communicating bad news, caring for the clinical care provider, and importance of a multidisciplinary team approach to end‐of‐life care. Each of these articles will specifically address the relevance and implications of these topics for the practice of hospital medicine.

The Journal of Hospital Medicine looks forward to reviewing these articles from the Palliative Care Task Force and invites additional submissions relevant to the practice, teaching, or study of palliative care in the hospital setting.

This issue of the Journal of Hospital Medicine contains the inaugural article in a planned series addressing key palliative care topics relevant for the practice, teaching, and study of hospital medicine. As was noted by Diane Meier in her article Palliative Care in Hospitals1 and in Steve Pantilat's accompanying editorial, Palliative Care and Hospitalists: A Partnership for Hope,2 hospitalists are well positioned to increase access to palliative care for all hospitalized patients. Achieving this goal will require that hospitalists attain at least basic competence in the components of high‐quality, comprehensive palliative care (assessment and treatment of pain and other symptom distress, communication about goals of care, and provision of practical and psychosocial support, care coordination, continuity, and bereavement services). Palliative care is becoming more prominent in medical school and residency curricula, palliative care fellowship opportunities are proliferating, a number of palliative care resources are available on the Internet, and motivated hospital‐based providers may attain palliative care education via a variety of educational programs and faculty development courses (see Table 1 in the Meier article).1 Some hospital medicine programs have specifically targeted faculty development in palliative care competencies.4

Recognizing the salience of palliative care for the practice of hospital medicine, the Society of Hospital Medicine (SHM) created the Palliative Care Task Force specifically to raise awareness of the importance of palliative care to hospital medicine and charged it with developing relevant palliative care educational materials. The Palliative Care Task Force has selected the Journal of Hospital Medicine as a means of disseminating palliative care content through a series of peer‐reviewed articles on palliative care topics relevant to hospital medicine. The articles will address practical matters relevant to care at the bedside in addition to policy issues. The article in this issue, Discussing Resuscitation Preferences: Challenges and Rewards,3 addresses the common barriers to and provides practical advice for conducting these frequent, but often difficult, conversations. Planned topics, addressing some of the key domains of palliative care clinical practice, include: pain management, symptom control, communicating bad news, caring for the clinical care provider, and importance of a multidisciplinary team approach to end‐of‐life care. Each of these articles will specifically address the relevance and implications of these topics for the practice of hospital medicine.

The Journal of Hospital Medicine looks forward to reviewing these articles from the Palliative Care Task Force and invites additional submissions relevant to the practice, teaching, or study of palliative care in the hospital setting.

This issue of the Journal of Hospital Medicine contains the inaugural article in a planned series addressing key palliative care topics relevant for the practice, teaching, and study of hospital medicine. As was noted by Diane Meier in her article Palliative Care in Hospitals1 and in Steve Pantilat's accompanying editorial, Palliative Care and Hospitalists: A Partnership for Hope,2 hospitalists are well positioned to increase access to palliative care for all hospitalized patients. Achieving this goal will require that hospitalists attain at least basic competence in the components of high‐quality, comprehensive palliative care (assessment and treatment of pain and other symptom distress, communication about goals of care, and provision of practical and psychosocial support, care coordination, continuity, and bereavement services). Palliative care is becoming more prominent in medical school and residency curricula, palliative care fellowship opportunities are proliferating, a number of palliative care resources are available on the Internet, and motivated hospital‐based providers may attain palliative care education via a variety of educational programs and faculty development courses (see Table 1 in the Meier article).1 Some hospital medicine programs have specifically targeted faculty development in palliative care competencies.4

Recognizing the salience of palliative care for the practice of hospital medicine, the Society of Hospital Medicine (SHM) created the Palliative Care Task Force specifically to raise awareness of the importance of palliative care to hospital medicine and charged it with developing relevant palliative care educational materials. The Palliative Care Task Force has selected the Journal of Hospital Medicine as a means of disseminating palliative care content through a series of peer‐reviewed articles on palliative care topics relevant to hospital medicine. The articles will address practical matters relevant to care at the bedside in addition to policy issues. The article in this issue, Discussing Resuscitation Preferences: Challenges and Rewards,3 addresses the common barriers to and provides practical advice for conducting these frequent, but often difficult, conversations. Planned topics, addressing some of the key domains of palliative care clinical practice, include: pain management, symptom control, communicating bad news, caring for the clinical care provider, and importance of a multidisciplinary team approach to end‐of‐life care. Each of these articles will specifically address the relevance and implications of these topics for the practice of hospital medicine.

The Journal of Hospital Medicine looks forward to reviewing these articles from the Palliative Care Task Force and invites additional submissions relevant to the practice, teaching, or study of palliative care in the hospital setting.