JOURNAL OF PALLIATIVE MEDICINE Volume 17, Number 1, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2013.9459
Notes from the Editor
Palliative Medicine in Health Care Systems Charles F. von Gunten, MD, PhD, Editor-in-Chief
I
pitfalls?.the essential elements?.the expendable elements? In this issue we can see some of those contributions. Some, like the contribution from Romania that illustrates the need for skilled help at home beyond just willing family, is research only possible in a health care setting where such care is unavailable to anyone.1 The ability to evaluate the skills of all health care professionals engaged in interdisciplinary care will also be important.2 We must develop system outcome measures beyond morbidity and mortality.3 In my new role I am encountering ambivalence in my colleagues with whom I engage. The ambivalence I encounter has little to do with whether or not palliative medicine has value—that is given. Rather, the ambivalence is the reptilian brain resistance to change. This ambivalence is eerily familiar. It mirrors the ambivalence I have facilitated on a daily basis with patients and their families—the shift from the problemoriented approach to the goal-oriented approach. The shift from the familiar to something different. It shouldn’t be surprising that change is met with resistance in the health care system in the same way we encounter it in patients. What will be needed for this next period in our development as a field? Endless patience, a sense of humor, and a willingness to frame angry outbursts or passive-aggressive avoidance not as personal affronts, but as normal responses to fear and uncertainty. I am so grateful that I no longer fly into a towering rage when encountering a barrier. Now that I am older and more experienced, if not wiser, I recognize the patterns. Therefore, each of us is exceedingly well prepared for the work ahead. The risks are high. The setback to system-wide end-of-life care that the Liverpool Pathway flap represents is, to my mind, an example of taking a skillful approach to care developed in specialist settings and putting it into unskilled hands.4 In my earliest days as a consultant, when I introduced anticholinergics into the general hospital for death rattle, I suddenly found scopolamine infusions rampantly prescribed by house staff for cough. While we can understand the enthusiasm to incorporate new information, we must get the implementation right. We must ensure that the competencies of generalist palliative care are present in the health care workforce so that specialist palliative care plays its proper role. I hope you are up to the challenges—my own care when I need it rests on the outcome!
have a new job—Corporate Vice President, Medical Affairs, Hospice and Palliative Medicine, OhioHealth, a moderate-sized nonprofit health care system in central Ohio. Its mission is to deliver high-quality care at reasonable cost to the 45% of the state population it serves. It has numerous residency training programs because it seeks to train the physicians who will serve the community. In other words, it represents bread and butter medicine in the United States. The fact that they want someone at a corporate level help them develop hospice and palliative care for the entire system speaks volumes about how far we have come as a field, and the next challenges we face. My plan has three steps. Step 1 is to help the hospice transform from a community hospice to one that serves all of the patients of the system—subtle but clear differences in my mind. Step 2 is to ensure that palliative care teams serve all of the hospitals and post-acute areas of the system. Step 3 is to shape the processes of care so that palliative care is as routine as hand washing. It took more than 70 years for the ‘discovery’ that washing hands improves surgical outcomes to become routine in the nation’s surgical suites. It took another 100 years for it to become routine behavior for everyone. We shouldn’t become too discouraged it if takes longer than we want for palliative care to become as routine as hand washing. This new phase in my career mirrors the development of our field. When I started, our professional association was only a few years out from its founding around a campfire in Colorado. When David Weissman and I did a session for the American Academy of Hospice and Palliative Medicine in Snowbird, Utah, in 1996 about how to bill and get paid for working in the field, 200 physicians were agog. Billing for the clinical work we do, let alone having our subspecialty formally recognized by the American Board of Medical Specialties with accredited fellowships was thought to be loony according to the conventional wisdom of the day. Who would have imagined that our field would now be at the forefront of health care policy? Now you cannot find a policy paper that doesn’t say something about the role that palliative medicine needs to play in addressing the need to provide higher-value health care. The research reported in the Journal of Palliative Medicine and elsewhere over the past 16 years has proved that palliative medicine delivers on the value equation—improved quality at lower cost. As we begin the 17th year of publishing high-impact research that moves the field forward, I want to see more research that helps us understand how best to implement that knowledge in the health care systems in which we work. How do we take the elements of palliative care we have developed and implement them broadly in health care? What are the pearls?.the
References 1. Foreva G, Assenova R: ‘‘Hidden Patients:’’ The relatives of patients in need of palliative care. J Palliat Med 2014:17; 56–61.
2
NOTES FROM THE EDITOR 2. Blackhall L, Erickson J, Brashers V, Owen J, Thomas S: Development and validation of a Collaborative Behaviors Objective Assessment Tool (CBOAT) for end of life communication. J Palliat Med 2014:17;68– 74.
3 3. Badgwell B, Krouse R, Klimberg S, Bruera E: Outcome measures other than morbidity and mortality for patients with incurable cancer and gastrointestinal obstruction. J Palliat Med 2014:17;18–26. 4. Billings JA, Block S: Editor’s notes. J Palliat Med 2013:16; 1492–1495.
Notes from the Editor
Palliative Medicine in Health Care Systems Charles F. von Gunten, MD, PhD, Editor-in-Chief
I
pitfalls?.the essential elements?.the expendable elements? In this issue we can see some of those contributions. Some, like the contribution from Romania that illustrates the need for skilled help at home beyond just willing family, is research only possible in a health care setting where such care is unavailable to anyone.1 The ability to evaluate the skills of all health care professionals engaged in interdisciplinary care will also be important.2 We must develop system outcome measures beyond morbidity and mortality.3 In my new role I am encountering ambivalence in my colleagues with whom I engage. The ambivalence I encounter has little to do with whether or not palliative medicine has value—that is given. Rather, the ambivalence is the reptilian brain resistance to change. This ambivalence is eerily familiar. It mirrors the ambivalence I have facilitated on a daily basis with patients and their families—the shift from the problemoriented approach to the goal-oriented approach. The shift from the familiar to something different. It shouldn’t be surprising that change is met with resistance in the health care system in the same way we encounter it in patients. What will be needed for this next period in our development as a field? Endless patience, a sense of humor, and a willingness to frame angry outbursts or passive-aggressive avoidance not as personal affronts, but as normal responses to fear and uncertainty. I am so grateful that I no longer fly into a towering rage when encountering a barrier. Now that I am older and more experienced, if not wiser, I recognize the patterns. Therefore, each of us is exceedingly well prepared for the work ahead. The risks are high. The setback to system-wide end-of-life care that the Liverpool Pathway flap represents is, to my mind, an example of taking a skillful approach to care developed in specialist settings and putting it into unskilled hands.4 In my earliest days as a consultant, when I introduced anticholinergics into the general hospital for death rattle, I suddenly found scopolamine infusions rampantly prescribed by house staff for cough. While we can understand the enthusiasm to incorporate new information, we must get the implementation right. We must ensure that the competencies of generalist palliative care are present in the health care workforce so that specialist palliative care plays its proper role. I hope you are up to the challenges—my own care when I need it rests on the outcome!
have a new job—Corporate Vice President, Medical Affairs, Hospice and Palliative Medicine, OhioHealth, a moderate-sized nonprofit health care system in central Ohio. Its mission is to deliver high-quality care at reasonable cost to the 45% of the state population it serves. It has numerous residency training programs because it seeks to train the physicians who will serve the community. In other words, it represents bread and butter medicine in the United States. The fact that they want someone at a corporate level help them develop hospice and palliative care for the entire system speaks volumes about how far we have come as a field, and the next challenges we face. My plan has three steps. Step 1 is to help the hospice transform from a community hospice to one that serves all of the patients of the system—subtle but clear differences in my mind. Step 2 is to ensure that palliative care teams serve all of the hospitals and post-acute areas of the system. Step 3 is to shape the processes of care so that palliative care is as routine as hand washing. It took more than 70 years for the ‘discovery’ that washing hands improves surgical outcomes to become routine in the nation’s surgical suites. It took another 100 years for it to become routine behavior for everyone. We shouldn’t become too discouraged it if takes longer than we want for palliative care to become as routine as hand washing. This new phase in my career mirrors the development of our field. When I started, our professional association was only a few years out from its founding around a campfire in Colorado. When David Weissman and I did a session for the American Academy of Hospice and Palliative Medicine in Snowbird, Utah, in 1996 about how to bill and get paid for working in the field, 200 physicians were agog. Billing for the clinical work we do, let alone having our subspecialty formally recognized by the American Board of Medical Specialties with accredited fellowships was thought to be loony according to the conventional wisdom of the day. Who would have imagined that our field would now be at the forefront of health care policy? Now you cannot find a policy paper that doesn’t say something about the role that palliative medicine needs to play in addressing the need to provide higher-value health care. The research reported in the Journal of Palliative Medicine and elsewhere over the past 16 years has proved that palliative medicine delivers on the value equation—improved quality at lower cost. As we begin the 17th year of publishing high-impact research that moves the field forward, I want to see more research that helps us understand how best to implement that knowledge in the health care systems in which we work. How do we take the elements of palliative care we have developed and implement them broadly in health care? What are the pearls?.the
References 1. Foreva G, Assenova R: ‘‘Hidden Patients:’’ The relatives of patients in need of palliative care. J Palliat Med 2014:17; 56–61.
2
NOTES FROM THE EDITOR 2. Blackhall L, Erickson J, Brashers V, Owen J, Thomas S: Development and validation of a Collaborative Behaviors Objective Assessment Tool (CBOAT) for end of life communication. J Palliat Med 2014:17;68– 74.
3 3. Badgwell B, Krouse R, Klimberg S, Bruera E: Outcome measures other than morbidity and mortality for patients with incurable cancer and gastrointestinal obstruction. J Palliat Med 2014:17;18–26. 4. Billings JA, Block S: Editor’s notes. J Palliat Med 2013:16; 1492–1495.
![[Ultrasound in palliative care medicine].](/assets/img/hold.png)
