Transcription:
Hospice is Palliative Care – But Not All Palliative Care is Hospice

Deborah Howell (Host): Hello, and welcome to the show. You're listening to Weekly Dose of Wellness, brought to you by MemorialCare Health System. I'm Deborah Howell, and today's guest is Dr. Lowell Kleinman, a family medicine physician with MemorialCare Medical Group in San Clemente. He is board certified in family medicine and hospice and palliative care and believes in compassionate continuity of care for all his patients, and especially for families dealing with serious illnesses. Welcome, Dr. Kleinman.

Dr. Kleinman (Guest): Hi! Good morning.

Deborah: Today we're going to be talking a little bit about palliative care. Who should receive it and where it's delivered? First of all, what is palliative care, and how is it different from hospice care?

Dr. Kleinman: Palliative care is a type of medical care that is patient-and-family focused. The difference between palliative care and hospice care is a question that comes up very, very often and there's a lot of confusion out there.

Deborah: Right.

Dr. Kleinman: A lot of confusion, actually, amongst doctors. The main focus of palliative care is on getting a cure and controlling the symptoms of your illness and the quality of your life, whereas hospice is for when a patient is clearly dying and we don't expect them to live beyond six months, and so we switch from a focus on cure to a focus on the quality of the days that remain.

Deborah: That's a huge difference.

Dr. Kleinman: It's a big difference, and it's especially important in hospice to focus on the quality of those days with regards to the symptoms that people have. I can give you an example.

Deborah: Please.

Dr. Kleinman: I have a patient who has a type of cancer that is spreading, unfortunately. We know that she can get chemotherapy and radiation therapy and that there's a possibility of a cure. So while she's going through those treatments and seeing her oncologist and her radiation oncologist, she's also seeing me—I'm a palliative care physician—and I'm focusing on the symptoms that she's having. For example, after her treatments, she tends to get nausea. A part of her disease has spread to some of her bone areas, and so she has pain there. So I'm treating with medications that treat those conditions. I have a similar patient who, unfortunately, her prognosis is much worse. She has transitioned from palliative care to hospice care. She's no longer receiving chemotherapy, and she's chosen to stop her radiation therapy. We're focusing on issues like—and these are tough issues and tough things to hear about—but issues like where do you want to die. In her case, it's very important to her that she doesn't die in a hospital setting, that she doesn't end up in the ICU. So that's one of her what we call "goals." It's important for her to actually attend a wedding that's three months down the road, so we're making sure that the medicines that we're using aren't creating an overly sedated situation around that time, where she wouldn't be able to enjoy the wedding.

Deborah: I see. Okay. It's more for her comfort.

Dr. Kleinman: Yes, it's comfort. The other good thing about hospice is when you're enrolled in hospice, there's a team approach. So not only is there a physician like myself, but there are chaplains and social workers and aids and nurses and home health people that come by and help with everything, from making sure that medications are delivered and taken properly to making sure the person's comfortable at home, to getting hospital beds and supplies. So you get this really huge team. The team approach is very, very important. It sounds a little bit odd to hear, but we now know that when patients enroll in hospice—and this is odd—they tend to actually live a little bit longer than were they to have the same disease and not enroll in hospice.

Deborah: I would absolutely echo that, because I've had three family members in the last three years go through hospice, and I have to say, it is the most wonderful, comforting thing for the person and for the family.

Dr. Kleinman: The thing that we think is responsible for some patients living a little bit longer—and certainly having a better quality of life of the days that remain—is this team approach. So you can see how the close attention that team members will pay can help. So, when people are involved in hospice, they get visitors every week. At a minimum, somebody comes by and frequently, more often than that, there's a lot of attention paid to the family as well. So it's really a family-centered approach.

Deborah: I think it's really the most wonderful thing. It really includes the family in the team.

Dr. Kleinman: Right, yes, the family members. In this case that I'm talking to you about, her husband is very, very involved, and of course he's having his own emotional difficulties, as you'd expect. So he gets to talk to somebody as well. There's support there. And the support after the person passes away, we call it bereavement support. We have counselors and social workers who were especially trained in bereavement support. That's part of this as well.

Deborah: Doctor, why do you think there's an increase in interest in palliative care by both patients and doctors?

Dr. Kleinman: I think it's coming from a couple of different sources. First and foremost, I think that palliative care is just becoming better known to the population at large. So we're hearing stories about patients and friends and colleagues who have been enrolled in palliative care, and we're hearing how they did better compared to folks that weren't exposed to palliative care. I think there's this groundswell for patients who are seriously ill who realize that this is something that they can use and it can help them.
Physicians, as well, I think physicians now are seeing their patients being enrolled in palliative care, and they're seeing the difference as well. The other issue I think is really more of a social issue that, in our country, especially, we're just not very comfortable talking about death and talking about dying. That includes all of us—physicians, patients, everybody alike—has challenges talking about those issues. But I think that's changing as our population is aging, as we are needing to have more conversations. These death-and-dying discussions, there's more commonplace. We're seeing some social movements, actually, that are aimed at making this conversation easier. One in particular is called the Conversation Project. People can find that. They just google "Conversation Project." It's an excellent, excellent idea. The idea is to have a kitchen table discussion with your loved one who has a serious illness about what their wishes are.

Deborah: Right.

Dr. Kleinman: It is a series of questions, and they're well thought out, and it guides the conversation.

Deborah: I think everybody should do this with every member of their family over the age of what, 21?

Dr. Kleinman: The Conversation Project is aimed at people with serious illness, and the questions are really for people with serious illnesses and have to think about this kind of thing. But it doesn't mean that anybody at any age can't have the conversation. It opens up the door to discussions around advanced directives and wishes and what do you want when you have a serious illness, what do you want to focus on, what are your goals, what's important to you, where do you want to receive your care.

Deborah: What sorts of illnesses are treated by palliative care?

Dr. Kleinman: Many different illnesses. Most people still think of palliative care as for people who are dying. That's really hospice, and hospice, by the way, is a subset of palliative care. But anyone with a serious illness can receive palliative care. I think I could best describe this with another example. I have a patient who has what's called congestive heart failure. His heart is not pumping out very well. He gets tired. He gets low energy. He's short of breath at times. But he's not what we call hospice-appropriate because we would be very surprised if he passed away in six months. He doesn't seem like he will be good for hospice. But he can receive palliative care, where our focus is how do we help you control your symptoms. How do we make it so that you can go to the supermarket, or go shopping, or go for walks without feeling short of breath that you can't do these things? What medicines can we use? What aids, what devices can we get you in your home to help with this? So, that someone who has congestive heart failure, same type of scenario patients who have COPD or emphysema. They benefit from palliative care as well.

Deborah: I can see the benefits. Now, where is the palliative care delivered?

Dr. Kleinman: Palliative care is delivered anywhere the patient is. For example, it could be in an office setting. If you're seeing your cardiologist or you're seeing your family doctor or your pulmonologist, you can ask for a palliative care counsel. They'll refer you to a physician or a nurse practitioner, somebody with expertise in the area, and you can go and get a visit or consult. That's an office-based approach. Palliative care can be delivered in the house as well. We have patients who have heart failure, for example, or emphysema, and it's very hard for them to get to the physician's office. We don't think that they're appropriate for hospice, but they're appropriate for palliative care. So we have teams that can go to the home and deliver palliative care. So, any setting where a patient with a serious illness is, where we want to focus on the goals of care and expert management of the symptoms.

Deborah: That's a beautiful thing. How can people find out more about palliative care, because we have less than a minute, unfortunately?

Dr. Kleinman:   Well, what I would do is use the Internet and Google "palliative care," and a lot of really, really good sites will come up. A good place to use is called palliativedoctors.org. That's where you'll find a way to get local resources. You can always call me, Dr. Kleinman, and you can find me online as well.

Deborah:   Wonderful. Thank you so much, Dr. Kleinman. It's been so informative to have you on the program. Listen to the podcast, or for more info, please visit memorialcare.org. I'm Deborah Howell. This has been your Weekly Dose of Wellness. Have a great day.