Transcription:
What is Palliative Care?

Melanie Cole (Host): A chronic illness or life-threatening health condition can present an array of tough questions and challenges. Palliative care can relieve symptoms of a disease while maintaining the highest possible quality of life for the patients. My guests today are Dr. Kirti Joseph, she’s a palliative care physician and a member of the St. Luke’s Cornwall Medical Group and Sue Martino; she’s a nurse practitioner with St. Luke’s Cornwall Hospital. Ladies let’s just start with a definition, Dr. Joseph I’ll start with you. Tell us what palliative medicine is and give us a little bit of the evolution of how this came about.

Kirti Joseph, MD (Guest): Hi Melanie. Thank you for having me today. I am very honored to be talking to you. So, palliative medicine is actually something that is very important today. more and more people are dealing with chronic and advanced illnesses. They are living longer but that doesn’t mean that they are living a good full life, and that’s where palliative care comes in. it’s for patients that might be going through cancer or heart failure or renal disease and they feel that they have a lot of symptoms like pain or shortness of breath or nausea and vomiting and also part of – there are social problems. These are people that are bikers or hunters, or they used to fish a lot that now they don’t have the ability to go out and do these things anymore. And that is sort of where palliative care comes in with a multidisciplinary approach. It usually involves a clinician; a social worker and we have referrals to resources for psychologist or people that can really help you live a full live when you are dealing with treating these chronic advancing illnesses. As we all know, hospice is a very, very well-known concept. Hospice is something that has been there for a lot longer and they found that unfortunately hospice is something that is only offered to people once they decide to stop treatment. But hospice is a very, very effective and important aspect of treatment. So, we found that the whole reason that palliative care came about; one of the first fellowships actually happened in the 1980s for palliative care and the purpose of that was to extend that same service that hospice provides to patients that are also undergoing treatment for chronic illnesses.

Melanie: Sue, next question to you as Dr. Joseph mentioned hospice care; one of the most common questions people have are myths or misconceptions surrounding palliative care, is it just another term for hospice or end of life care. Is it used for non-terminal patients more often than not? And give us a good definition of hospice care versus palliative care.

Sue Martino, NP (Guest): Sure Melanie. And it is a very common question and it is a very common misconception. Hospice care is employed in the care plan of a patient who has stopped aggressive treatments because there is no benefit at that time in life. So, in other words, chemotherapy is not effective. Radiation or surgery or sometimes even dialysis may not be effective in improving this patient’s condition. So, hospice is employed. It is a six-month benefit which can be extended if needed, but it is for patients who are stopping invasive and aggressive measures and are now being treated for their symptoms. So, that means that we look at these patients and we look at their pain, we look at their difficulty in breathing, their perhaps nausea and vomiting, confusion, agitation and we treat them based on those symptoms. We are not looking for a diagnosis. We are not looking to do bloodwork or scans or x-rays unless absolutely necessary and we include the families in this care plan to help support the patient at end of life. On the other side of that coin is palliative care in which we also get involved with symptom management, but we are doing it in the context of aggressive measures. So, when a patient is on palliative care, they can receive x-rays and surgeries and transfusions and IVs and antibiotics and all kinds of aggressive measures because we do feel that this is a situation or a condition that can show improvement and the patient’s quality of life will be better. So, that’s the basic difference. Palliative care during treatment, hospice when treatment is no longer going to make a big difference.

Melanie: Dr. Joseph, you mentioned a multidisciplinary approach to palliative care. Tell us about who is involved and actually what is it that palliative care entails? Is it medicational? Are there any interventions, procedural interventions? Explain a little bit about who is involved and what they are doing.  

Dr. Joseph: Absolutely. So, in our hospital at St. Luke’s what we have here is there is myself, I’m a physician. We have Sue Martino who is a nurse practitioner who has had extensive experience in ICU settings, in hospice settings and she was the one that actually started the palliative care program at this hospital. And we now were able to also add a social worker who also has a lot of experience with providing counseling for family members and children of patients that have passed on or that have been dealing with chronic issues. And we do have at hand chaplain services available. So, at palliative care, what do we do, what does palliative care mean? We do not do any procedures. But what we mainly provide are medications. Medications to help with symptoms, complex pain symptoms. You know this is not just pain that goes away with Tylenol or Advil. A lot of times our patients with all these chronic illnesses have very, very complex pain. We work with opiates, we work with – I’m certified in medical marijuana. We work with antidepressants and neuropathic pain agents to help with these complex pain and symptoms that patients are having. It’s not just pain. A lot of our COPD and CHF patients also have really, really bad shortness of breath and that’s the most limiting thing that they often encounter in their lives. So, medications to help with that. Medications to help with sleep where a lot of our dementia patients have sundowning and agitation symptoms at nighttime. So, these are the different types of – these are just examples of some of the symptoms that we help with medications.

The other thing that we do is time devoted to intensive family meetings and patient and family counseling. Remember that when somebody has a chronic or advanced illness, it’s not just the patient that’s going through this; it’s their entire family and their loved ones. So, we – and a lot of times more often than not, somebody goes into see their doctor and they come out and they feel like they don’t know – they didn’t understand anything that was just told to them. So, we have the time to devote to these intensive family meetings to go over with them everything that was just discussed and everything about their illness and imaging results or whatever they may have had. Communication and support for involving patient, family and physician questions concerning the goals of care and of course coordination of care, transition across healthcare settings. So, one of the things to really remember is that we don’t just work independently. We work very, very closely with that patient’s primary care provider or that patient’s oncologist or that patient’s nephrologist whatever the primary problem is that that patient may be facing; we work very closely with that physician as well. And what we find is that it’s not just for the patient; it’s actually pretty satisfying for that provider as well to have an extra layer of support provided to their patient and their families.

Melanie: Sue can someone get palliative care even if they are homebound or at home and does insurance cover palliative care?

Sue: Palliative care does not get reimbursed at home as a specialty. It gets reimbursed for the home care portion as any other diagnosis would get. So, insurance will cover that patient at home in terms of giving them support through homecare agencies whether that’s a nurse’s aid that might be able to go over and help the patient get washed up or have something to eat, a visiting nurse who could go over. The difference being Melanie is that that plan of care is communicated with the home care agency to say this is a palliative care focus. So, if I were to go to the patient’s house; I could bill as a doctor’s visit, but- and that would be covered by insurance, but the homecare itself, is under the generalized homecare that you would receive automatically.

Melanie: So, that’s very understandable and I’m glad that you cleared that up for people. So, Dr. Joseph, let’s wrap this up. How does somebody find a palliative care specialist such as yourself? You mentioned referral at the very beginning. Is this only on referral basis? You also mentioned that they can keep their own primary care physician, you work with their oncologist or their physician. So how do they find palliative care? What’s the first step families should do?

Dr. Joseph: Absolutely, that’s a great question. So, yes, I mean it is a referral-based system. So, you can absolutely ask your primary care physicians about it to see if they know of any palliative care providers. As far as I know, Sue and I, we provide outpatient at Cornwall Services at Cornwall, but definitely you can ask your primary care provider about referral to palliative care. I actually once had a patient that was seeing an oncologist in Goshen and he happened to go online because he knew what palliative care was and since he wanted to get palliative care services; he was an advanced pancreatic cancer patient that was getting chemotherapy but also had horrible nausea, vomiting and pain and he just Googled the closest palliative care doctors and that’s how he found me and he called me and he came to see me and we really were able to help him out quite a bit. He was able to go to Orlando to see Harry Potter World and that was his goal. So, that’s another way you can always Google online and find palliative care providers.

Sue: And I would like to add that sometimes also if you look under the website of your local hospital; they may have services offered and a lot of times palliative care service is listed there, and you can contact them.

Melanie: Sue, wrap it up for us what you want people to know. When you get asked everyday about palliative care and oh does it – is it hospice care, is it end of life, what’s the difference? Wrap it all up for us with your best advice for families seeking relief from painful conditions and palliative care.

Sue: I think that’s a great way to end this. The palliative care department is there to help support the quality of life for patients and their families. We don’t just focus on the patients, we include the families with support and education and we are the bridge between symptoms and sometimes very, very technical terminology that patients are getting given by their physicians. There are lots and lots of specialists in the world now, that’s what medicine has come to. We are focused on every system having its own doctor and sometimes it’s difficult to put that all together and understand is that getting better or is that not because this doctor says one thing and that doctor says another. Palliative care can put that in perspective, can support the symptoms that may go along with treatments like chemotherapy side effects for example and be able to keep a plan of care focused. Palliative care becomes more of a common term. People will get to understand, and we will continue to explain. Palliative care during active treatment, hospice during end of life. And they are both very, very intense moments in people’s conditions and their illnesses and we are trained to do both of those things.

Melanie: Thank you so much ladies for joining us today and sharing your expertise about the difference between palliative and hospice care. People don’t understand the differences. You have cleared it up so very well. And thank you for all the great work that you are doing. This is Doc Talk presented by St. Luke’s Cornwall Hospital. For more information please visit www.stlukescornwallhospital.org, that’s www.stlukescornwallhospital.org. I’m Melanie Cole. Thanks so much for listening.