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How Can Advance Care Planning and Palliative Care Work More Collaboratively?

Tuesday, September 21, 2021

Advance care planning, goals-of-care conversations, clarification of medical prospects, expression of preferences for current and future treatment, promotion of patient autonomy and self-determination – all of these are essential outcomes for palliative care. Palliative care is a multidisciplinary medical specialty that focuses on relieving symptoms of serious illness, reducing stress, enhancing coping, and improving quality of life for the patient and for loved ones. But it all starts with talking about goals of care.

An advance care planning service like Iris Healthcare, although it does not  deliver symptom management, works hard to help people clarify and sort out their preferences for care with the participation of any family members who want to join the conversation. These dialogues are conducted with trained counselors using videoconferencing technologies such as Zoom or Teams.

A conventional palliative care service typically sends members of its multidisciplinary team of specialists, physician, nurse, social worker, spiritual care professionals to the patient’s bedside to clarify needs, preferences and concerns. That can happen in the hospital, in the patient’s home or in other settings.

Increasingly, a variety of programs are emerging to do at least some of this kind of work from a distance, via telephone or Zoom. However, some essential palliative care services, whether prescribing an opioid for pain management or providing a bed bath for a bedbound patient, may not be possible from afar.

How can these complementary, philosophically compatible, sometimes even overlapping services of advance care planning and palliative care be linked up, coordinated, and made to share information about their respective patients? And what would be the benefit for those who have responsibility for the care of relevant populations?

“We have a serious workforce shortage right now in palliative care, and that’s not projected to change significantly anytime soon,” says Stephen Bekanich, MD, a board-certified palliative care physician who provides consultations in Austin, Texas. There aren’t enough trained, credentialed, skilled palliative care specialists to go around, while growing awareness of this new specialty in recent years has caused demand to skyrocket. Dr. Bekanich, Chief Medical Officer of Iris Healthcare, says that in his dual capacity he has a good view of the needs, the opportunities and the challenges of harmonizing these two types of service.

What if a service such as Iris’s advance care planning could be effectively linked to palliative care providers in the community? Much of the initial work of goals clarification and enhanced understanding of the patient’s condition, prospects and preferred treatment priorities would be well underway before palliative care even gets involved. Counselors might conduct an initial screening of whether a palliative care referral for more specific professional interventions to address the patient’s medical and other needs is appropriate at this time, while at the same time weeding out false positives that don’t need this level of intervention. 

Iris counselors could then, in consultation with the patient’s physician, offer a referral to a partnering palliative care service, sharing with permission what has already been discussed and agreed to by the patient. With the patient’s preferences and values already gleaned, the palliative care team could hit the ground running, much of its initial information-gathering agenda with the patient already completed, thereby utilizing the team’s scarce resources more efficiently.

Iris has already tapped into directories of palliative care services nationwide, through collaborative partnerships. “But I struggle to find palliative care services that say they are able to meet all the needs of our target populations within their service area in a timely manner,” Dr. Bekanich says.

Not all organizations calling themselves palliative care employ the full multidisciplinary team or address patients’ medical needs. Others are so overbooked that it might take weeks for them to link up with a referred patient – rather than the 24-hour response time that such patients really need. “There are some markets where I can’t find any palliative care providers with which to partner,” he says.

“But that’s where an advance care planning service such as ours, which can more easily scale up in response to need and see clients further upstream in their clinical pathway, could really help to maximize the reach of a busy palliative care service. It might be years before the patient even needs palliative care, but when patients and families have a better understanding of what lies ahead and how they want to relate to it, it’s more likely that the palliative care service would get utilized in the best way,” Dr. Bekanich says.

The Iris team could look for triggers of when a palliative care referral might be timely – such as increasing symptoms or hospital and emergency room utilization. The patient may have a serious diagnosis but hasn’t yet show significant symptom needs. But there still is a lot to talk about. Advance care planning can be a softer landing into palliative care, in addition to making more efficient use of the respective resources, he says.

A growing number of health plans, accountable care organizations, physician groups and integrated delivery systems are coming to recognize the value of palliative care and of organized advance care planning, Dr. Bekanich says. “They say they have tried to connect with traditional palliative care services but they haven’t been able to scale up to cover the needs of the covered population.” How can these kinds of services be better integrated and mobilized in response to the need?

“We have plenty of examples of phenomenal palliative care programs that are incredibly effective in matching patient preferences, values and symptom management needs with interventions that could help them live well with serious illness, with more autonomy and more functional ability,” he says. “There is a lot of room to grow this palliative care network and enhance the connections and communications.” 

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