The COVID-19 crisis focused the world’s attention on the frail elderly and people suffering from chronic illnesses. The majority of the hospitalizations and deaths during the crisis occurred in these most vulnerable groups. Infection with COVID-19 meant that these individuals would be taken away from their homes and would possibly die in the hospital. Death in the hospital continues to occur for the majority of Americans despite the fact that surveys consistently show that over 80% of individuals would prefer to die at home.
It does not need to be this way. Many elderly and chronically ill could be treated at home as well, particularly because doing so would help prevent the spread of the virus. For many such patients, care of COVID-19 infections could be integrated into the model of palliative care. Understanding what this model would look like begins with clarifying the definition of palliative care and understanding how it differs from hospice care.
What is Palliative Care?
Palliative care is a holistic approach to medical care whose ultimate goal is the relief of suffering. By contrast, hospice care begins when curative treatments end. Patients receiving palliative care are treated with antibiotics for infections and even with chemotherapeutic agents for cancers. The word “palliative” has acquired negative connotations, as in the context of surgery that is meant to be palliative (i.e., to relieve symptoms) as opposed to cure disease by (for example) removing an entire tumor. However, palliative care is as therapeutic as any type of curative therapy. In many ways, palliative care is synonymous with holistic care.
Palliative care aims to relieve the social, spiritual, and emotional consequences of illness as well. In short, palliative care treats the patient, not the disease. According to this definition, one could argue that all of healthcare should be palliative care. Specialization in medicine has made this virtually impossible. For example, emergency physicians and orthopedic surgeons are not trained to practice palliative or holistic care, and neither should they. These physicians can, however, communicate with a patient’s palliative care team. The insights they receive from these communications almost certainly result in delivery of better care.
Location, Location, Location
Palliative care is necessarily multi-disciplinary in nature. It requires cooperation among primary care physicians, specialists, nurses, and even clergy. Because the well-being of the patient is paramount, the location where palliative care takes place is critically important.
Palliative care frequently begins in an acute care hospital, although it can begin in a long-term care facility or the outpatient clinic setting as well. Nevertheless, because the focus of palliative care is the well-being of the patient, its ideal location is the patient’s home.
One of the major goals of palliative care at home is to counteract medicine’s decades-old tendency to over-medicalize serious chronic illnesses. As paradoxical as that sounds, it makes perfect sense to a chronically-ill individual whose self-image is not necessarily defined by their illness. They see themselves as people first, and as sick people somewhere down the list of self-definitions. Overtreatment of medical conditions can lead to serious medication side effects, unneeded medical testing and undue patient suffering. An individual with a chronic disease who is cared for in familiar surroundings such as a home is more likely to feel like a person and less like a patient.
Paying for Palliative Care
Because this type of care often begins in acute care hospitals, palliative care is typically reimbursed by Medicare and commercial insurers. Continued reimbursement for care out of the hospital will depend on demonstrating to governments and policy makers the benefits of palliative care: substantial decreases in numbers of days of spent in the intensive care unit and excellent outcomes during the three months post-discharge, including substantial reductions in hospital readmissions.
Integration with Hospice Care
Although palliative and hospice models of care differ and they have different goals, these two models can be integrated with one another. Hospice care specializes in caring for patients during the final 6 months of their lives. Palliative care can ease the transition into hospice care, without imposing stress on a patient by moving them from one facility to another. In fact, care can transition seamlessly with the patient remaining at home.
Acute Care in the Post-Covid 19 World
If the palliative care paradigm were to take hold, it would not necessarily mean the end of the acute care hospital. To the contrary, there will always be a level of care that can only be delivered in the specialized facilities that hospitals provide. One of the unintended consequences of the Covid-19 crisis is that it provided a glimpse of what acute care hospitals might look like if palliative care at home were to become the standard. There would be many fewer admissions, and emergency rooms would be much quieter. Many of the “worried well” admitted for observation would be taken care of at home by their palliative care teams.
The phenomenon of the “social admission” would disappear. These admissions to acute care hospitals occur when a patient’s social determinants of health have deteriorated to the point that they must be admitted to inpatient units because caregivers judge that the patient cannot care for themselves at home and has no friends or family to support them.
The Covid-19 pandemic created an opportunity for substantial positive change in the way healthcare is delivered. The crisis demonstrated the potential of telemedicine in general and care at home in particular.