An extra layer of care

Every day, physicians at Enloe Medical Center see patients with chronic illnesses. The conditions may not be considered life-threatening, but they aren’t cured in a single visit to a clinic or hospital ward.

These patients are candidates for palliative care, also known as supportive care. They don’t need to give up their physician or treatments; rather, they gain a physician, a nurse-practitioner or both who are trained in providing medication and therapies that complement the treatment already being received.

Enloe launched its new Supportive and Palliative Care Service on Aug. 13, with the humble goal of serving two patients a week. In just the first two weeks, eight patients got referrals.

“We’re already blowing our predicted consultation numbers out of the water,” said Dr. Marcia Nelson, Enloe’s vice president of medical affairs and the administrative driving force behind the program. “That just shows there truly is a need for practitioners to spend extra time with patients and help them direct their care.”

Communication is a major component of palliative medicine. Dr. Samuel Brown, director of the palliative-care program, and his nurse practitioner, Lori Philips, meet extensively with patients and family members to ascertain specific needs and collaboratively coordinate treatment plans.

Brown is used to listening—he’s a psychiatrist who’s been serving as medical director of Enloe Behavioral Health. He previously spent 12 years as medical director of a hospice program, providing palliative care for terminally ill patients in the final months of their lives.

“Palliative care actually modified, and is an extension of, hospice,” Brown explained. “A unique thing about hospice is its holistic approach. … It became obvious that people with chronic illnesses who weren’t dying of them still would benefit from this approach.”

The word palliative, he continued, comes from the Latin word “pallium”—a coat or cloak. “It’s protective,” Brown said. “[Palliative care] protects patients from the ravages of illness.”

Patients who receive palliative care may have cancer in which their life expectancy goes beyond six months. They may have heart or lung conditions. They may have gastroenterological issues, urological disease or back trouble.

“I define palliative care the way patients have found it most easy to understand,” said Nelson, citing research into the subject. “It’s specialized medicine that focuses on relieving the symptoms, pain and stress of serious illness. The differentiator [from hospice]: It’s appropriate at any age and any stage of an illness.”

Palliative-care practitioners seek to help patients in four areas:

• Symptoms—managing pain and discomfort. “We focus on treating these symptoms to maintain quality of life,” Brown said.

• Psychosocial issues—the psychological concerns of the patient as well as his/her immediate relatives. “We see illness as affecting the whole family unit,” Brown said, “so we want to explore the effect on all family members.”

• Spiritual/existential issues—how the condition and treatments mesh with the patient’s personal beliefs. Not everyone follows an organized religion, Brown said, but “everybody wants to leave a footprint in the sand and a legacy, so everyone has existential issues.”

• Realistic goals—ensuring patients’ expectations are “consistent with their illness.”

Beyond these, there is no set checklist Brown uses when meeting with patients and families. The conversations are organic and may take place over several consultations.

“I recently saw a young woman in her 20s with a chronic illness—the issues she has are different than someone who is 82 with metastatic cancer,” Brown said. “We don’t go in with a cookie cutter, we don’t go in with a fill-in-the-blanks [form], but there are background things we want to corral.”

Palliative care isn’t brand new at Enloe. The medical center launched a program in 2005, but it folded after a year.

“The need was there,” Nelson said, “but the timing wasn’t right. The administrative support wasn’t there.”

Still, she said, “the medical staff continued to remember when palliative care was available.” Hospital-based physicians kept the conversation alive, and in 2010, with the support of new administrators, she embarked on re-establishing the supportive service.

The timing coincided with Nelson’s pursuit of a master’s degree in medical management. This would be her thesis project.

“She put all the pieces together and got the stakeholders [the CEO, the board and hospital departments] to back us up,” Brown said.

Laying the groundwork took about a year. Now Brown, Philips and nurse manager Gail Cunha have the service up and running.

“We’re busier than we expected to be,” Brown said. “To have this other layer of care, to be able to spend a couple hours with that family to make a palliative-care consultation, ultimately improves the quality of care.”

It also makes fiscal sense. Both Brown and Nelson explained that readmitting a patient for the same chronic condition requires more tests and treatment than managing the chronic illness.

Nelson stressed that palliative care is not about rationing care—it’s about focusing care. “It’s about listening to patients and hearing what’s most important to them,” she continued. “When you do that, you can create patient-directed treatment plans that are less expensive and deliver better care.”

Again, the process doesn’t take physicians out of the loop. Palliative care simply increases the size of the treatment team.

“What we want is an informed patient,” Brown said. “We educate patients, and they can make an informed decision about what treatments we want to pursue and what treatments we don’t.”

In the end, Nelson explained, “We have good resources for patients. Sometimes it just takes an extra amount of time to understand what the patient needs.”