Who Should Palliative Care See? Diane Meier, Bob Arnold, and Justin Sanders

As Diane Meier remarks to start today’s podcast, palliative care has come a long way from the days when we were the “brink of death” consult. We’re seeing patients earlier and earlier in the course of illness.  In fact, the evidence base for specialist palliative care is arguably stronger in the outpatient setting than the inpatient setting.

In some ways, as Eric remarked, we are a victim of our own success. We’ve pushed on the boundaries of seeing patients earlier in the course of illness, we’ve demonstrated remarkable value to our colleagues and health systems: now they want us to see more and more patients, with conditions we would not have previously considered core to palliative care practice.

Our guests modeled respectful disagreement, and we were somewhat surprised that there was more agreement than we expected.  I’m sure you will all have strong feelings about the opinions expressed, please let us know!

In addition to Diane Meier, we welcome back Bob Arnold and Justin Sanders to talk through these issues, including:

• We agree specialist palliative care is for people with “serious illness” - but what constitutes “serious illness”

• Is a limited prognosis part of the definition of serious illness?  We discuss the Center to Advance Palliative Care definition of palliative care and Amy Kelley’s oft-cited definition of serious illness.  

• Many patients with conditions that overlap with palliative care would benefit from our help, e.g. chronic pain, opioid use disorder, mental illness. Our health system is not meeting their needs.  Should palliative care see them, in the absence of a clear life-limiting illness?

• How limited a prognosis should we consider here - months, years…decades?

• We have a tremendous workforce shortage.  There are not enough specialist palliative care providers to see all patients with advanced cancer, much less the many other conditions whose guidelines now say should include palliative care.  The reality does not match the mission.  Does that change our mission? 

• Should local workforce issues dictate who should see palliative care? See this article by Pelleg in which clinicians at Mt Sinai agreed that patients with serious illness and high risk of mortality should be prioritized, explicitly excluding patients with chronic pain or psychosocial distress in the absence of serious illness.

• What is the role for Patient Reported Outcomes (PROs)? e.g. patients regularly reporting pain or other symptoms and an escalation in symptoms triggering a palliative care intervention. 

• How is the definition of who should see palliative care expanding in Canada, and is there a linkage to who is eligible for medical aid in dying in Canada.  Justin makes a good plug for the McGill National Palliative Care Grand Rounds Programme

• What is our vision for where palliative care should be 10 years from now? Population health specialists, or healing patients one visit at a time? To be sure, these are not mutually exclusive.

• How long should palliative care fellowship be - should we expand it to 3 years so palliative care specialists can care for people with a wider range of conditions?  

• What is Precision Palliative Care? Diane mentions this article by Ramy Sedhom on a couple of occasions.  

• Should palliative care see patients with sickle cell disease? How about survivorship clinics? How about very elderly patients with multiple mild chronic conditions (e.g. mild heart failure, mild COPD, mild cognitive impairment, arthritis, diabetes, hypertension)?

• And much more!

Please listen to the audio only version of Stand by Me - my son Renn added an upright base, snap, and triangle parts - it’s much better than the live version for YouTube that I accidentally started in a much too high key!