BY TONI LAPP
One size does not fit all when it comes to hospice-based palliative care. In fact, the prevailing model of care often fails many elderly patients, says a group of researchers.
That's because older patients typically suffer from multiple chronic illnesses, making an accurate prognosis difficult and leading to either lack of eligibility for or very late entry into hospice.
In fact, palliative care -- care that makes the patient feel better and function better -- should be a priority throughout the aging process, regardless of whether death is imminent, according to family physician Anthony Jerant, M.D., of Sacramento, Calif.
Jerant leads a team of four researchers from the University of California, Davis, School of Medicine who have proposed a new framework for palliative care.
According to the Institute of Medicine and the World Health Organization, palliative care is the active, total care of patients whose disease does not respond to curative care. But in the framework proposed by Jerant's group, palliative care should be offered while curative care is ongoing -- well before the attempt to cure is abandoned and the patient is eligible for hospice.
Jerant's team calls the new framework the "TLC" model. TLC means timely and team-oriented, longitudinal (care evolves as a balance between palliative and curative measures), and collaborative and comprehensive.
"I wouldn't even use the term palliative when initially meeting an older patient," says Jerant, "but would say, 'I want to talk about your symptoms, how you're feeling and functioning.'"
Too often, he adds, physicians offer curative care to the exclusion of palliative care. Part of the blame lies with payment models that delay palliative measures.
But physicians can and should still talk with their elderly patients to determine those patients' goals, says Jerant.
Preliminary results from the study of the TLC model appear in the January/February Annals of Family Medicine, online at http://www.annfammed.org/.
The study participants were not terminally ill and, therefore, they were not hospice candidates, says Jerant. Yet all were approaching the end of life and were found to have unmet palliative needs such as pain, mobility problems, depression and incontinence.
While Jerant concedes it was a fairly small study (data were presented on 50 subjects at two facilities) and the model was used in an assisted-living facility, he says the principles might be adaptable for use in ambulatory care.
A fundamental concept of the model is that palliative care should be a focus of care throughout the aging process, regardless of whether death is imminent.
That's profound, because it would change the way doctors relate to their older patients, says Jerant. It's all about being proactive, he says.
For instance, writing out prescriptions and going over lab results often fill the time for a patient visit. Physicians can miss opportunities to improve that person's quality of life. To avoid repeatedly neglecting palliation, schedule a follow-up visit to talk about what symptoms may be limiting the person's potential, Jerant suggests.
"Most older people get to a point where they perceive that they're nearing the end of life," Jerant says. "We should also talk about that explicitly with elderly patients.
"We can pursue many goals with our medical care; we can't necessarily lengthen life, but we can ask older patients what their main goal is in seeking care -- to live longer or maximize how well they feel."
For an online resource on palliative care, visit http://www.palliativecare-la.org/.
To reach writer Toni Lapp, e-mail tlapp@aafp.org.
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