VCU news

By Lorraine Cichowski and Thomas Smith

RICHMOND, Va. – Caring for seriously ill patients, including those near the end of their lives, in a hospital-based, specialty palliative care unit could reduce costs dramatically while, at the same time, provide more appropriate care to patients in their final days, according to a provocative new study by Virginia Commonwealth University. 

The research, the first of its kind to compare the cost of a hospital’s palliative care unit with the cost of caring for seriously and terminally ill patients in a regular hospital setting, makes a strong case for treating patients with complex medical conditions in a specialty hospital unit. The study is published in the October issue of the Journal of Palliative Medicine.

“End-of-life care suffers from lack of quality care and high costs,” says Thomas J. Smith, M.D., chair of VCU’s Division of Hematology/Oncology and an expert in the growing medical specialty known as palliative care, which focuses on the relief of pain, symptoms and the stress of the most serious and complex illnesses. Smith was the lead author of the article.

“But medically appropriate care and caring for people at the end-of-life can be done effectively in the U.S. care system, and we can afford it. It will require medical professionals to be frank about the possible goals of care, develop standard plans based on the evidence and assign only caregivers who are good at palliative care and interested in it,” Smith says. “Patients want to be free of pain, independent and at home, if at all possible. But when patients are hospitalized at the end-of-life, they can receive excellent symptom control in a caring environment. Over 90% of our patients have excellent symptom control and are very pleased with their care. An added benefit is that the total cost of care can be reduced by almost half, which saves society money.”

Smith and his colleagues studied the cost of care for the 237 patients who were admitted to the Thomas Palliative Care Unit between May and December 2000 – the first six months of operation of the specialty care unit, which is located in the VCU Medical Center and operated in conjunction with VCU’s Massey Cancer Center and the Thomas Palliative Care Foundation. The 11-bed unit is staffed by an interdisciplinary team of specialists, including internists, oncologists, pulmonologists, infectious disease experts, nurses, social workers, clergy and administrators, and uses a set of palliative care guidelines for the most common conditions, including pain and delirium.

Of the 237 patients, 52 percent had cancer, and the others suffered from various conditions, including AIDS, vascular diseases and organ failure.

Researchers found that for the 123 patients who were transferred to the Palliative Care Unit from either intensive care units or other units at the VCU Medical Center, charges and costs per day were reduced by 66 percent overall and 74 percent in the case of medications and diagnostic tests when they compared the days prior to a patient’s transfer to the average Palliative Care Unit stay.  In addition, they found, the variation in costs was reduced significantly.

The researchers also compared the charges and costs for the hospitalization of 38 patients who died in the Palliative Care Unit to 38 similar patients who died in other VCU Medical Center units. The daily charges were 59 percent lower -- $2,172 v. $5,304.

Among the 38 patients who died in the Palliative Care Unit, all had chaplain visits offered compared with one-third of the non-Palliative Care Unit patients, Smith noted. In all but one of the non-Palliative Care Unit cases, death was predictable from the admission history, but only one had a hospice discussion, and none had been enrolled in a hospice.

Smith said the study revealed evidence outside the Palliative Care Unit of intensive and expensive interventions in the cases of people who clearly were identified as dying and whose families had accepted the impending death.  Those interventions included expensive antibiotics, tube feedings and planned diagnostic tests such as magnetic resonance.

“Patients who were not transferred to the Palliative Care Unit generally kept those interventions,” Smith said. “The most likely reason is that the attending medical care team did not know how to change care patterns. Sometimes the family or patient is simply not ready to accept the inevitable. A curriculum to teach the skills of defining goals of care and switching from active treatment to palliative care is now available.”

VCU’s Massey Cancer Center recently was chosen as a Palliative Care Leadership Center by the Center to Advance Palliative Care, a national program of the Robert Wood Johnson Foundation. VCU’s palliative care program will teach other cancer centers the optimal way to provide treatment aimed at relieving pain and symptoms as part of state-of-the-art cancer care. 

Palliative care is becoming more important with the aging of the baby boomers and increasingly longer lives, some marked by chronic diseases that last for many years. The other issue is cost; one-eighth of total Medicare expenditures occur in the last month of a patient’s life. According to the American Health Association, 26 percent of academic hospitals and 17 percent of community hospitals now have palliative care services.