Palliative Care Policy: Priorities, Challenges & Implementation

Introduction: Why Palliative Care Was Chosen as a Policy Priority

According to the report released as part of National Priorities and Goals: Aligning Our Efforts to Transform America's Healthcare (NQF, 2009; Partnership, 2008), the National Priorities Partnership (NPP) identified six priorities that, if addressed, could improve the quality of health care delivered to U.S. citizens. The NPP consists of 48 major U.S. health care organizations working in collaboration with the National Quality Forum (NQF) to identify and advance priorities aimed at improving health care in the future (NQF, 2009). Among these six priorities, the NPP has identified palliative care as one that can help improve patient-centered utilization outcomes. This policy discussion provides background to help identify steps that assist in matching medical treatment to the objectives of patients and their families, with particular attention to access to quality hospice services and palliative care (Meier, 2011).

Enhancing the Value of Health Care

The value of health care refers to the ratio of quality to cost. Value can be improved by reducing cost while simultaneously improving quality. People with multiple functional impairments and chronic conditions constitute approximately 10% of patients in the United States, yet account for more than half of all health care costs (Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, and The Lewin Group, 2010). Hospital-based palliative care programs are evolving (Goldsmith, Dietrich, Du, & Morrison, 2008) and have increased their value by reducing the cost of care for seriously ill patients and those suffering from complex conditions. Hospices certified under Medicare serve over 1.5 million dying Americans every year. Hospice programs and palliative care are therefore crucial to improving health care value through their ability to improve quality of care and reduce overall system costs.

Improving the Quality of Care

Palliative care and hospice programs are designed to improve the psychological and physical symptoms experienced by patients and family caregivers, improve bereavement outcomes, and ensure patient satisfaction. These goals are achieved through care provided by nurses, social workers, spiritual counselors, psychologists, aides, pharmacists, and physicians. Palliative care and hospice teams are charged with establishing goals and plans for safe transitions out of health care facilities and supporting families in crisis.

Proper communication about a patient's prognosis and care goals across all team members ensures better decision-making and consistent follow-up. Family-level discussions lower costs and reduce burden on the family (Wright et al., 2010), reduce dissatisfaction, and improve bereavement outcomes. Recent studies have demonstrated that both palliative and hospice care are associated with significant prolongation of patient life (Bakitas et al., 2009; Connor, Pyenson, Fitch, Spence, & Iwasaki, 2007).

Relevance to Nursing and the Health Profession

A national audit of hospital deaths revealed that 25% of patients need not have died in a hospital setting if adequate community resources were in place. Without hospice beds or community support, however, many families have few choices even when a patient's condition deteriorates (Hospice Friendly Hospitals Programme, 2010). This situation places heavy demands on emergency departments, bed utilization, and discharge rates.

For example, Milford Care Center has been able to reduce in-hospital death rates by 6%. At the national level, palliative care has reduced the proportion of deaths occurring in hospitals from 43% to 21%, and increased the proportion of deaths occurring at home from 26% to 42%. Studies conducted in the United States, Canada, and Spain have demonstrated that palliative care has a positive impact on the cost of acute care (Irish Hospice Foundation, 2014). These findings indicate that the development of palliative care programs benefits both patients and the health care system by reducing costs associated with prolonged hospital stays.

Financial Impact and Ethical Foundations

Financial Impact on the Community and Organizations

According to recent statistics (Morrison et al., 2008), palliative care has generated savings of $2,659 per patient. In the United States, approximately 2% of the 30 million people hospitalized annually die in the hospital (AHRQ, 2002). This figure includes the 4% of patients discharged with chronic illness who may still benefit from palliative care services. Data from 2009 indicates that all U.S. hospitals with more than 50 beds have established palliative care centers (Goldsmith et al., 2008). These centers affect more than 1.5% of all discharges and are estimated to save over $1.2 billion annually.

The Impact of Values on the Policy Issue

Care is considered a core value in both personal life and professional practice. Hospital palliative services have grown in significance precisely because they provide needed care even when medicine cannot offer a cure. Patients deserve quality health care during illness, and hospitals are therefore obligated to offer such programs in accordance with the principles of non-maleficence and beneficence. Clinicians must always work to relieve pain and improve the quality of life of their patients to the best of their abilities (Paulus, 2008).

Ethics and the Principles of Care

The ethics of care theory places particular importance on the elements of relationship and human interdependence. It seeks to maintain relationships by promoting the well-being of both caregivers and care receivers, and is anchored in the motivation to care for those who are vulnerable or dependent. Care ethics affirms the importance of caring, moral deliberation, and practical reasoning (Sander-Staudt, 2015). Meeting one's own needs and the needs of others is central to this ethical framework.