Talking About Treatment Options and Palliative Care: A Guide for Clinicians

At Time of Diagnosis: Begin to Understand Your Patient’s Priorities and Goals
When patients first learn that they have a potentially life-limiting illness their focus is on curing the disease. However, there are opportunities as an initial plan of care is developed to discuss the benefits of advance care planning and the differences between curative and palliative care. Introducing the concept of palliative care as care focused on alleviating symptoms even as you work to cure the illness will allow you to continue referencing palliation of symptoms, optimizing functional capacities, and the importance of psychosocial support for the patient and the family.

The following questions, when introduced during a conversation about treatment options can provide clinicians with information about what is important to the patient. Simply asking one or two of these questions can lead to future discussions about palliative care and present the patient with an opportunity to explore the topic with you when they are ready.

• As we think about treatment options, what is one thing about you that you think is important to share with me?
• What is your biggest fear when you think about your diagnosis?
• What is your biggest fear about the treatments we have discussed?
• What does quality of life mean to you?
• As things progress, how much do you want to know about your disease and all the various treatment options?
• With whom do you want me to share information, and how much?

When Treatment May Not Be Working: Exploring End-of-Life Options
At some point, it may become apparent that continued treatments are not likely to offer any specific therapeutic benefit for your patient. One question that is often used to frame a discussion about ending curative treatment protocols is “Would you be surprised if your patient died in the next six to twelve months?” If the answer is no, it may be time to begin the transition away from treatments with curative intent and emphasize beneficial disease modifying therapies and palliative care.

In addition to the questions listed above, the following can help you begin/continue the dialogue with your patient.

• Are you comfortable?
• Do you feel that any of your treatments are causing you more harm than good?
• Do you feel like you have good “quality of life” right now?
• If we could do one thing, other than cure your illness, to bring you quality of life, what do you think it would be?
• Let’s talk again about how much information you want to have about your disease.
  

Explaining Treatment Options
Sometimes “the way we’ve always done it” is not always the most effective way to communicate with patients. The goal is to make sure you are “heard” by patients, that they understand their options, and that they are able to make choices about end-of-life care that meets their individual needs.

Here are some new approaches, offered in counterpoint to some of the more traditional ways of communicating
with patients.

Understanding Your Patient’s Needs: Responding to Patient/Caregiver Inquiries
Listening to what your patient is saying or not saying is a crucial part to understanding their needs. Questions a patient may ask you are listed below, along with what they might be thinking and truly wanting to know.

This guide was developed to help clinicians explore with patients and caregivers wishes, hopes and fears about their care so that patient preferences, based upon realistic expectations, can be the foundation of treatment decisions. These decisions often require redefining hope: hope for an optimized quality of life, as defined by the patient.

Understand Physician Reimbursement When Patients Receive Hospice Care

Depending on your relationship with your local hospice and the individual patient receiving hospice care, you can receive reimbursement. Call your local hospice if you have any questions about which “type of physician” you are.

Attending physician, non-employee: The patient designates the physician primarily responsible for his/her care during the election process.
Attending physician, employee: If the attending is an employee of the hospice or volunteers with the hospice (e.g., as medical director or physician member of the interdisciplinary group) the physician’s professional services are billed to Medicare Part A by the hospice.
Consulting Physician: Any physician services other than those rendered by the attending physician are classified as consulting physician services.
Administrative Services: Include participating in the establishment, review and updating of the plan of care, supervising care and services, and establishing governing policies (physician member of IDG).
Professional Services: Actual procedures and billable care plan oversight services performed by the physician as designated by the appropriate CPT-4 code. These include physician consultation, physician interpretation of an x-ray, CT scan, or MRI, or physician interpretation of a laboratory test.
Technical Services: Include lab, x-rays, and any other non-professional services performed by the physician or other health care professional.