Perceptions and utilization of palliative care services in acute care hospitals

Objective: To understand perceptions of palliative care in acute care hospitals and identify barriers to earlier use of palliative care in the illness trajectory. Methods: In Pennsylvania hospitals, we completed semistructured interviews with 131 providers involved in decision making or discharge planning. We used qualitative methods to analyze transcripts. Results: Most interviewees characterized palliative care as end-of-life or hospice care that is initiated after the decision to limit curative treatment is made. Few recognized the role of palliative care in managing symptoms and addressing psychosocial needs of patients with chronic illnesses other than cancer. Interviewees viewed earlier and broader palliative care consultations less in terms of clinical benefits than in terms of cost savings accrued from shorter terminal hospitalizations. In general, they thought nurses were most likely to facilitate these consultations, surgeons were most likely to resist them, and intensive care specialists were most likely to view palliative care as within their own scope of practice. Suggestions for broadening palliative care utilization included providing education and training, improving financial reimbursement and sustainability for palliative care, and fostering a hospital culture that turns to high-intensity care only if it meets individual needs and goals of chronically ill patients. Conclusions: In acute care hospitals, palliative care is primarily perceived as a means to limit life-sustaining treatment or allow death. Moving consultation earlier in the hospitalization of "dying" patients is a greater preoccupation than increasing palliative service use earlier in the illness trajectory. Any move short of far upstream will require palliative care specialists to market benefits to patients and referring providers in ways that emphasize compatibility with parallel treatment plans and do not threaten provider autonomy.