Timothy E. Quill

Generalist plus specialist palliative care--creating a more sustainable model.

The U.S. palliative care model adds another layer of specialized care to a complex, expensive health care environment, and there are too few palliative care specialists to meet demand. Distinguishing primary from specialist palliative care would improve quality of care.

A National Survey of Physician-Assisted Suicide and Euthanasia in the United States

BACKGROUND Although there have been many studies of physician-assisted suicide and euthanasia in the United States, national data are lacking. METHODS In 1996, we mailed questionnaires to a stratified probability sample of 3102 physicians in the 10 specialties in which doctors are most likely to receive requests from patients for assistance with suicide or euthanasia. We weighted the results to obtain nationally representative data. RESULTS We received 1902 completed questionnaires (response rate, 61 percent). Eleven percent of the physicians said that under current legal constraints, there were circumstances in which they would be willing to hasten a patients death by prescribing medication, and 7 percent said that they would provide a lethal injection; 36 percent and 24 percent, respectively, said that they would do so if it were legal. Since entering practice, 18.3 percent of the physicians (unweighted number, 320) reported having received a request from a patient for assistance with suicide and 11.1 percent (unweighted number, 196) had received a request for a lethal injection. Sixteen percent of the physicians receiving such requests (unweighted number, 42), or 3.3 percent of the entire sample, reported that they had written at least one prescription to be used to hasten death, and 4.7 percent (unweighted number, 59), said that they had administered at least one lethal injection. CONCLUSIONS A substantial proportion of physicians in the United States report that they receive requests for physician-assisted suicide and euthanasia, and about 7 percent of those who responded to our survey have complied with such requests at least once.

Proactive palliative care in the medical intensive care unit: Effects on length of stay for selected high-risk patients

Objective:The purpose of this study was to examine the effect of proactive palliative care consultation on length of stay for high-risk patients in the medical intensive care unit (MICU). Design:A prospective pre/post nonequivalent control group design was used for this performance improvement study. Setting:Seventeen-bed adult MICU. Patients:Of admissions to the MICU, 191 patients were identified as having a serious illness and at high risk of dying: 65 patients in the usual care phase and 126 patients in the proactive palliative care phase. To be included in the sample, a patient had to meet one of the following criteria: a) intensive care admission following a current hospital stay of ≥10 days; b) age >80 yrs in the presence of two or more life-threatening comorbidities (e.g., end-stage renal disease, severe congestive heart failure); c) diagnosis of an active stage IV malignancy; d) status post cardiac arrest; or e) diagnosis of an intracerebral hemorrhage requiring mechanical ventilation. Interventions:Palliative care consultations. Measurements and Main Results:Primary measures were patient lengths of stay a) for the entire hospitalization; b) in the MICU; and c) from MICU admission to hospital discharge. Secondary measures included mortality rates and discharge disposition. There were no significant differences between the usual care and proactive palliative care intervention groups in respect to age, gender, race, screening criteria, discharge disposition, or mortality. Patients in the proactive palliative care group had significantly shorter lengths of stay in the MICU (8.96 vs. 16.28 days, p = .0001). There were no differences between the two groups on total length of stay in the hospital or length of stay from MICU admission to hospital discharge. Conclusions:Proactive palliative care consultation was associated with a significantly shorter MICU length of stay in this high-risk group without any significant differences in mortality rates or discharge disposition.

Palliative Care Consultation Teams Cut Hospital Costs For Medicaid Beneficiaries

Patients facing serious or life-threatening illnesses account for a disproportionately large share of Medicaid spending. We examined 2004-07 data to determine the effect on hospital costs of palliative care team consultations for patients enrolled in Medicaid at four New York State hospitals. On average, patients who received palliative care incurred

Discussing palliative care with patients

6,900 less in hospital costs during a given admission than a matched group of patients who received usual care. These reductions included

Nonabandonment: A Central Obligation for Physicians

4,098 in hospital costs per admission for patients discharged alive, and

Partnerships in Patient Care: A Contractual Approach

7,563 for patients who died in the hospital. Consistent with the goals of a majority of patients and their families, palliative care recipients spent less time in intensive care, were less likely to die in intensive care units, and were more likely to receive hospice referrals than the matched usual care patients. We estimate that the reductions in Medicaid hospital spending in New York State could eventually range from

The Medical Interview: A Core Curriculum for Residencies in Internal Medicine

84 million to

The Ambiguity of Clinical Intentions

252 million annually (assuming that 2 percent and 6 percent of Medicaid patients discharged from the hospital received palliative care, respectively), if every hospital with 150 or more beds had a fully operational palliative care consultation team.

The impact of a program in mindful communication on primary care physicians.

In addition to addressing the physical suffering of dying patients, physicians can extend their caring by acknowledging and exploring psychosocial, existential, or spiritual suffering. As patients ...