Palliative care refers to a collaborative, comprehensive, interdisciplinary approach to improve the quality of life of patients living with debilitating, chronic or terminal illness. Palliative care is appropriate at any stage of illness and should be provided simultaneously with all other medical treatments. This approach includes the prevention and relief of suffering by means of early identification, assessment, and treatment of pain and other distressing symptoms such as dyspnea, nausea, fatigue, anxiety and depression; and attention to the physical, psychosocial and spiritual needs of patients and their families.

Hospitalists provide palliative care in multiple realms including 1) patients dying in the hospital; 2) patients discharged to home or another institution for end‐of‐life care; 3) patients with newly diagnosed life‐threatening illness; 4) patients requiring complex inpatient symptom management interventions; 5) patients for whom it is appropriate to shift the goal of care away from disease cure or stabilization and toward the maximization of comfort; and 6) patients with serious, chronic illness such as heart failure, COPD, liver disease, dementia, and cancer. Hospitalists lead, coordinate, and participate in initiatives to improve the identification and treatment of patients and families in need of palliative care.

KNOWLEDGE

Hospitalists should be able to:

• Determine effective management strategies for patients requiring palliative care.

• Describe potential adverse effects from medications and procedures directed at palliation.

• Formulate strategies for prevention and treatment of complications of palliative care interventions.

• Assess the impact of interventions including feeding tubes, parenteral nutrition, mechanical ventilation, and intravenous fluids on patient comfort and prognosis.

• Describe the concept of double effect with respect to palliative care intervention.

• Name the basic tenets of hospice care and the Medicare hospice benefit.

• Identify indicators of clinical stability that allow for safe transitions of care and continuity after discharge.

• Explain the role of palliative care throughout the course of illness and how it can be provided alongside all other appropriate medical treatments.

• Describe signs and symptoms of the last 24 hours of life and how to discuss these observations with families.

• Describe the responsibilities of the hospitalist after a patient dies, including pronouncing a person dead, completing the death certificate, requesting an autopsy, notifying family and PCP, and contacting the organ donor network.

SKILLS

Hospitalists should be able to:

• Obtain a thorough and relevant history, review the medical record, and perform a comprehensive physical examination to identify symptoms, co‐morbidities, medications or social influences that impact the palliative care plan.

• Direct individual patient's palliative care delivery from admission to discharge.

• Formulate a communication plan for delivering prognostic information.

• Conduct effective and compassionate family meetings.

• Formulate specific patient centered palliative care plans that include pain management; integration of psychiatric, social, spiritual and other support services; and discharge planning.

• Recognize and address the psychosocial effects of complex, acute life threatening illness in hospitalized patients.

• Assess and respond to patient's symptoms, which may include pain, dyspnea, nausea, constipation, fatigue, anorexia, anxiety, depression and delirium.

• Anticipate adverse effects and double effect from interventions and initiate measures to minimize such problems.

• Communicate effectively with patients and families about patient's values and goals of care.

• Communicate effectively with patients and families about hospice and know how to refer a patient to hospice.

• Respond to patient requests for assisted suicide and identify and address other important ethical issues.

ATTITUDES

Hospitalists should be able to:

• Convey diagnosis, prognosis, treatment and support options available for patients and families in a clear, concise, compassionate, culturally sensitive and timely manner.

• Determine patient and family understanding of severity of illness, prognosis and their role in determining the goals of their care.

• Promote the ethical imperative of frequent pain assessment and adequate control.

• Appreciate that all pain is subjective and acknowledge patient's self reports of pain.

• Discuss with patients and families goals for pain management strategies and functional status and set targets for pain control.

• Appreciate that good palliative care for patients with certain conditions often involves the use of therapies typically thought of as curative.

• Conduct meetings with patients and families to establish goals of care that reflect the patient's wishes.

• Determine existence of advance directives and provide patients and families with resources to understand and execute such directives.

• Advocate incorporation of patient wishes into care plans.

• Recognize the need for frequent family meetings.

• Address resuscitation status and patient preferences for care early during hospital stay.

• Maintain rapport with patients and families and a consistent approach to management during transfers of care.

• Recognize impact of cultural and spiritual factors to the provision of palliative care.

• Appreciate the role of other members of the healthcare team including nursing and social services, pharmacy, psychology and pastoral care in providing comprehensive palliative care, and work closely with these team members in caring for patients with serious, chronic and terminal illnesses and their families.

• Provide reassurance to patients and families that clinical providers will be available to provide ongoing care and relief of symptoms.

• Formulate a comprehensive discharge plan that will empower the patient, family and subsequent providers to anticipate and manage changing symptoms, emergency situations, and increasing dependency.

• Lead, coordinate or participate in efforts to establish or improve palliative care in the hospital, which may include establishing a palliative care consultation service.

• Consider palliative care issues at hospital management and committee meetings.

• Engage providers and administrators in the study of local palliative care delivery to include efficacy of pain assessment and intervention, patient and family satisfaction with care delivery, impact on hospital occupancy and costs, and fulfilled expectations of referring and collaborating providers and services.

Palliative care refers to a collaborative, comprehensive, interdisciplinary approach to improve the quality of life of patients living with debilitating, chronic or terminal illness. Palliative care is appropriate at any stage of illness and should be provided simultaneously with all other medical treatments. This approach includes the prevention and relief of suffering by means of early identification, assessment, and treatment of pain and other distressing symptoms such as dyspnea, nausea, fatigue, anxiety and depression; and attention to the physical, psychosocial and spiritual needs of patients and their families.

Hospitalists provide palliative care in multiple realms including 1) patients dying in the hospital; 2) patients discharged to home or another institution for end‐of‐life care; 3) patients with newly diagnosed life‐threatening illness; 4) patients requiring complex inpatient symptom management interventions; 5) patients for whom it is appropriate to shift the goal of care away from disease cure or stabilization and toward the maximization of comfort; and 6) patients with serious, chronic illness such as heart failure, COPD, liver disease, dementia, and cancer. Hospitalists lead, coordinate, and participate in initiatives to improve the identification and treatment of patients and families in need of palliative care.

KNOWLEDGE

Hospitalists should be able to:

• Determine effective management strategies for patients requiring palliative care.

• Describe potential adverse effects from medications and procedures directed at palliation.

• Formulate strategies for prevention and treatment of complications of palliative care interventions.

• Assess the impact of interventions including feeding tubes, parenteral nutrition, mechanical ventilation, and intravenous fluids on patient comfort and prognosis.

• Describe the concept of double effect with respect to palliative care intervention.

• Name the basic tenets of hospice care and the Medicare hospice benefit.

• Identify indicators of clinical stability that allow for safe transitions of care and continuity after discharge.

• Explain the role of palliative care throughout the course of illness and how it can be provided alongside all other appropriate medical treatments.

• Describe signs and symptoms of the last 24 hours of life and how to discuss these observations with families.

• Describe the responsibilities of the hospitalist after a patient dies, including pronouncing a person dead, completing the death certificate, requesting an autopsy, notifying family and PCP, and contacting the organ donor network.

SKILLS

Hospitalists should be able to:

• Obtain a thorough and relevant history, review the medical record, and perform a comprehensive physical examination to identify symptoms, co‐morbidities, medications or social influences that impact the palliative care plan.

• Direct individual patient's palliative care delivery from admission to discharge.

• Formulate a communication plan for delivering prognostic information.

• Conduct effective and compassionate family meetings.

• Formulate specific patient centered palliative care plans that include pain management; integration of psychiatric, social, spiritual and other support services; and discharge planning.

• Recognize and address the psychosocial effects of complex, acute life threatening illness in hospitalized patients.

• Assess and respond to patient's symptoms, which may include pain, dyspnea, nausea, constipation, fatigue, anorexia, anxiety, depression and delirium.

• Anticipate adverse effects and double effect from interventions and initiate measures to minimize such problems.

• Communicate effectively with patients and families about patient's values and goals of care.

• Communicate effectively with patients and families about hospice and know how to refer a patient to hospice.

• Respond to patient requests for assisted suicide and identify and address other important ethical issues.

ATTITUDES

Hospitalists should be able to:

• Convey diagnosis, prognosis, treatment and support options available for patients and families in a clear, concise, compassionate, culturally sensitive and timely manner.

• Determine patient and family understanding of severity of illness, prognosis and their role in determining the goals of their care.

• Promote the ethical imperative of frequent pain assessment and adequate control.

• Appreciate that all pain is subjective and acknowledge patient's self reports of pain.

• Discuss with patients and families goals for pain management strategies and functional status and set targets for pain control.

• Appreciate that good palliative care for patients with certain conditions often involves the use of therapies typically thought of as curative.

• Conduct meetings with patients and families to establish goals of care that reflect the patient's wishes.

• Determine existence of advance directives and provide patients and families with resources to understand and execute such directives.

• Advocate incorporation of patient wishes into care plans.

• Recognize the need for frequent family meetings.

• Address resuscitation status and patient preferences for care early during hospital stay.

• Maintain rapport with patients and families and a consistent approach to management during transfers of care.

• Recognize impact of cultural and spiritual factors to the provision of palliative care.

• Appreciate the role of other members of the healthcare team including nursing and social services, pharmacy, psychology and pastoral care in providing comprehensive palliative care, and work closely with these team members in caring for patients with serious, chronic and terminal illnesses and their families.

• Provide reassurance to patients and families that clinical providers will be available to provide ongoing care and relief of symptoms.

• Formulate a comprehensive discharge plan that will empower the patient, family and subsequent providers to anticipate and manage changing symptoms, emergency situations, and increasing dependency.

• Lead, coordinate or participate in efforts to establish or improve palliative care in the hospital, which may include establishing a palliative care consultation service.

• Consider palliative care issues at hospital management and committee meetings.

• Engage providers and administrators in the study of local palliative care delivery to include efficacy of pain assessment and intervention, patient and family satisfaction with care delivery, impact on hospital occupancy and costs, and fulfilled expectations of referring and collaborating providers and services.

Palliative care refers to a collaborative, comprehensive, interdisciplinary approach to improve the quality of life of patients living with debilitating, chronic or terminal illness. Palliative care is appropriate at any stage of illness and should be provided simultaneously with all other medical treatments. This approach includes the prevention and relief of suffering by means of early identification, assessment, and treatment of pain and other distressing symptoms such as dyspnea, nausea, fatigue, anxiety and depression; and attention to the physical, psychosocial and spiritual needs of patients and their families.

Hospitalists provide palliative care in multiple realms including 1) patients dying in the hospital; 2) patients discharged to home or another institution for end‐of‐life care; 3) patients with newly diagnosed life‐threatening illness; 4) patients requiring complex inpatient symptom management interventions; 5) patients for whom it is appropriate to shift the goal of care away from disease cure or stabilization and toward the maximization of comfort; and 6) patients with serious, chronic illness such as heart failure, COPD, liver disease, dementia, and cancer. Hospitalists lead, coordinate, and participate in initiatives to improve the identification and treatment of patients and families in need of palliative care.

KNOWLEDGE

Hospitalists should be able to:

• Determine effective management strategies for patients requiring palliative care.

• Describe potential adverse effects from medications and procedures directed at palliation.

• Formulate strategies for prevention and treatment of complications of palliative care interventions.

• Assess the impact of interventions including feeding tubes, parenteral nutrition, mechanical ventilation, and intravenous fluids on patient comfort and prognosis.

• Describe the concept of double effect with respect to palliative care intervention.

• Name the basic tenets of hospice care and the Medicare hospice benefit.

• Identify indicators of clinical stability that allow for safe transitions of care and continuity after discharge.

• Explain the role of palliative care throughout the course of illness and how it can be provided alongside all other appropriate medical treatments.

• Describe signs and symptoms of the last 24 hours of life and how to discuss these observations with families.

• Describe the responsibilities of the hospitalist after a patient dies, including pronouncing a person dead, completing the death certificate, requesting an autopsy, notifying family and PCP, and contacting the organ donor network.

SKILLS

Hospitalists should be able to:

• Obtain a thorough and relevant history, review the medical record, and perform a comprehensive physical examination to identify symptoms, co‐morbidities, medications or social influences that impact the palliative care plan.

• Direct individual patient's palliative care delivery from admission to discharge.

• Formulate a communication plan for delivering prognostic information.

• Conduct effective and compassionate family meetings.

• Formulate specific patient centered palliative care plans that include pain management; integration of psychiatric, social, spiritual and other support services; and discharge planning.

• Recognize and address the psychosocial effects of complex, acute life threatening illness in hospitalized patients.

• Assess and respond to patient's symptoms, which may include pain, dyspnea, nausea, constipation, fatigue, anorexia, anxiety, depression and delirium.

• Anticipate adverse effects and double effect from interventions and initiate measures to minimize such problems.

• Communicate effectively with patients and families about patient's values and goals of care.

• Communicate effectively with patients and families about hospice and know how to refer a patient to hospice.

• Respond to patient requests for assisted suicide and identify and address other important ethical issues.

ATTITUDES

Hospitalists should be able to:

• Convey diagnosis, prognosis, treatment and support options available for patients and families in a clear, concise, compassionate, culturally sensitive and timely manner.

• Determine patient and family understanding of severity of illness, prognosis and their role in determining the goals of their care.

• Promote the ethical imperative of frequent pain assessment and adequate control.

• Appreciate that all pain is subjective and acknowledge patient's self reports of pain.

• Discuss with patients and families goals for pain management strategies and functional status and set targets for pain control.

• Appreciate that good palliative care for patients with certain conditions often involves the use of therapies typically thought of as curative.

• Conduct meetings with patients and families to establish goals of care that reflect the patient's wishes.

• Determine existence of advance directives and provide patients and families with resources to understand and execute such directives.

• Advocate incorporation of patient wishes into care plans.

• Recognize the need for frequent family meetings.

• Address resuscitation status and patient preferences for care early during hospital stay.

• Maintain rapport with patients and families and a consistent approach to management during transfers of care.

• Recognize impact of cultural and spiritual factors to the provision of palliative care.

• Appreciate the role of other members of the healthcare team including nursing and social services, pharmacy, psychology and pastoral care in providing comprehensive palliative care, and work closely with these team members in caring for patients with serious, chronic and terminal illnesses and their families.

• Provide reassurance to patients and families that clinical providers will be available to provide ongoing care and relief of symptoms.

• Formulate a comprehensive discharge plan that will empower the patient, family and subsequent providers to anticipate and manage changing symptoms, emergency situations, and increasing dependency.

• Lead, coordinate or participate in efforts to establish or improve palliative care in the hospital, which may include establishing a palliative care consultation service.

• Consider palliative care issues at hospital management and committee meetings.

• Engage providers and administrators in the study of local palliative care delivery to include efficacy of pain assessment and intervention, patient and family satisfaction with care delivery, impact on hospital occupancy and costs, and fulfilled expectations of referring and collaborating providers and services.

Community‐acquired pneumonia (cap) is an infection of the lung parenchyma that begins in the community and is diagnosed within 48 hours of admission to the hospital. in the u.s. each year, cap is the most common infectious cause of death and the sixth leading cause of death overall in the united states. the healthcare cost and utilization project (hcup) attributed 831,000 discharges to the diagnosis related group (drg) for simple pneumonia in 2002. these patients were hospitalized for a mean of 5.4 days and had an in‐hospital mortality of 4.9%. the mean charges for these patients were $13,000 per patient and the mean length‐of‐stay was 4.7 days with in‐house mortality of 1.7%. quality indicators have been created around the key processes of care for patients with cap, and these indicators are used to evaluate performance of states, healthcare organizations, physician groups, and individual physicians. from admission to discharge, hospitalists apply evidence based practice guidelines to the management of cap and lead initiatives to improve quality of care and reduce practice variability.

KNOWLEDGE

Hospitalists should be able to:

• Define cap, list the likely etiologies and signs and symptoms, and distinguish from hospital‐acquired pneumonia.

• Differentiate cap from other processes that may mimic cap or other causes of infiltrates on chest x‐ray.

• Describe the indicated tests required to evaluate and treat cap.

• Explain indications for respiratory isolation.

• Identify patients with co‐morbidities (such as the immunocompromised patient and those with diabetes mellitus) and extremes of age (the elderly and very young) who are at risk for a complicated course of cap.

• Identify specific pathogens that predispose patients to a complicated course of cap.

• Explain patient specific risk factors and presence of specific organisms that predispose patients to a complicated course of cap.

• Describe indicated therapeutic modalities for cap including oxygen therapy, respiratory care modalities and antibiotic selection.

• Predict patient risk for morbidity and mortality from cap using an evidence based tool such as the pneumonia patient outcomes research team (port) / pneumonia severity index (psi) validated risk score.

• Explain goals for hospital discharge, including evidence based measures of clinical stability for safe care transition.

SKILLS

Hospitalists should be able to:

• Elicit a focused history to identify symptoms consistent with cap and demographic factors that may predispose patients to cap.

• Perform a targeted physical examination to elicit signs consistent with cap and differentiate it from other mimicking conditions.

• Select and interpret indicated laboratory, microbiologic and radiological studies to confirm diagnosis of cap, and risk stratify patients.

• Apply evidence based tools such as the pneumonia severity index, to triage decisions and identify factors that support the need for intensive care unit (icu) admission.

• Initiate empiric antibiotic selection based on exposure to long term or group care, severity of illness, and evidence based national guidelines, taking into account local resistance patterns.

• Formulate a subsequent treatment plan that includes narrowing antibiotic therapies based on available culture data and patient response to treatment.

• Recognize and address complications of cap and/or inadequate response to therapy including respiratory failure and emerging parapneumonic effusions.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the history and prognosis of cap.

• Communicate with patients and families to explain the goals of care plan, including clinical stability criteria, the importance of prevention measures such as smoking cessation, and required follow‐up care.

• Communicate with patients and families to explain tests and procedures, and the use and potential side effects of pharmacologic agents.

• Recognize indications for specialty consultation.

• Promote prevention strategies, which may include smoking cessation and indicated vaccinations.

• Collaborate with primary care physicians and emergency physicians in making the admission decision.

• Document treatment plan and discharge instructions, and identify the outpatient clinician responsible for follow‐up of pending tests.

• Recognize and address barriers to follow‐up care and anticipated post‐discharge requirements.

• Utilize evidence based recommendations for the treatment of patients with cap

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate or participate in efforts to identify, address and monitor quality indicators for cap including assessment of oxygenation, obtaining blood cultures prior to administration of antibiotics, prompt administration of antibiotics, and providing indicated vaccinations and smoking cessation education.

• Implement systems to ensure hospital wide adherence to national standards and document those measures as specified by recognized organizations (jcaho, idsa, ats)

• Integrate port score / psi in conjunction with patient specific factors and clinical judgment into the admission decision.

• Lead, coordinate or participate in multidisciplinary initiatives, which may include collaboration with infectious disease and pulmonary specialists, to promote patient safety and cost effective diagnostic and management strategies for patients with cap.

• Lead efforts to educate staff on the importance of smoking cessation counseling and other prevention measures.

Community‐acquired pneumonia (cap) is an infection of the lung parenchyma that begins in the community and is diagnosed within 48 hours of admission to the hospital. in the u.s. each year, cap is the most common infectious cause of death and the sixth leading cause of death overall in the united states. the healthcare cost and utilization project (hcup) attributed 831,000 discharges to the diagnosis related group (drg) for simple pneumonia in 2002. these patients were hospitalized for a mean of 5.4 days and had an in‐hospital mortality of 4.9%. the mean charges for these patients were $13,000 per patient and the mean length‐of‐stay was 4.7 days with in‐house mortality of 1.7%. quality indicators have been created around the key processes of care for patients with cap, and these indicators are used to evaluate performance of states, healthcare organizations, physician groups, and individual physicians. from admission to discharge, hospitalists apply evidence based practice guidelines to the management of cap and lead initiatives to improve quality of care and reduce practice variability.

KNOWLEDGE

Hospitalists should be able to:

• Define cap, list the likely etiologies and signs and symptoms, and distinguish from hospital‐acquired pneumonia.

• Differentiate cap from other processes that may mimic cap or other causes of infiltrates on chest x‐ray.

• Describe the indicated tests required to evaluate and treat cap.

• Explain indications for respiratory isolation.

• Identify patients with co‐morbidities (such as the immunocompromised patient and those with diabetes mellitus) and extremes of age (the elderly and very young) who are at risk for a complicated course of cap.

• Identify specific pathogens that predispose patients to a complicated course of cap.

• Explain patient specific risk factors and presence of specific organisms that predispose patients to a complicated course of cap.

• Describe indicated therapeutic modalities for cap including oxygen therapy, respiratory care modalities and antibiotic selection.

• Predict patient risk for morbidity and mortality from cap using an evidence based tool such as the pneumonia patient outcomes research team (port) / pneumonia severity index (psi) validated risk score.

• Explain goals for hospital discharge, including evidence based measures of clinical stability for safe care transition.

SKILLS

Hospitalists should be able to:

• Elicit a focused history to identify symptoms consistent with cap and demographic factors that may predispose patients to cap.

• Perform a targeted physical examination to elicit signs consistent with cap and differentiate it from other mimicking conditions.

• Select and interpret indicated laboratory, microbiologic and radiological studies to confirm diagnosis of cap, and risk stratify patients.

• Apply evidence based tools such as the pneumonia severity index, to triage decisions and identify factors that support the need for intensive care unit (icu) admission.

• Initiate empiric antibiotic selection based on exposure to long term or group care, severity of illness, and evidence based national guidelines, taking into account local resistance patterns.

• Formulate a subsequent treatment plan that includes narrowing antibiotic therapies based on available culture data and patient response to treatment.

• Recognize and address complications of cap and/or inadequate response to therapy including respiratory failure and emerging parapneumonic effusions.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the history and prognosis of cap.

• Communicate with patients and families to explain the goals of care plan, including clinical stability criteria, the importance of prevention measures such as smoking cessation, and required follow‐up care.

• Communicate with patients and families to explain tests and procedures, and the use and potential side effects of pharmacologic agents.

• Recognize indications for specialty consultation.

• Promote prevention strategies, which may include smoking cessation and indicated vaccinations.

• Collaborate with primary care physicians and emergency physicians in making the admission decision.

• Document treatment plan and discharge instructions, and identify the outpatient clinician responsible for follow‐up of pending tests.

• Recognize and address barriers to follow‐up care and anticipated post‐discharge requirements.

• Utilize evidence based recommendations for the treatment of patients with cap

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate or participate in efforts to identify, address and monitor quality indicators for cap including assessment of oxygenation, obtaining blood cultures prior to administration of antibiotics, prompt administration of antibiotics, and providing indicated vaccinations and smoking cessation education.

• Implement systems to ensure hospital wide adherence to national standards and document those measures as specified by recognized organizations (jcaho, idsa, ats)

• Integrate port score / psi in conjunction with patient specific factors and clinical judgment into the admission decision.

• Lead, coordinate or participate in multidisciplinary initiatives, which may include collaboration with infectious disease and pulmonary specialists, to promote patient safety and cost effective diagnostic and management strategies for patients with cap.

• Lead efforts to educate staff on the importance of smoking cessation counseling and other prevention measures.

Community‐acquired pneumonia (cap) is an infection of the lung parenchyma that begins in the community and is diagnosed within 48 hours of admission to the hospital. in the u.s. each year, cap is the most common infectious cause of death and the sixth leading cause of death overall in the united states. the healthcare cost and utilization project (hcup) attributed 831,000 discharges to the diagnosis related group (drg) for simple pneumonia in 2002. these patients were hospitalized for a mean of 5.4 days and had an in‐hospital mortality of 4.9%. the mean charges for these patients were $13,000 per patient and the mean length‐of‐stay was 4.7 days with in‐house mortality of 1.7%. quality indicators have been created around the key processes of care for patients with cap, and these indicators are used to evaluate performance of states, healthcare organizations, physician groups, and individual physicians. from admission to discharge, hospitalists apply evidence based practice guidelines to the management of cap and lead initiatives to improve quality of care and reduce practice variability.

KNOWLEDGE

Hospitalists should be able to:

• Define cap, list the likely etiologies and signs and symptoms, and distinguish from hospital‐acquired pneumonia.

• Differentiate cap from other processes that may mimic cap or other causes of infiltrates on chest x‐ray.

• Describe the indicated tests required to evaluate and treat cap.

• Explain indications for respiratory isolation.

• Identify patients with co‐morbidities (such as the immunocompromised patient and those with diabetes mellitus) and extremes of age (the elderly and very young) who are at risk for a complicated course of cap.

• Identify specific pathogens that predispose patients to a complicated course of cap.

• Explain patient specific risk factors and presence of specific organisms that predispose patients to a complicated course of cap.

• Describe indicated therapeutic modalities for cap including oxygen therapy, respiratory care modalities and antibiotic selection.

• Predict patient risk for morbidity and mortality from cap using an evidence based tool such as the pneumonia patient outcomes research team (port) / pneumonia severity index (psi) validated risk score.

• Explain goals for hospital discharge, including evidence based measures of clinical stability for safe care transition.

SKILLS

Hospitalists should be able to:

• Elicit a focused history to identify symptoms consistent with cap and demographic factors that may predispose patients to cap.

• Perform a targeted physical examination to elicit signs consistent with cap and differentiate it from other mimicking conditions.

• Select and interpret indicated laboratory, microbiologic and radiological studies to confirm diagnosis of cap, and risk stratify patients.

• Apply evidence based tools such as the pneumonia severity index, to triage decisions and identify factors that support the need for intensive care unit (icu) admission.

• Initiate empiric antibiotic selection based on exposure to long term or group care, severity of illness, and evidence based national guidelines, taking into account local resistance patterns.

• Formulate a subsequent treatment plan that includes narrowing antibiotic therapies based on available culture data and patient response to treatment.

• Recognize and address complications of cap and/or inadequate response to therapy including respiratory failure and emerging parapneumonic effusions.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the history and prognosis of cap.

• Communicate with patients and families to explain the goals of care plan, including clinical stability criteria, the importance of prevention measures such as smoking cessation, and required follow‐up care.

• Communicate with patients and families to explain tests and procedures, and the use and potential side effects of pharmacologic agents.

• Recognize indications for specialty consultation.

• Promote prevention strategies, which may include smoking cessation and indicated vaccinations.

• Collaborate with primary care physicians and emergency physicians in making the admission decision.

• Document treatment plan and discharge instructions, and identify the outpatient clinician responsible for follow‐up of pending tests.

• Recognize and address barriers to follow‐up care and anticipated post‐discharge requirements.

• Utilize evidence based recommendations for the treatment of patients with cap

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate or participate in efforts to identify, address and monitor quality indicators for cap including assessment of oxygenation, obtaining blood cultures prior to administration of antibiotics, prompt administration of antibiotics, and providing indicated vaccinations and smoking cessation education.

• Implement systems to ensure hospital wide adherence to national standards and document those measures as specified by recognized organizations (jcaho, idsa, ats)

• Integrate port score / psi in conjunction with patient specific factors and clinical judgment into the admission decision.

• Lead, coordinate or participate in multidisciplinary initiatives, which may include collaboration with infectious disease and pulmonary specialists, to promote patient safety and cost effective diagnostic and management strategies for patients with cap.

• Lead efforts to educate staff on the importance of smoking cessation counseling and other prevention measures.

The field of palliative care has grown rapidly in recent years in response to patient need and clinician interest in effective approaches to managing chronic life‐threatening illness.1 This article reviews the clinical, educational, demographic, and financial imperatives driving this growth, describes the clinical components of palliative care and the range of service models available, defines the relationship of hospital‐based palliative care to hospice, summarizes the literature on palliative care outcomes, and presents practical resources for clinicians seeking knowledge and skills in the field.

DEFINITION

Palliative care is medical care focused on the relief of suffering and support for the best possible quality of life for patients facing serious, life‐threatening illness and their families. It aims to identify and address the physical, psychological, and practical burdens of illness. Palliative care in the United States grew out of the hospice movement that originated in both the United Kingdom and the United States about 30 years ago. Hospice care was developed specifically to address the needs of the dying and their families and was codified in the United States by the addition in 1983 of a federal Medicare benefit for hospice care. In the last 30 years the Medicare hospice benefit has enabled more than 7 million patients and their families to receive intensive palliative care for the terminally ill, primarily in the home. The growth in the number and needs of seriously and chronically ill patients who are not clearly terminally ill has led to the development of palliative care services outside the hospice benefit provided by Medicare (and other insurers). Both hospice and nonhospice professionals have participated in extending the hospice approach through development of palliative care services. Palliative care may be delivered simultaneously with all appropriate curative and life‐prolonging interventions. In practice, palliative care practitioners provide assessment and treatment of pain and other symptom distress; employ communication skills with patients, families, and colleagues; support complex medical decision making and goal setting based on identifying and respecting patient wishes and goals; and promote medically informed care coordination, continuity, and practical support for patients, family caregivers, and professional colleagues across healthcare settings and through the trajectory of an illness.1, 2

Palliative care is both a general approach to health care and a growing practice specialty for professionals committing most or all of their time to the delivery of palliative care services.3 The term palliative medicine refers to the physician discipline within the larger field of palliative care. As of 2005, more than 1890 physicians have received specialty certification through a palliative care credentialing exam given by the American Board of Hospice and Palliative Medicine.4 Formal recognition of the subspecialty is currently being sought in collaboration with the American Board of Medical Specialties.5 As of August 2005, there were more than 50 postgraduate palliative care subspecialty fellowship programs in the United States.6 Between 2000 and 2003, the American Hospital Association (AHA) annual survey recorded a 67% growth in the number of hospital‐based palliative care programs reported, from 632 to 1027, for a total of 25% of responding AHA member hospitals.7

REASONS FOR GROWTH IN PALLIATIVE CARE

A primary justification for the rapid growth in palliative care programs in institutional settings is the abundant data demonstrating the high prevalence of pain and symptom distress in hospitals,811 nursing homes,12, 13 and community settings.14 Virtually all persons with serious illness spend at least some time in a hospital, usually on multiple occasions, in the course of their disease or condition.15 Despite the finding that when polled more than 90% of Americans say they would prefer to die at home, more than 75% of adult deaths occur in institutional settings (hospital or nursing homes)more than 50% in hospitals and 25% in nursing homesand 85% of pediatric deaths occur in hospitals.16, 17 Further, more than half of persons older than age 85 die in a nursing home and 43% of persons older than age 65 reside in a long‐term care facility at some time before they die,1821 a figure projected to rise substantially over the next several decades. The much larger number of patients who are not dying but are living with chronic, debilitating, and life‐threatening illness also need expert symptom management, communication and decision‐making support, and coordination of care across settings. In one national survey, physicians reported that poor care coordination resulted in patient communication problems, lack of emotional support for patients, adverse drug reactions, unnecessary hospitalization, patients not functioning to potential, and unnecessary pain.22 In addition to studies demonstrating high degrees of symptom distress across all age groups in hospitalized and nursing home patients,814 other works have shown high use of burdensome, nonbeneficial technologies among the seriously ill,2327 caregiver burden on families,2831 and communication problems between these patients, their families, and their treating physicians about the goals of care and the medical decisions that should follow.32, 33 Other studies have reported broad dissatisfaction with the general quality of care for the seriously ill and dying in hospitals and nursing homes,18, 34 specifically, perceptions of impersonal and indifferent care. Several studies of patients and their families have identified relief of suffering, practical support needs, open communication, and opportunities to relieve burdens on and strengthen relationships with family as the top‐priority needs from the healthcare system.3440

The growth in the number and needs of the elderly with multiple chronic conditions who will turn to the healthcare system in coming years underscores the need to create a delivery system in the United States that can be responsive to these priorities. By 2030 the number of persons with chronic conditions will exceed 157 million.4144 With the possible exception of advanced cancer conditions (accounting for 24% of adult deaths), in which prognosis is somewhat more reliably linked to performance status,4243 prognostication of outcome is a highly inexact science for the chronically ill of all ages and in a range of diagnostic categories, including stroke, dementia, and end‐stage cardiac, renal, hepatic, and pulmonary diseases. This has been a major part of the impetus for the growth in palliative care services not predicated on a link to terminal prognoses.4143 Hospitals and nursing homes are under increasing pressure to structure care processes in a manner fitted to the needs of the seriously ill because of studies demonstrating poor quality of care, demands from patients and families, accreditation requirements, and the costs of care for this patient population. More than 95% of Medicare spending goes to the 63% of Medicare patients with two or more chronic conditions, and three quarters of Medicare dollars go to hospitals.44 Hospital costs have risen nearly 10% per year in each of the last 2 years, because of both the increasing numbers of patients turning to them for care and the growth in the number and expense of effective life‐prolonging therapies. These forces have stimulated the development of new models for the efficient and effective care of patients with serious and complex illness.2227, 44

CLINICAL COMPONENTS

The three primary domains of palliative care clinical practice are assessment and treatment of pain and other symptom distress, including psychiatric symptoms64; communication about goals of care and support for complex medical decision making; and provision of practical and psychosocial support, care coordination, and continuity, as well as bereavement services if death occurs.1, 2, 65 Palliative care specialists work to support primary and specialist physicians in the care of complex and seriously ill patients by providing intensive bedside treatment and reassessment of multiple‐symptom distress, by helping with time‐consuming and difficult interactions with distressed patients and family members, and by attempting to ensure a seamless, safe, and well‐communicated discharge and follow‐up process after the patient leaves the hospital.66 Resources for physicians seeking more knowledge or training in the treatment of symptom distress and other aspects of palliative care are given in Table 1.

The core components of symptom management67, 68 include: 1) Routine and repeated formal assessment, without which most symptoms will be neither identified nor addressed; 2) Expertise in prescribing, including the safe use of opioid analgesics, adjuvant approaches to pain management, and management of a wide range of other common and distressing symptoms and syndromes including, for example, delirium, dyspnea, fatigue, nausea, bowel obstruction, and depression69; and 3) Skillful management of treatment side effects, which is required to successfully control symptoms.

Communication skills and effective support for making decisions about clinical care goals include not only fundamental physician responsibilities such as communicating bad news and elucidating patient wishes for future care, but also the ability to promote communication and consensus about care goals among multiple specialist consultants, to address and resolve disagreements and conflicts among patients, families, and providers about goals of care, and to assist in the evolving process of balancing the benefits with the burdens of various medical interventions.32, 7073

The great majority of care for an illness is provided at home by family members neither trained nor emotionally prepared for these responsibilities.51, 74 The burden on family caregivers is one of the top concerns of seriously ill patients.35 Patients and families often struggle with anxieties about doing the wrong thing, difficulty traveling to physicians' offices, social isolation, and a high prevalence of preventable suffering of all types.3440 Palliative care clinicians attempt to improve the success and sustainability of the discharge plan by providing medically informed and therefore more appropriate care management recommendations and by mobilizing a range of community resources to increase the likelihood that families will be able to manage the care at home with the necessary supports and backups in place, including appropriate screening and referrals for complicated grief and bereavement.51, 75, 76 Several small prospective studies of palliative care have suggested that palliative care has resulted in reduction in the number of emergency department visits and hospitalizations and in the length of hospital stays, presumably because of the efficacy and comprehensiveness of care coordination in averting crises.54, 55, 61, 9798

CLINICAL MODELS

Given the multifaceted approach needed to support patient quality of life throughout advanced illness, one profession or individual cannot be expected to provide all aspects of palliative care. As described in the recently completed National Consensus Project Guidelines for Quality Palliative Care,2 specialty‐level palliative care is optimally delivered through an interdisciplinary team consisting of appropriately trained and credentialed physicians, nurses, and social workers with additional support and contributions from chaplains, rehabilitative experts, psychiatrists, and other professionals as indicated. Clearly, however, the staffing of a palliative care program will depend critically on the needs and capacities of the setting. A full interdisciplinary team is needed for a large tertiary‐care teaching hospital, whereas a part‐time advance‐practice nurse with backup from colleagues as needed may suffice for a small rural hospital or long‐term care setting. Specialist‐level palliative care is delivered through a range of clinical models and settings, including inpatient consultation services, dedicated inpatient units, and outpatient practices, among others.77, 78 Programs within the United States are housed in a range of clinical subspecialties including oncology, geriatrics, nursing, case management, hospitalist, and other programs, depending on the locus of leadership and administrative support.77, 78 Most programs are supported by utilizing diverse sources,77 including physician and nurse‐practitioner billing through insurers such as Medicare Part B,53, 81 as well as hospital support typically predicated on cost avoidance analyses, foundation and other grants, and philanthropy. Detailed guidance on appropriate documentation and billing for palliative care physician services may be found in Schapiro et al.,53 von Gunten,79 and on the Web site of the Center to Advance Palliative Care (www.capc.org).77

RELATIONSHIP TO HOSPICE

Although new clinical specialties in palliative medicine and nursing are emerging, in the United States palliative care for those in the terminal stages of illness has been delivered through hospice programs for more than 30 years. Under current regulatory and payment guidelines hospice care is delivered to patients who are certified by their physicians as likely to die within 6 months if the disease follows its usual course and who are willing to give up insurance coverage for medical treatment primarily focused on cure or prolongation of life. It is noteworthy that there is great variability among United States hospices, with some able to support continued disease‐modifying treatments such as chemotherapy and radiation if a patient so desires.2 Hospice programs aim to create increased opportunity for death at home, focusing on symptom control and the psychological and spiritual issues that are paramount to persons in the terminal phases of illness. Once the hospice benefit has been accessed, patients and families receive comprehensive case‐managed services across all settings of care (although the great majority of hospice care is delivered at home) from an interdisciplinary team, coverage for medications and equipment related to the terminal illness, and practical, psychosocial, respite, and bereavement support for caregivers.80, 81 Several recent studies have confirmed the findings of an earlier work82 in demonstrating the beneficial outcomes of hospice care including reduced mortality in spouses and high levels of family satisfaction.18, 83 Palliative care programs based in both hospital and community settings have led to increases in hospice referral rates and hospice length of stay, promoting continuity of palliative care and the intensive palliation and family support needed as death approaches.55 Coordination and partnerships between palliative care and hospice programs are critical to achieving continuity of palliative care throughout the full course of an illness and across the continuum of care settings.2

IMPACT OF PALLIATIVE CARE ON QUALITY OF CARE

Reports on palliative care specialist services utilizing diverse models and approaches have suggested a range of benefits from palliative care, including reduced pain4547 and other symptom distress,45, 48, 49 improved health‐related quality of life,95 high patient and family satisfaction18, 4951, 96 with care and with physician communication, and increased likelihood of the location of death being outside a hospital.33, 49, 52, 9799

Because it can help to demonstrate care structures, processes, and outcomes associated with improved quality (such as routine assessment of pain in the hospital), a palliative care program may help hospitals measure and meet Joint Commission for Accreditation of Healthcare Organizations (JCAHO) requirements in the domains of pain management, communication, family and patient education, and continuity of care, among others.53 Several groups have reported marked increases in hospice referral rate and hospice length of stay as a result of hospital‐ and nursing‐home‐based palliative care programs, presumably as a result of enhanced case identification, counseling, and referral processes.54, 55 Case control and observational studies of palliative care and ethics consultation services have demonstrated reductions in costs per day and in hospital and ICU lengths of stay, presumably because of enhanced support for discussions about the goals of care and the resulting facilitation of patient and family decisions about the types and settings of future care.50, 5561 Hospitals have begun to invest in palliative care services, both to enhance quality of care and because of their measurable impact on reducing ICU and total bed days and their efficacy in supporting transitions from high‐intensity, high‐cost hospital settings to more appropriate and desired care settings, such as the home.5563, 9798 Observational studies have yielded no differences in mortality between patients receiving palliative care and controls receiving the usual care.48, 55, 56

EDUCATION IN PALLIATIVE CARE

Curricular content on palliative care has been noticeably lacking from medical and nursing education curricula, textbooks, and certifying examinations, although this is beginning to change.8491 Both the Liaison Committee for Medical Education (LCME) and the Accreditation Council for Graduate Medical Education (ACGME) now require or strongly encourage programs to provide under‐ and postgraduate training in palliative care in order to be accredited.89, 90 As of 2005, more than 50% of teaching hospitals had established palliative care clinical services,92 which constitute the necessary platform for clinical training. The rapid growth in the availability of postgraduate fellowship training in palliative medicine will produce the faculty leaders needed for these educational and research programs in medical school and residency training programs.93, 94 Physicians in practice may gain knowledge and skills through a range of national courses and Web‐based resources and through preparation for the certifying exam given annually by the American Board of Hospice and Palliative Medicine4 (Table 1).

CONCLUSIONS

The growth in palliative care specialists and programs in hospitals in the United States represents a grass roots professional response to the needs of a patient population with chronic advanced illnesses and family care burdens within a healthcare system structured to provide care for acute intercurrent illness. Rapid increases in the number of new hospital programs, as well as early studies indicating improved clinical, satisfaction, and utilization outcomes, suggest that palliative care services are likely to become a routine and well‐integrated part of the healthcare continuum in the United States over the next several years. A number of resources are available to healthcare professionals seeking more training as well as to hospitals or nursing homes wishing to establish their own clinical or educational programs. Such programs have provided a platform for both newly graduated and seasoned professionals to continue to serve the needs of their patients through the assessment and relief of suffering, provided simultaneously with efforts to cure or mitigate disease.

The field of palliative care has grown rapidly in recent years in response to patient need and clinician interest in effective approaches to managing chronic life‐threatening illness.1 This article reviews the clinical, educational, demographic, and financial imperatives driving this growth, describes the clinical components of palliative care and the range of service models available, defines the relationship of hospital‐based palliative care to hospice, summarizes the literature on palliative care outcomes, and presents practical resources for clinicians seeking knowledge and skills in the field.

DEFINITION

Palliative care is medical care focused on the relief of suffering and support for the best possible quality of life for patients facing serious, life‐threatening illness and their families. It aims to identify and address the physical, psychological, and practical burdens of illness. Palliative care in the United States grew out of the hospice movement that originated in both the United Kingdom and the United States about 30 years ago. Hospice care was developed specifically to address the needs of the dying and their families and was codified in the United States by the addition in 1983 of a federal Medicare benefit for hospice care. In the last 30 years the Medicare hospice benefit has enabled more than 7 million patients and their families to receive intensive palliative care for the terminally ill, primarily in the home. The growth in the number and needs of seriously and chronically ill patients who are not clearly terminally ill has led to the development of palliative care services outside the hospice benefit provided by Medicare (and other insurers). Both hospice and nonhospice professionals have participated in extending the hospice approach through development of palliative care services. Palliative care may be delivered simultaneously with all appropriate curative and life‐prolonging interventions. In practice, palliative care practitioners provide assessment and treatment of pain and other symptom distress; employ communication skills with patients, families, and colleagues; support complex medical decision making and goal setting based on identifying and respecting patient wishes and goals; and promote medically informed care coordination, continuity, and practical support for patients, family caregivers, and professional colleagues across healthcare settings and through the trajectory of an illness.1, 2

Palliative care is both a general approach to health care and a growing practice specialty for professionals committing most or all of their time to the delivery of palliative care services.3 The term palliative medicine refers to the physician discipline within the larger field of palliative care. As of 2005, more than 1890 physicians have received specialty certification through a palliative care credentialing exam given by the American Board of Hospice and Palliative Medicine.4 Formal recognition of the subspecialty is currently being sought in collaboration with the American Board of Medical Specialties.5 As of August 2005, there were more than 50 postgraduate palliative care subspecialty fellowship programs in the United States.6 Between 2000 and 2003, the American Hospital Association (AHA) annual survey recorded a 67% growth in the number of hospital‐based palliative care programs reported, from 632 to 1027, for a total of 25% of responding AHA member hospitals.7

REASONS FOR GROWTH IN PALLIATIVE CARE

A primary justification for the rapid growth in palliative care programs in institutional settings is the abundant data demonstrating the high prevalence of pain and symptom distress in hospitals,811 nursing homes,12, 13 and community settings.14 Virtually all persons with serious illness spend at least some time in a hospital, usually on multiple occasions, in the course of their disease or condition.15 Despite the finding that when polled more than 90% of Americans say they would prefer to die at home, more than 75% of adult deaths occur in institutional settings (hospital or nursing homes)more than 50% in hospitals and 25% in nursing homesand 85% of pediatric deaths occur in hospitals.16, 17 Further, more than half of persons older than age 85 die in a nursing home and 43% of persons older than age 65 reside in a long‐term care facility at some time before they die,1821 a figure projected to rise substantially over the next several decades. The much larger number of patients who are not dying but are living with chronic, debilitating, and life‐threatening illness also need expert symptom management, communication and decision‐making support, and coordination of care across settings. In one national survey, physicians reported that poor care coordination resulted in patient communication problems, lack of emotional support for patients, adverse drug reactions, unnecessary hospitalization, patients not functioning to potential, and unnecessary pain.22 In addition to studies demonstrating high degrees of symptom distress across all age groups in hospitalized and nursing home patients,814 other works have shown high use of burdensome, nonbeneficial technologies among the seriously ill,2327 caregiver burden on families,2831 and communication problems between these patients, their families, and their treating physicians about the goals of care and the medical decisions that should follow.32, 33 Other studies have reported broad dissatisfaction with the general quality of care for the seriously ill and dying in hospitals and nursing homes,18, 34 specifically, perceptions of impersonal and indifferent care. Several studies of patients and their families have identified relief of suffering, practical support needs, open communication, and opportunities to relieve burdens on and strengthen relationships with family as the top‐priority needs from the healthcare system.3440

The growth in the number and needs of the elderly with multiple chronic conditions who will turn to the healthcare system in coming years underscores the need to create a delivery system in the United States that can be responsive to these priorities. By 2030 the number of persons with chronic conditions will exceed 157 million.4144 With the possible exception of advanced cancer conditions (accounting for 24% of adult deaths), in which prognosis is somewhat more reliably linked to performance status,4243 prognostication of outcome is a highly inexact science for the chronically ill of all ages and in a range of diagnostic categories, including stroke, dementia, and end‐stage cardiac, renal, hepatic, and pulmonary diseases. This has been a major part of the impetus for the growth in palliative care services not predicated on a link to terminal prognoses.4143 Hospitals and nursing homes are under increasing pressure to structure care processes in a manner fitted to the needs of the seriously ill because of studies demonstrating poor quality of care, demands from patients and families, accreditation requirements, and the costs of care for this patient population. More than 95% of Medicare spending goes to the 63% of Medicare patients with two or more chronic conditions, and three quarters of Medicare dollars go to hospitals.44 Hospital costs have risen nearly 10% per year in each of the last 2 years, because of both the increasing numbers of patients turning to them for care and the growth in the number and expense of effective life‐prolonging therapies. These forces have stimulated the development of new models for the efficient and effective care of patients with serious and complex illness.2227, 44

CLINICAL COMPONENTS

The three primary domains of palliative care clinical practice are assessment and treatment of pain and other symptom distress, including psychiatric symptoms64; communication about goals of care and support for complex medical decision making; and provision of practical and psychosocial support, care coordination, and continuity, as well as bereavement services if death occurs.1, 2, 65 Palliative care specialists work to support primary and specialist physicians in the care of complex and seriously ill patients by providing intensive bedside treatment and reassessment of multiple‐symptom distress, by helping with time‐consuming and difficult interactions with distressed patients and family members, and by attempting to ensure a seamless, safe, and well‐communicated discharge and follow‐up process after the patient leaves the hospital.66 Resources for physicians seeking more knowledge or training in the treatment of symptom distress and other aspects of palliative care are given in Table 1.

The core components of symptom management67, 68 include: 1) Routine and repeated formal assessment, without which most symptoms will be neither identified nor addressed; 2) Expertise in prescribing, including the safe use of opioid analgesics, adjuvant approaches to pain management, and management of a wide range of other common and distressing symptoms and syndromes including, for example, delirium, dyspnea, fatigue, nausea, bowel obstruction, and depression69; and 3) Skillful management of treatment side effects, which is required to successfully control symptoms.

Communication skills and effective support for making decisions about clinical care goals include not only fundamental physician responsibilities such as communicating bad news and elucidating patient wishes for future care, but also the ability to promote communication and consensus about care goals among multiple specialist consultants, to address and resolve disagreements and conflicts among patients, families, and providers about goals of care, and to assist in the evolving process of balancing the benefits with the burdens of various medical interventions.32, 7073

The great majority of care for an illness is provided at home by family members neither trained nor emotionally prepared for these responsibilities.51, 74 The burden on family caregivers is one of the top concerns of seriously ill patients.35 Patients and families often struggle with anxieties about doing the wrong thing, difficulty traveling to physicians' offices, social isolation, and a high prevalence of preventable suffering of all types.3440 Palliative care clinicians attempt to improve the success and sustainability of the discharge plan by providing medically informed and therefore more appropriate care management recommendations and by mobilizing a range of community resources to increase the likelihood that families will be able to manage the care at home with the necessary supports and backups in place, including appropriate screening and referrals for complicated grief and bereavement.51, 75, 76 Several small prospective studies of palliative care have suggested that palliative care has resulted in reduction in the number of emergency department visits and hospitalizations and in the length of hospital stays, presumably because of the efficacy and comprehensiveness of care coordination in averting crises.54, 55, 61, 9798

CLINICAL MODELS

Given the multifaceted approach needed to support patient quality of life throughout advanced illness, one profession or individual cannot be expected to provide all aspects of palliative care. As described in the recently completed National Consensus Project Guidelines for Quality Palliative Care,2 specialty‐level palliative care is optimally delivered through an interdisciplinary team consisting of appropriately trained and credentialed physicians, nurses, and social workers with additional support and contributions from chaplains, rehabilitative experts, psychiatrists, and other professionals as indicated. Clearly, however, the staffing of a palliative care program will depend critically on the needs and capacities of the setting. A full interdisciplinary team is needed for a large tertiary‐care teaching hospital, whereas a part‐time advance‐practice nurse with backup from colleagues as needed may suffice for a small rural hospital or long‐term care setting. Specialist‐level palliative care is delivered through a range of clinical models and settings, including inpatient consultation services, dedicated inpatient units, and outpatient practices, among others.77, 78 Programs within the United States are housed in a range of clinical subspecialties including oncology, geriatrics, nursing, case management, hospitalist, and other programs, depending on the locus of leadership and administrative support.77, 78 Most programs are supported by utilizing diverse sources,77 including physician and nurse‐practitioner billing through insurers such as Medicare Part B,53, 81 as well as hospital support typically predicated on cost avoidance analyses, foundation and other grants, and philanthropy. Detailed guidance on appropriate documentation and billing for palliative care physician services may be found in Schapiro et al.,53 von Gunten,79 and on the Web site of the Center to Advance Palliative Care (www.capc.org).77

RELATIONSHIP TO HOSPICE

Although new clinical specialties in palliative medicine and nursing are emerging, in the United States palliative care for those in the terminal stages of illness has been delivered through hospice programs for more than 30 years. Under current regulatory and payment guidelines hospice care is delivered to patients who are certified by their physicians as likely to die within 6 months if the disease follows its usual course and who are willing to give up insurance coverage for medical treatment primarily focused on cure or prolongation of life. It is noteworthy that there is great variability among United States hospices, with some able to support continued disease‐modifying treatments such as chemotherapy and radiation if a patient so desires.2 Hospice programs aim to create increased opportunity for death at home, focusing on symptom control and the psychological and spiritual issues that are paramount to persons in the terminal phases of illness. Once the hospice benefit has been accessed, patients and families receive comprehensive case‐managed services across all settings of care (although the great majority of hospice care is delivered at home) from an interdisciplinary team, coverage for medications and equipment related to the terminal illness, and practical, psychosocial, respite, and bereavement support for caregivers.80, 81 Several recent studies have confirmed the findings of an earlier work82 in demonstrating the beneficial outcomes of hospice care including reduced mortality in spouses and high levels of family satisfaction.18, 83 Palliative care programs based in both hospital and community settings have led to increases in hospice referral rates and hospice length of stay, promoting continuity of palliative care and the intensive palliation and family support needed as death approaches.55 Coordination and partnerships between palliative care and hospice programs are critical to achieving continuity of palliative care throughout the full course of an illness and across the continuum of care settings.2

IMPACT OF PALLIATIVE CARE ON QUALITY OF CARE

Reports on palliative care specialist services utilizing diverse models and approaches have suggested a range of benefits from palliative care, including reduced pain4547 and other symptom distress,45, 48, 49 improved health‐related quality of life,95 high patient and family satisfaction18, 4951, 96 with care and with physician communication, and increased likelihood of the location of death being outside a hospital.33, 49, 52, 9799

Because it can help to demonstrate care structures, processes, and outcomes associated with improved quality (such as routine assessment of pain in the hospital), a palliative care program may help hospitals measure and meet Joint Commission for Accreditation of Healthcare Organizations (JCAHO) requirements in the domains of pain management, communication, family and patient education, and continuity of care, among others.53 Several groups have reported marked increases in hospice referral rate and hospice length of stay as a result of hospital‐ and nursing‐home‐based palliative care programs, presumably as a result of enhanced case identification, counseling, and referral processes.54, 55 Case control and observational studies of palliative care and ethics consultation services have demonstrated reductions in costs per day and in hospital and ICU lengths of stay, presumably because of enhanced support for discussions about the goals of care and the resulting facilitation of patient and family decisions about the types and settings of future care.50, 5561 Hospitals have begun to invest in palliative care services, both to enhance quality of care and because of their measurable impact on reducing ICU and total bed days and their efficacy in supporting transitions from high‐intensity, high‐cost hospital settings to more appropriate and desired care settings, such as the home.5563, 9798 Observational studies have yielded no differences in mortality between patients receiving palliative care and controls receiving the usual care.48, 55, 56

EDUCATION IN PALLIATIVE CARE

Curricular content on palliative care has been noticeably lacking from medical and nursing education curricula, textbooks, and certifying examinations, although this is beginning to change.8491 Both the Liaison Committee for Medical Education (LCME) and the Accreditation Council for Graduate Medical Education (ACGME) now require or strongly encourage programs to provide under‐ and postgraduate training in palliative care in order to be accredited.89, 90 As of 2005, more than 50% of teaching hospitals had established palliative care clinical services,92 which constitute the necessary platform for clinical training. The rapid growth in the availability of postgraduate fellowship training in palliative medicine will produce the faculty leaders needed for these educational and research programs in medical school and residency training programs.93, 94 Physicians in practice may gain knowledge and skills through a range of national courses and Web‐based resources and through preparation for the certifying exam given annually by the American Board of Hospice and Palliative Medicine4 (Table 1).

CONCLUSIONS

The growth in palliative care specialists and programs in hospitals in the United States represents a grass roots professional response to the needs of a patient population with chronic advanced illnesses and family care burdens within a healthcare system structured to provide care for acute intercurrent illness. Rapid increases in the number of new hospital programs, as well as early studies indicating improved clinical, satisfaction, and utilization outcomes, suggest that palliative care services are likely to become a routine and well‐integrated part of the healthcare continuum in the United States over the next several years. A number of resources are available to healthcare professionals seeking more training as well as to hospitals or nursing homes wishing to establish their own clinical or educational programs. Such programs have provided a platform for both newly graduated and seasoned professionals to continue to serve the needs of their patients through the assessment and relief of suffering, provided simultaneously with efforts to cure or mitigate disease.

The field of palliative care has grown rapidly in recent years in response to patient need and clinician interest in effective approaches to managing chronic life‐threatening illness.1 This article reviews the clinical, educational, demographic, and financial imperatives driving this growth, describes the clinical components of palliative care and the range of service models available, defines the relationship of hospital‐based palliative care to hospice, summarizes the literature on palliative care outcomes, and presents practical resources for clinicians seeking knowledge and skills in the field.

DEFINITION

Palliative care is medical care focused on the relief of suffering and support for the best possible quality of life for patients facing serious, life‐threatening illness and their families. It aims to identify and address the physical, psychological, and practical burdens of illness. Palliative care in the United States grew out of the hospice movement that originated in both the United Kingdom and the United States about 30 years ago. Hospice care was developed specifically to address the needs of the dying and their families and was codified in the United States by the addition in 1983 of a federal Medicare benefit for hospice care. In the last 30 years the Medicare hospice benefit has enabled more than 7 million patients and their families to receive intensive palliative care for the terminally ill, primarily in the home. The growth in the number and needs of seriously and chronically ill patients who are not clearly terminally ill has led to the development of palliative care services outside the hospice benefit provided by Medicare (and other insurers). Both hospice and nonhospice professionals have participated in extending the hospice approach through development of palliative care services. Palliative care may be delivered simultaneously with all appropriate curative and life‐prolonging interventions. In practice, palliative care practitioners provide assessment and treatment of pain and other symptom distress; employ communication skills with patients, families, and colleagues; support complex medical decision making and goal setting based on identifying and respecting patient wishes and goals; and promote medically informed care coordination, continuity, and practical support for patients, family caregivers, and professional colleagues across healthcare settings and through the trajectory of an illness.1, 2

Palliative care is both a general approach to health care and a growing practice specialty for professionals committing most or all of their time to the delivery of palliative care services.3 The term palliative medicine refers to the physician discipline within the larger field of palliative care. As of 2005, more than 1890 physicians have received specialty certification through a palliative care credentialing exam given by the American Board of Hospice and Palliative Medicine.4 Formal recognition of the subspecialty is currently being sought in collaboration with the American Board of Medical Specialties.5 As of August 2005, there were more than 50 postgraduate palliative care subspecialty fellowship programs in the United States.6 Between 2000 and 2003, the American Hospital Association (AHA) annual survey recorded a 67% growth in the number of hospital‐based palliative care programs reported, from 632 to 1027, for a total of 25% of responding AHA member hospitals.7

REASONS FOR GROWTH IN PALLIATIVE CARE

A primary justification for the rapid growth in palliative care programs in institutional settings is the abundant data demonstrating the high prevalence of pain and symptom distress in hospitals,811 nursing homes,12, 13 and community settings.14 Virtually all persons with serious illness spend at least some time in a hospital, usually on multiple occasions, in the course of their disease or condition.15 Despite the finding that when polled more than 90% of Americans say they would prefer to die at home, more than 75% of adult deaths occur in institutional settings (hospital or nursing homes)more than 50% in hospitals and 25% in nursing homesand 85% of pediatric deaths occur in hospitals.16, 17 Further, more than half of persons older than age 85 die in a nursing home and 43% of persons older than age 65 reside in a long‐term care facility at some time before they die,1821 a figure projected to rise substantially over the next several decades. The much larger number of patients who are not dying but are living with chronic, debilitating, and life‐threatening illness also need expert symptom management, communication and decision‐making support, and coordination of care across settings. In one national survey, physicians reported that poor care coordination resulted in patient communication problems, lack of emotional support for patients, adverse drug reactions, unnecessary hospitalization, patients not functioning to potential, and unnecessary pain.22 In addition to studies demonstrating high degrees of symptom distress across all age groups in hospitalized and nursing home patients,814 other works have shown high use of burdensome, nonbeneficial technologies among the seriously ill,2327 caregiver burden on families,2831 and communication problems between these patients, their families, and their treating physicians about the goals of care and the medical decisions that should follow.32, 33 Other studies have reported broad dissatisfaction with the general quality of care for the seriously ill and dying in hospitals and nursing homes,18, 34 specifically, perceptions of impersonal and indifferent care. Several studies of patients and their families have identified relief of suffering, practical support needs, open communication, and opportunities to relieve burdens on and strengthen relationships with family as the top‐priority needs from the healthcare system.3440

The growth in the number and needs of the elderly with multiple chronic conditions who will turn to the healthcare system in coming years underscores the need to create a delivery system in the United States that can be responsive to these priorities. By 2030 the number of persons with chronic conditions will exceed 157 million.4144 With the possible exception of advanced cancer conditions (accounting for 24% of adult deaths), in which prognosis is somewhat more reliably linked to performance status,4243 prognostication of outcome is a highly inexact science for the chronically ill of all ages and in a range of diagnostic categories, including stroke, dementia, and end‐stage cardiac, renal, hepatic, and pulmonary diseases. This has been a major part of the impetus for the growth in palliative care services not predicated on a link to terminal prognoses.4143 Hospitals and nursing homes are under increasing pressure to structure care processes in a manner fitted to the needs of the seriously ill because of studies demonstrating poor quality of care, demands from patients and families, accreditation requirements, and the costs of care for this patient population. More than 95% of Medicare spending goes to the 63% of Medicare patients with two or more chronic conditions, and three quarters of Medicare dollars go to hospitals.44 Hospital costs have risen nearly 10% per year in each of the last 2 years, because of both the increasing numbers of patients turning to them for care and the growth in the number and expense of effective life‐prolonging therapies. These forces have stimulated the development of new models for the efficient and effective care of patients with serious and complex illness.2227, 44

CLINICAL COMPONENTS

The three primary domains of palliative care clinical practice are assessment and treatment of pain and other symptom distress, including psychiatric symptoms64; communication about goals of care and support for complex medical decision making; and provision of practical and psychosocial support, care coordination, and continuity, as well as bereavement services if death occurs.1, 2, 65 Palliative care specialists work to support primary and specialist physicians in the care of complex and seriously ill patients by providing intensive bedside treatment and reassessment of multiple‐symptom distress, by helping with time‐consuming and difficult interactions with distressed patients and family members, and by attempting to ensure a seamless, safe, and well‐communicated discharge and follow‐up process after the patient leaves the hospital.66 Resources for physicians seeking more knowledge or training in the treatment of symptom distress and other aspects of palliative care are given in Table 1.

The core components of symptom management67, 68 include: 1) Routine and repeated formal assessment, without which most symptoms will be neither identified nor addressed; 2) Expertise in prescribing, including the safe use of opioid analgesics, adjuvant approaches to pain management, and management of a wide range of other common and distressing symptoms and syndromes including, for example, delirium, dyspnea, fatigue, nausea, bowel obstruction, and depression69; and 3) Skillful management of treatment side effects, which is required to successfully control symptoms.

Communication skills and effective support for making decisions about clinical care goals include not only fundamental physician responsibilities such as communicating bad news and elucidating patient wishes for future care, but also the ability to promote communication and consensus about care goals among multiple specialist consultants, to address and resolve disagreements and conflicts among patients, families, and providers about goals of care, and to assist in the evolving process of balancing the benefits with the burdens of various medical interventions.32, 7073

The great majority of care for an illness is provided at home by family members neither trained nor emotionally prepared for these responsibilities.51, 74 The burden on family caregivers is one of the top concerns of seriously ill patients.35 Patients and families often struggle with anxieties about doing the wrong thing, difficulty traveling to physicians' offices, social isolation, and a high prevalence of preventable suffering of all types.3440 Palliative care clinicians attempt to improve the success and sustainability of the discharge plan by providing medically informed and therefore more appropriate care management recommendations and by mobilizing a range of community resources to increase the likelihood that families will be able to manage the care at home with the necessary supports and backups in place, including appropriate screening and referrals for complicated grief and bereavement.51, 75, 76 Several small prospective studies of palliative care have suggested that palliative care has resulted in reduction in the number of emergency department visits and hospitalizations and in the length of hospital stays, presumably because of the efficacy and comprehensiveness of care coordination in averting crises.54, 55, 61, 9798

CLINICAL MODELS

Given the multifaceted approach needed to support patient quality of life throughout advanced illness, one profession or individual cannot be expected to provide all aspects of palliative care. As described in the recently completed National Consensus Project Guidelines for Quality Palliative Care,2 specialty‐level palliative care is optimally delivered through an interdisciplinary team consisting of appropriately trained and credentialed physicians, nurses, and social workers with additional support and contributions from chaplains, rehabilitative experts, psychiatrists, and other professionals as indicated. Clearly, however, the staffing of a palliative care program will depend critically on the needs and capacities of the setting. A full interdisciplinary team is needed for a large tertiary‐care teaching hospital, whereas a part‐time advance‐practice nurse with backup from colleagues as needed may suffice for a small rural hospital or long‐term care setting. Specialist‐level palliative care is delivered through a range of clinical models and settings, including inpatient consultation services, dedicated inpatient units, and outpatient practices, among others.77, 78 Programs within the United States are housed in a range of clinical subspecialties including oncology, geriatrics, nursing, case management, hospitalist, and other programs, depending on the locus of leadership and administrative support.77, 78 Most programs are supported by utilizing diverse sources,77 including physician and nurse‐practitioner billing through insurers such as Medicare Part B,53, 81 as well as hospital support typically predicated on cost avoidance analyses, foundation and other grants, and philanthropy. Detailed guidance on appropriate documentation and billing for palliative care physician services may be found in Schapiro et al.,53 von Gunten,79 and on the Web site of the Center to Advance Palliative Care (www.capc.org).77

RELATIONSHIP TO HOSPICE

Although new clinical specialties in palliative medicine and nursing are emerging, in the United States palliative care for those in the terminal stages of illness has been delivered through hospice programs for more than 30 years. Under current regulatory and payment guidelines hospice care is delivered to patients who are certified by their physicians as likely to die within 6 months if the disease follows its usual course and who are willing to give up insurance coverage for medical treatment primarily focused on cure or prolongation of life. It is noteworthy that there is great variability among United States hospices, with some able to support continued disease‐modifying treatments such as chemotherapy and radiation if a patient so desires.2 Hospice programs aim to create increased opportunity for death at home, focusing on symptom control and the psychological and spiritual issues that are paramount to persons in the terminal phases of illness. Once the hospice benefit has been accessed, patients and families receive comprehensive case‐managed services across all settings of care (although the great majority of hospice care is delivered at home) from an interdisciplinary team, coverage for medications and equipment related to the terminal illness, and practical, psychosocial, respite, and bereavement support for caregivers.80, 81 Several recent studies have confirmed the findings of an earlier work82 in demonstrating the beneficial outcomes of hospice care including reduced mortality in spouses and high levels of family satisfaction.18, 83 Palliative care programs based in both hospital and community settings have led to increases in hospice referral rates and hospice length of stay, promoting continuity of palliative care and the intensive palliation and family support needed as death approaches.55 Coordination and partnerships between palliative care and hospice programs are critical to achieving continuity of palliative care throughout the full course of an illness and across the continuum of care settings.2

IMPACT OF PALLIATIVE CARE ON QUALITY OF CARE

Reports on palliative care specialist services utilizing diverse models and approaches have suggested a range of benefits from palliative care, including reduced pain4547 and other symptom distress,45, 48, 49 improved health‐related quality of life,95 high patient and family satisfaction18, 4951, 96 with care and with physician communication, and increased likelihood of the location of death being outside a hospital.33, 49, 52, 9799

Because it can help to demonstrate care structures, processes, and outcomes associated with improved quality (such as routine assessment of pain in the hospital), a palliative care program may help hospitals measure and meet Joint Commission for Accreditation of Healthcare Organizations (JCAHO) requirements in the domains of pain management, communication, family and patient education, and continuity of care, among others.53 Several groups have reported marked increases in hospice referral rate and hospice length of stay as a result of hospital‐ and nursing‐home‐based palliative care programs, presumably as a result of enhanced case identification, counseling, and referral processes.54, 55 Case control and observational studies of palliative care and ethics consultation services have demonstrated reductions in costs per day and in hospital and ICU lengths of stay, presumably because of enhanced support for discussions about the goals of care and the resulting facilitation of patient and family decisions about the types and settings of future care.50, 5561 Hospitals have begun to invest in palliative care services, both to enhance quality of care and because of their measurable impact on reducing ICU and total bed days and their efficacy in supporting transitions from high‐intensity, high‐cost hospital settings to more appropriate and desired care settings, such as the home.5563, 9798 Observational studies have yielded no differences in mortality between patients receiving palliative care and controls receiving the usual care.48, 55, 56

EDUCATION IN PALLIATIVE CARE

Curricular content on palliative care has been noticeably lacking from medical and nursing education curricula, textbooks, and certifying examinations, although this is beginning to change.8491 Both the Liaison Committee for Medical Education (LCME) and the Accreditation Council for Graduate Medical Education (ACGME) now require or strongly encourage programs to provide under‐ and postgraduate training in palliative care in order to be accredited.89, 90 As of 2005, more than 50% of teaching hospitals had established palliative care clinical services,92 which constitute the necessary platform for clinical training. The rapid growth in the availability of postgraduate fellowship training in palliative medicine will produce the faculty leaders needed for these educational and research programs in medical school and residency training programs.93, 94 Physicians in practice may gain knowledge and skills through a range of national courses and Web‐based resources and through preparation for the certifying exam given annually by the American Board of Hospice and Palliative Medicine4 (Table 1).

CONCLUSIONS

The growth in palliative care specialists and programs in hospitals in the United States represents a grass roots professional response to the needs of a patient population with chronic advanced illnesses and family care burdens within a healthcare system structured to provide care for acute intercurrent illness. Rapid increases in the number of new hospital programs, as well as early studies indicating improved clinical, satisfaction, and utilization outcomes, suggest that palliative care services are likely to become a routine and well‐integrated part of the healthcare continuum in the United States over the next several years. A number of resources are available to healthcare professionals seeking more training as well as to hospitals or nursing homes wishing to establish their own clinical or educational programs. Such programs have provided a platform for both newly graduated and seasoned professionals to continue to serve the needs of their patients through the assessment and relief of suffering, provided simultaneously with efforts to cure or mitigate disease.

I'm used to feeling inadequate. Oftentimes, what ails my patients I'm not able to address, let alone fix. But one time I crossed the line from absorber of sorrows to active agent.

All set with my preconceived notions, I went into the hospital room to see Stan. He had severe hypertension and had had several previous transient ischemic attacks, and now he was back with another. His renal function was minimal, with dialysis coming soon. Despite our repeatedly having social work arrange outpatient appointments, he had never followed up. Last admission, they even gave him a month's worth of his antihypertensive medications, but here he was 6 weeks later off meds and admitted again.

I spoke with him but we got nowhere. He maintained that he could not afford his medication. I asked him why he didn't work. He said that he did do odd jobs, and besides, in a few months he would qualify for Social Security. I guess I was in a bad mood, so I heard myself ask, Do you realize you are playing with fire here? You will end up with a real stroke? Simply saying you want to wait for Social Security is not a plan.

Stan looked at me closely. Probably judging me to be about half his age, he said, Whatever, doc. Don't you have someone else to lecture? I sat down, took a deep breath, and tried to sound kind when I said, Do you realize that you will need dialysis soon? Stan replied that he had no intention of going on dialysis. We went in circles, with me trying to determine if he was delusional, suicidal, or trying to shock me. We left it as it was. The medical system would do its best, but his life was his to run.

Bending the HIPPA rules, I went to the nurse's station and called Stan's daughter to get some background, answers to questions like why she couldn't help him buy his medication. I was wholly in my righteous problem‐solving mode. Yet she was not alarmed by my dire prognostics. When the call was about to end, I asked if all of us could meet when she came to pick him up the next day. After a pause, she stated, I'm not coming up. Tell him to wait in the lobby for me. I'll be there to pick him up sometime after 5. Collecting her dad from the hospital on Christmas Eve, and she couldn't be bothered to enter the building? I hung up, sat back in my chair, and stared at my progress note.

I subsequently found out from the case manager that after being discharged, unlike before, he was going to a homeless shelter, not his daughter's house. I thought he must have been an awful father for a child to turn her own dad away on Christmas Eve.

Clearly, she had had no intention of picking him up from the hospital before my call; I had inadvertently shamed her into it.

I went back to talk with Stan. I decided to make inquiries of him based only on the information I was supposed to have. The case manager tells me you're going to the homeless shelter tomorrow. Don't you live with your daughter?

Not realizing that the doctors and case managers were on the same team, he seemed somewhat taken aback. I found a chair and sat down as he spoke. I wasn't always like this, you know. I'm not a drinker, nuts, or anything; I just was put out to pasture. I'm a computer programmer but not the new kind. I worked on those huge 1960s types. The personal computer revolution put me out of business. Before I had a chance to say anything, he continued, I know what you're thinking, I should have gotten trained or something to keep up, but I didn't, you know, I just didn't. I should've.

He must have seen a flicker of compassion on my face, as he went on, I've been staying with my daughter on and off for years. I'd get some job, get a place, but never for long. I don't like to stay with her. She has her own life, her own problems. She doesn't need me getting in the way, especially around Christmas. Around the holidays, I go to the shelter. My grandkids don't need me ruining the season.

He may well have been a lousy father, but I didn't see his medical noncompliance as a personal affront anymore. He should have made some different decisions in the past, but now he was a 64‐year‐old homeless man, alone. So, besides lecturing him on his blood pressure and work habits, could I do anything really helpful?

It didn't take me long to come up with something. The problem was how to approach it. Feeling like I was breaking some rule, I trailed him to the hospital lobby right after discharge. To my chagrin, he didn't so much as slow down. He saw his daughter's car, walked out, and got in her car before I knew what to do. Feeling like a fool, I stood at the window, noted how slate gray and dour the sky was, in complete contrast to the festive lobby, and thought about how useless I really was in the end. All my good intentions aside, he was no better off for having me as his doctor.

I bought myself a cup of coffee and while walking lost in thought, I literally bumped into Stan coming through the hospital's main doors. Laughing awkwardly, he said, I forgot my jacket in my room. He looked more scared now than he did after hearing my dire pronouncements of doom. He seemed like a child whose mother was angry at his forgetfulness. As he shuffled off, I couldn't stand it any longer. I didn't want him rushing around worried that his daughter would get fed up and leave. I told him to tell his daughter that I knew where his jacket was and that I'd be right back with it.

I got the coat, and when I approached him back in the lobby, I gave it to him. I then handed him the money I had set aside in my white coat. Trying to make myself sound casual, I said, Use this to take your grandkids out to dinner and buy them something. Neither wanting to give him a chance to say no nor wishing to make it more awkward for him, I quickly turned around and left without looking back.

As I resumed my $2 cup of coffee, I wondered if I had acted as a doctor, as a good Samaritan, or as an egoist? I was not deluded into believing I could buy his pride back for long with my pocket change. But maybe I could be a good person in addition to a caring, up‐to‐date doctor.

Later that day in the ER, a very sad place on Christmas Eve, I imagined Stan buying gifts or a fancy dinner for his family, just like he used to. He will need dialysis and probably will end up back in the shelter. I don't think he even knew my name, but maybe because I cared a little bit about what happened to him, he will, too.

I'm used to feeling inadequate. Oftentimes, what ails my patients I'm not able to address, let alone fix. But one time I crossed the line from absorber of sorrows to active agent.

All set with my preconceived notions, I went into the hospital room to see Stan. He had severe hypertension and had had several previous transient ischemic attacks, and now he was back with another. His renal function was minimal, with dialysis coming soon. Despite our repeatedly having social work arrange outpatient appointments, he had never followed up. Last admission, they even gave him a month's worth of his antihypertensive medications, but here he was 6 weeks later off meds and admitted again.

I spoke with him but we got nowhere. He maintained that he could not afford his medication. I asked him why he didn't work. He said that he did do odd jobs, and besides, in a few months he would qualify for Social Security. I guess I was in a bad mood, so I heard myself ask, Do you realize you are playing with fire here? You will end up with a real stroke? Simply saying you want to wait for Social Security is not a plan.

Stan looked at me closely. Probably judging me to be about half his age, he said, Whatever, doc. Don't you have someone else to lecture? I sat down, took a deep breath, and tried to sound kind when I said, Do you realize that you will need dialysis soon? Stan replied that he had no intention of going on dialysis. We went in circles, with me trying to determine if he was delusional, suicidal, or trying to shock me. We left it as it was. The medical system would do its best, but his life was his to run.

Bending the HIPPA rules, I went to the nurse's station and called Stan's daughter to get some background, answers to questions like why she couldn't help him buy his medication. I was wholly in my righteous problem‐solving mode. Yet she was not alarmed by my dire prognostics. When the call was about to end, I asked if all of us could meet when she came to pick him up the next day. After a pause, she stated, I'm not coming up. Tell him to wait in the lobby for me. I'll be there to pick him up sometime after 5. Collecting her dad from the hospital on Christmas Eve, and she couldn't be bothered to enter the building? I hung up, sat back in my chair, and stared at my progress note.

I subsequently found out from the case manager that after being discharged, unlike before, he was going to a homeless shelter, not his daughter's house. I thought he must have been an awful father for a child to turn her own dad away on Christmas Eve.

Clearly, she had had no intention of picking him up from the hospital before my call; I had inadvertently shamed her into it.

I went back to talk with Stan. I decided to make inquiries of him based only on the information I was supposed to have. The case manager tells me you're going to the homeless shelter tomorrow. Don't you live with your daughter?

Not realizing that the doctors and case managers were on the same team, he seemed somewhat taken aback. I found a chair and sat down as he spoke. I wasn't always like this, you know. I'm not a drinker, nuts, or anything; I just was put out to pasture. I'm a computer programmer but not the new kind. I worked on those huge 1960s types. The personal computer revolution put me out of business. Before I had a chance to say anything, he continued, I know what you're thinking, I should have gotten trained or something to keep up, but I didn't, you know, I just didn't. I should've.

He must have seen a flicker of compassion on my face, as he went on, I've been staying with my daughter on and off for years. I'd get some job, get a place, but never for long. I don't like to stay with her. She has her own life, her own problems. She doesn't need me getting in the way, especially around Christmas. Around the holidays, I go to the shelter. My grandkids don't need me ruining the season.

He may well have been a lousy father, but I didn't see his medical noncompliance as a personal affront anymore. He should have made some different decisions in the past, but now he was a 64‐year‐old homeless man, alone. So, besides lecturing him on his blood pressure and work habits, could I do anything really helpful?

It didn't take me long to come up with something. The problem was how to approach it. Feeling like I was breaking some rule, I trailed him to the hospital lobby right after discharge. To my chagrin, he didn't so much as slow down. He saw his daughter's car, walked out, and got in her car before I knew what to do. Feeling like a fool, I stood at the window, noted how slate gray and dour the sky was, in complete contrast to the festive lobby, and thought about how useless I really was in the end. All my good intentions aside, he was no better off for having me as his doctor.

I bought myself a cup of coffee and while walking lost in thought, I literally bumped into Stan coming through the hospital's main doors. Laughing awkwardly, he said, I forgot my jacket in my room. He looked more scared now than he did after hearing my dire pronouncements of doom. He seemed like a child whose mother was angry at his forgetfulness. As he shuffled off, I couldn't stand it any longer. I didn't want him rushing around worried that his daughter would get fed up and leave. I told him to tell his daughter that I knew where his jacket was and that I'd be right back with it.

I got the coat, and when I approached him back in the lobby, I gave it to him. I then handed him the money I had set aside in my white coat. Trying to make myself sound casual, I said, Use this to take your grandkids out to dinner and buy them something. Neither wanting to give him a chance to say no nor wishing to make it more awkward for him, I quickly turned around and left without looking back.

As I resumed my $2 cup of coffee, I wondered if I had acted as a doctor, as a good Samaritan, or as an egoist? I was not deluded into believing I could buy his pride back for long with my pocket change. But maybe I could be a good person in addition to a caring, up‐to‐date doctor.

Later that day in the ER, a very sad place on Christmas Eve, I imagined Stan buying gifts or a fancy dinner for his family, just like he used to. He will need dialysis and probably will end up back in the shelter. I don't think he even knew my name, but maybe because I cared a little bit about what happened to him, he will, too.

I'm used to feeling inadequate. Oftentimes, what ails my patients I'm not able to address, let alone fix. But one time I crossed the line from absorber of sorrows to active agent.

All set with my preconceived notions, I went into the hospital room to see Stan. He had severe hypertension and had had several previous transient ischemic attacks, and now he was back with another. His renal function was minimal, with dialysis coming soon. Despite our repeatedly having social work arrange outpatient appointments, he had never followed up. Last admission, they even gave him a month's worth of his antihypertensive medications, but here he was 6 weeks later off meds and admitted again.

I spoke with him but we got nowhere. He maintained that he could not afford his medication. I asked him why he didn't work. He said that he did do odd jobs, and besides, in a few months he would qualify for Social Security. I guess I was in a bad mood, so I heard myself ask, Do you realize you are playing with fire here? You will end up with a real stroke? Simply saying you want to wait for Social Security is not a plan.

Stan looked at me closely. Probably judging me to be about half his age, he said, Whatever, doc. Don't you have someone else to lecture? I sat down, took a deep breath, and tried to sound kind when I said, Do you realize that you will need dialysis soon? Stan replied that he had no intention of going on dialysis. We went in circles, with me trying to determine if he was delusional, suicidal, or trying to shock me. We left it as it was. The medical system would do its best, but his life was his to run.

Bending the HIPPA rules, I went to the nurse's station and called Stan's daughter to get some background, answers to questions like why she couldn't help him buy his medication. I was wholly in my righteous problem‐solving mode. Yet she was not alarmed by my dire prognostics. When the call was about to end, I asked if all of us could meet when she came to pick him up the next day. After a pause, she stated, I'm not coming up. Tell him to wait in the lobby for me. I'll be there to pick him up sometime after 5. Collecting her dad from the hospital on Christmas Eve, and she couldn't be bothered to enter the building? I hung up, sat back in my chair, and stared at my progress note.

I subsequently found out from the case manager that after being discharged, unlike before, he was going to a homeless shelter, not his daughter's house. I thought he must have been an awful father for a child to turn her own dad away on Christmas Eve.

Clearly, she had had no intention of picking him up from the hospital before my call; I had inadvertently shamed her into it.

I went back to talk with Stan. I decided to make inquiries of him based only on the information I was supposed to have. The case manager tells me you're going to the homeless shelter tomorrow. Don't you live with your daughter?

Not realizing that the doctors and case managers were on the same team, he seemed somewhat taken aback. I found a chair and sat down as he spoke. I wasn't always like this, you know. I'm not a drinker, nuts, or anything; I just was put out to pasture. I'm a computer programmer but not the new kind. I worked on those huge 1960s types. The personal computer revolution put me out of business. Before I had a chance to say anything, he continued, I know what you're thinking, I should have gotten trained or something to keep up, but I didn't, you know, I just didn't. I should've.

He must have seen a flicker of compassion on my face, as he went on, I've been staying with my daughter on and off for years. I'd get some job, get a place, but never for long. I don't like to stay with her. She has her own life, her own problems. She doesn't need me getting in the way, especially around Christmas. Around the holidays, I go to the shelter. My grandkids don't need me ruining the season.

He may well have been a lousy father, but I didn't see his medical noncompliance as a personal affront anymore. He should have made some different decisions in the past, but now he was a 64‐year‐old homeless man, alone. So, besides lecturing him on his blood pressure and work habits, could I do anything really helpful?

It didn't take me long to come up with something. The problem was how to approach it. Feeling like I was breaking some rule, I trailed him to the hospital lobby right after discharge. To my chagrin, he didn't so much as slow down. He saw his daughter's car, walked out, and got in her car before I knew what to do. Feeling like a fool, I stood at the window, noted how slate gray and dour the sky was, in complete contrast to the festive lobby, and thought about how useless I really was in the end. All my good intentions aside, he was no better off for having me as his doctor.

I bought myself a cup of coffee and while walking lost in thought, I literally bumped into Stan coming through the hospital's main doors. Laughing awkwardly, he said, I forgot my jacket in my room. He looked more scared now than he did after hearing my dire pronouncements of doom. He seemed like a child whose mother was angry at his forgetfulness. As he shuffled off, I couldn't stand it any longer. I didn't want him rushing around worried that his daughter would get fed up and leave. I told him to tell his daughter that I knew where his jacket was and that I'd be right back with it.

I got the coat, and when I approached him back in the lobby, I gave it to him. I then handed him the money I had set aside in my white coat. Trying to make myself sound casual, I said, Use this to take your grandkids out to dinner and buy them something. Neither wanting to give him a chance to say no nor wishing to make it more awkward for him, I quickly turned around and left without looking back.

As I resumed my $2 cup of coffee, I wondered if I had acted as a doctor, as a good Samaritan, or as an egoist? I was not deluded into believing I could buy his pride back for long with my pocket change. But maybe I could be a good person in addition to a caring, up‐to‐date doctor.

Later that day in the ER, a very sad place on Christmas Eve, I imagined Stan buying gifts or a fancy dinner for his family, just like he used to. He will need dialysis and probably will end up back in the shelter. I don't think he even knew my name, but maybe because I cared a little bit about what happened to him, he will, too.

Between 1996with the first appearance of hospitalists in the medical literatureand the present, the hospitalist workforce has grown to nearly 10,000.1, 2 More remarkable is the estimate that the number of hospitalists will double in the next 5 years.2 The rapid growth of hospital medicine raises significant issues for the care of older patients, who are hospitalized at high rates3 and suffer numerous complications from hospitalization including functional decline,4 delirium,5 and a disproportionate share of adverse events.6 Conversely, the needs of patients older than 65 years of age, whose hospital stays make up nearly 50% of acute‐care bed days, will shape the future of hospital medicine.3

To date, the hospital medicine literature has failed to address the particular challenges of treating older patients, focusing primarily on opportunities for reductions in costs and length of stay for hospitalists' Medicare patients (of about $1000 per admission and 0.5 days, respectively7, 8) when compared with those cared for by other physicians. This focus on economic efficiency reflects the early orientation of the hospitalist movement. More recently, leaders of the hospitalist professional organization, the Society of Hospital Medicine (SHM), have increasingly recognized that caring for the older population will require additional knowledge and clinical skills beyond that taught in internal medicine residencies.9 Beyond educational initiatives, however, hospitalists must reconsider the paradigms of hospital care that make the hospital setting so dangerous for the older patient.

Given the aging population and the predicted growth of hospital medicine, it is essential to develop an understanding of the impact of hospitalists on the care of older patients and to encourage clinical innovation at the intersection of hospital medicine and geriatrics. Consequently, this article 1) identifies and summarizes geriatric care approaches in hospitalist programs, 2) presents a case study of geriatric hospital care by a hospitalist group, and 3) highlights opportunities for innovation and further research.

METHODS

RESULTS

In 2003 the annual survey of the American Hospital Association identified 1415 hospitalist groups in the United States (Joe Miller, SHM senior vice‐president, personal communication). Remarkably, our query identified only 11 hospitalist groups with clinical innovations aimed at the older population. These innovations ranged from single individuals involved in targeted quality‐improvement projects to highly developed programs addressing an array of clinical needs for the hospitalized older patient. These 11 programs are summarized in Table 1 and described below.

DISCUSSION

Although SHM increasingly recognizes the challenges inherent in caring for older patients, few hospitalists are adapting their care for this vulnerable population. We identified only 11 innovations in geriatric care despite there being more than 1000 hospitalist groups. This apparent paucity of innovation in geriatrics might be explained by the relatively recent introduction of hospital medicine. As no hospitalist program is more than 10 years old, most programs are still focused on building core clinical activities or on other competing demands. In addition to time, funding may limit the typical program's ability to innovate without directly increasing revenue. Although the geriatrics literature supports that specialized inpatient care for older patients can result in increased physical functioning and quality of life at no additional cost, it may be that geriatricians have yet to make this case effectively to the hospitalist community.14, 15

The findings of this study were limited by our survey methodology. Specifically, our sample was limited to professional contacts and those using SHM listservs. In addition, some innovative hospitalists may not consider their programs to be geriatric programs and so may not have responded to our queries. Therefore, the reported innovations are not representative of geriatric care among all hospitalist groups, and we are unable to provide a comprehensive picture of geriatric care in hospitalist programs. In addition, we cannot comment on the effectiveness of the care approaches at participating institutions. For example, interdisciplinary care is an important tenet of geriatric medicine. Although six of our programs reported interdisciplinary rounds, it is unclear if these rounds are models of effective collaborative practice. Nonetheless, the information obtained from the structured interviews allowed the identification of several instructive themes discussed below.

CONCLUSIONS

The rapid growth of the hospitalist movement will significantly affect clinical care in American hospitals. As most hospital patients are older, the impact on acute care geriatrics cannot be overlooked. In our study, we identified only a small number of hospitalist groups that have made geriatric medicine a priority. These programs prioritize geriatric medicine through the employment of geriatrics‐trained staff, adaptation of geriatric care models such as ACE units, and commitment to clinical quality improvement and patient safety. They also focus on common clinical challenges for older patients, including postoperative and postdischarge care. Although much can be learned from these examples, programs at other institutions will need to be individualized to meet the specific needs of each hospital and community. The common goal of clinical excellence shared by hospitalists and geriatricians should motivate cooperation, collaborative approaches, and a joint clinical research agenda at all levels, as the current paradigm of hospital care remains inadequate to meet the needs of the acutely ill older patient.

Between 1996with the first appearance of hospitalists in the medical literatureand the present, the hospitalist workforce has grown to nearly 10,000.1, 2 More remarkable is the estimate that the number of hospitalists will double in the next 5 years.2 The rapid growth of hospital medicine raises significant issues for the care of older patients, who are hospitalized at high rates3 and suffer numerous complications from hospitalization including functional decline,4 delirium,5 and a disproportionate share of adverse events.6 Conversely, the needs of patients older than 65 years of age, whose hospital stays make up nearly 50% of acute‐care bed days, will shape the future of hospital medicine.3

To date, the hospital medicine literature has failed to address the particular challenges of treating older patients, focusing primarily on opportunities for reductions in costs and length of stay for hospitalists' Medicare patients (of about $1000 per admission and 0.5 days, respectively7, 8) when compared with those cared for by other physicians. This focus on economic efficiency reflects the early orientation of the hospitalist movement. More recently, leaders of the hospitalist professional organization, the Society of Hospital Medicine (SHM), have increasingly recognized that caring for the older population will require additional knowledge and clinical skills beyond that taught in internal medicine residencies.9 Beyond educational initiatives, however, hospitalists must reconsider the paradigms of hospital care that make the hospital setting so dangerous for the older patient.

Given the aging population and the predicted growth of hospital medicine, it is essential to develop an understanding of the impact of hospitalists on the care of older patients and to encourage clinical innovation at the intersection of hospital medicine and geriatrics. Consequently, this article 1) identifies and summarizes geriatric care approaches in hospitalist programs, 2) presents a case study of geriatric hospital care by a hospitalist group, and 3) highlights opportunities for innovation and further research.

METHODS

RESULTS

In 2003 the annual survey of the American Hospital Association identified 1415 hospitalist groups in the United States (Joe Miller, SHM senior vice‐president, personal communication). Remarkably, our query identified only 11 hospitalist groups with clinical innovations aimed at the older population. These innovations ranged from single individuals involved in targeted quality‐improvement projects to highly developed programs addressing an array of clinical needs for the hospitalized older patient. These 11 programs are summarized in Table 1 and described below.

DISCUSSION

Although SHM increasingly recognizes the challenges inherent in caring for older patients, few hospitalists are adapting their care for this vulnerable population. We identified only 11 innovations in geriatric care despite there being more than 1000 hospitalist groups. This apparent paucity of innovation in geriatrics might be explained by the relatively recent introduction of hospital medicine. As no hospitalist program is more than 10 years old, most programs are still focused on building core clinical activities or on other competing demands. In addition to time, funding may limit the typical program's ability to innovate without directly increasing revenue. Although the geriatrics literature supports that specialized inpatient care for older patients can result in increased physical functioning and quality of life at no additional cost, it may be that geriatricians have yet to make this case effectively to the hospitalist community.14, 15

The findings of this study were limited by our survey methodology. Specifically, our sample was limited to professional contacts and those using SHM listservs. In addition, some innovative hospitalists may not consider their programs to be geriatric programs and so may not have responded to our queries. Therefore, the reported innovations are not representative of geriatric care among all hospitalist groups, and we are unable to provide a comprehensive picture of geriatric care in hospitalist programs. In addition, we cannot comment on the effectiveness of the care approaches at participating institutions. For example, interdisciplinary care is an important tenet of geriatric medicine. Although six of our programs reported interdisciplinary rounds, it is unclear if these rounds are models of effective collaborative practice. Nonetheless, the information obtained from the structured interviews allowed the identification of several instructive themes discussed below.

CONCLUSIONS

The rapid growth of the hospitalist movement will significantly affect clinical care in American hospitals. As most hospital patients are older, the impact on acute care geriatrics cannot be overlooked. In our study, we identified only a small number of hospitalist groups that have made geriatric medicine a priority. These programs prioritize geriatric medicine through the employment of geriatrics‐trained staff, adaptation of geriatric care models such as ACE units, and commitment to clinical quality improvement and patient safety. They also focus on common clinical challenges for older patients, including postoperative and postdischarge care. Although much can be learned from these examples, programs at other institutions will need to be individualized to meet the specific needs of each hospital and community. The common goal of clinical excellence shared by hospitalists and geriatricians should motivate cooperation, collaborative approaches, and a joint clinical research agenda at all levels, as the current paradigm of hospital care remains inadequate to meet the needs of the acutely ill older patient.

Between 1996with the first appearance of hospitalists in the medical literatureand the present, the hospitalist workforce has grown to nearly 10,000.1, 2 More remarkable is the estimate that the number of hospitalists will double in the next 5 years.2 The rapid growth of hospital medicine raises significant issues for the care of older patients, who are hospitalized at high rates3 and suffer numerous complications from hospitalization including functional decline,4 delirium,5 and a disproportionate share of adverse events.6 Conversely, the needs of patients older than 65 years of age, whose hospital stays make up nearly 50% of acute‐care bed days, will shape the future of hospital medicine.3

To date, the hospital medicine literature has failed to address the particular challenges of treating older patients, focusing primarily on opportunities for reductions in costs and length of stay for hospitalists' Medicare patients (of about $1000 per admission and 0.5 days, respectively7, 8) when compared with those cared for by other physicians. This focus on economic efficiency reflects the early orientation of the hospitalist movement. More recently, leaders of the hospitalist professional organization, the Society of Hospital Medicine (SHM), have increasingly recognized that caring for the older population will require additional knowledge and clinical skills beyond that taught in internal medicine residencies.9 Beyond educational initiatives, however, hospitalists must reconsider the paradigms of hospital care that make the hospital setting so dangerous for the older patient.

Given the aging population and the predicted growth of hospital medicine, it is essential to develop an understanding of the impact of hospitalists on the care of older patients and to encourage clinical innovation at the intersection of hospital medicine and geriatrics. Consequently, this article 1) identifies and summarizes geriatric care approaches in hospitalist programs, 2) presents a case study of geriatric hospital care by a hospitalist group, and 3) highlights opportunities for innovation and further research.

METHODS

RESULTS

In 2003 the annual survey of the American Hospital Association identified 1415 hospitalist groups in the United States (Joe Miller, SHM senior vice‐president, personal communication). Remarkably, our query identified only 11 hospitalist groups with clinical innovations aimed at the older population. These innovations ranged from single individuals involved in targeted quality‐improvement projects to highly developed programs addressing an array of clinical needs for the hospitalized older patient. These 11 programs are summarized in Table 1 and described below.

DISCUSSION

Although SHM increasingly recognizes the challenges inherent in caring for older patients, few hospitalists are adapting their care for this vulnerable population. We identified only 11 innovations in geriatric care despite there being more than 1000 hospitalist groups. This apparent paucity of innovation in geriatrics might be explained by the relatively recent introduction of hospital medicine. As no hospitalist program is more than 10 years old, most programs are still focused on building core clinical activities or on other competing demands. In addition to time, funding may limit the typical program's ability to innovate without directly increasing revenue. Although the geriatrics literature supports that specialized inpatient care for older patients can result in increased physical functioning and quality of life at no additional cost, it may be that geriatricians have yet to make this case effectively to the hospitalist community.14, 15

The findings of this study were limited by our survey methodology. Specifically, our sample was limited to professional contacts and those using SHM listservs. In addition, some innovative hospitalists may not consider their programs to be geriatric programs and so may not have responded to our queries. Therefore, the reported innovations are not representative of geriatric care among all hospitalist groups, and we are unable to provide a comprehensive picture of geriatric care in hospitalist programs. In addition, we cannot comment on the effectiveness of the care approaches at participating institutions. For example, interdisciplinary care is an important tenet of geriatric medicine. Although six of our programs reported interdisciplinary rounds, it is unclear if these rounds are models of effective collaborative practice. Nonetheless, the information obtained from the structured interviews allowed the identification of several instructive themes discussed below.

CONCLUSIONS

The rapid growth of the hospitalist movement will significantly affect clinical care in American hospitals. As most hospital patients are older, the impact on acute care geriatrics cannot be overlooked. In our study, we identified only a small number of hospitalist groups that have made geriatric medicine a priority. These programs prioritize geriatric medicine through the employment of geriatrics‐trained staff, adaptation of geriatric care models such as ACE units, and commitment to clinical quality improvement and patient safety. They also focus on common clinical challenges for older patients, including postoperative and postdischarge care. Although much can be learned from these examples, programs at other institutions will need to be individualized to meet the specific needs of each hospital and community. The common goal of clinical excellence shared by hospitalists and geriatricians should motivate cooperation, collaborative approaches, and a joint clinical research agenda at all levels, as the current paradigm of hospital care remains inadequate to meet the needs of the acutely ill older patient.

In the United States, community‐acquired pneumonia (CAP) leads to nearly 1 million hospitalizations annually, with aggregate costs of hospitalization approaching $9 billion.1, 2 In an effort to improve the appropriate, cost‐effective care for patients with CAP, several professional societies have developed clinical practice guidelines and pathways for pneumonia.37 Although the guidelines address all aspects of care, they devote substantial attention to antibiotic recommendations. Most U.S. guidelines recommend treatment of hospitalized patients with an intravenous beta‐lactam combined with a macrolide, or a fluoroquinolone with activity against Streptococcus pneumoniae. Of the major U.S. CAP practice guidelines, only one6 recommends doxycycline as an alternative to a macrolide for inpatients.

Doxycycline is an attractive alternative to macrolides. Similar to macrolides, doxycycline is active against a wide variety of organisms including atypical bacteria (Chlamydia pneumoniae, Legionella pneumophilus, and Mycoplasma pneumoniae) and is well tolerated.810 In addition, it is inexpensive (cost of $1.00/day [awp] for 100 mg p.o. bid), and rates of tetracycline/doxycycline resistance among S. pneumoniae isolates have remained low, in contrast to the increasing rates of resistance to macrolides and fluoroquinolones.11, 12 The most recent guidelines from the Infectious Diseases Society of America cited limited published clinical data on the effectiveness of doxycycline in CAP as a barrier to increased use.7 Only one study of hospitalized patients has been published in the era of penicillin‐resistant pneumococcus, and this study included only 43 low‐risk patients treated with doxycycline.13 At the university hospital affiliated with the University of California, San Francisco, ceftriaxone plus doxycycline is generally recommended as initial empiric antibiotic therapy for patients hospitalized with CAP, but significant variability in prescribing exists, allowing for comparisons between patients treated with different initial empiric antibiotic regimens. We compared outcomes of hospitalized patients with CAP treated with ceftriaxone plus doxycycline to those of patients treated with alternative initial empiric therapy at an academic medical center.

METHODS

RESULTS

DISCUSSION

In our hospital setting, the use of ceftriaxone plus doxycycline as the initial empiric antibiotic therapy for patients hospitalized with community‐acquired pneumonia was associated with significantly lower inpatient and 30‐day mortality, even after adjusting for clinical differences between groups. We did not find a difference between regimens in hospital length of stay or 30‐day readmission rate. In case the multivariable model was insufficient to account for the clinical differences (i.e., selection bias) between groups, we also performed an analysis of a subgroup of less severely ill patients by excluding those admitted from nursing homes, those admitted to the intensive care unit, and those with aspiration pneumonia. In this subset, use of ceftriaxone plus doxycycline remained associated with lower inpatient mortality but not with lower 30‐day mortality. Although, as an observational study, the results of our findings could still be a result of residual confounding, we believe the results provide valuable information regarding doxycycline.

Combination therapy with a macrolide, but not doxycycline, is advocated by the practice guidelines of several major U.S. professional societies,3, 4, 7 apparently because of a lack of data on the effectiveness of combination therapy with doxycycline.7 Only one randomized, unblinded study, in 87 low‐risk patients hospitalized with CAP, that compared monotherapy with IV doxycycline versus physician‐determined therapy has been conducted.13 This study found no differences between treatment groups in clinical outcomes but did find that use of doxycycline was associated with shorter hospital stays and reduced costs. Our results, achieved in a real‐world setting in relatively ill hospitalized patients (58% were in PSI risk class IV or V), provide further support for the use of combination therapy with doxycycline.

Hospitalized patients treated with a beta‐lactam in combination with a macrolide are often discharged on macrolide monotherapy. In our population most patients treated with ceftriaxone plus doxycycline were discharged on doxycycline if they required continued therapy (data not shown). In the current era of resistance of Streptococcus pneumoniae to antibiotics, there is good reason to believe doxycycline may perform as well, if not better, than macrolides when hospitalized patients with CAP are discharged on oral monotherapy. Macrolide resistance rates among invasive pneumococcal isolates in the United States doubled from 10% to 20% during a period in which prescriptions for macrolides increased by 13%.12 In addition, a large surveillance study of more than 1500 isolates collected in 1999 and 2000 found that 26% of the isolates were resistant to macrolides, whereas only 16% were resistant to tetracycline.16 In vitro testing against S. Pneumoniae has also suggested that tetracycline resistance overestimates doxycycline resistance.17, 18 More recently, Streptococcus pneumoniae susceptibility data from the SENTRY Antimicrobial Surveillance program reaffirmed doxycycline's in vitro superiority over macrolides.17

Our study had several limitations. The study design adopted precluded determining whether favorable results with the use of ceftriaxone plus doxycycline resulted from an effect unique to this combination of antibiotics, the possible anti‐inflammatory properties of doxycycline alone,19, 20 or unmeasured confounders. For example, processes of care that affect clinical outcomes for patients hospitalized with CAP, such as the timing of antibiotic delivery, the timing of blood cultures, and stability assessment on discharge were not measured in this study. To affect outcomes, these processes of care would need to be differentially distributed between our comparison groups. However, because this study was performed in a single institution during a single interval, it is likely that the performance of these processes of care would be similar for all patients.

In conclusion, ceftriaxone plus doxycycline appears to be an effective, and possibly superior, therapy for patients hospitalized with CAP. Randomized controlled trials of doxycycline‐containing regimens versus other regimens are warranted.

In the United States, community‐acquired pneumonia (CAP) leads to nearly 1 million hospitalizations annually, with aggregate costs of hospitalization approaching $9 billion.1, 2 In an effort to improve the appropriate, cost‐effective care for patients with CAP, several professional societies have developed clinical practice guidelines and pathways for pneumonia.37 Although the guidelines address all aspects of care, they devote substantial attention to antibiotic recommendations. Most U.S. guidelines recommend treatment of hospitalized patients with an intravenous beta‐lactam combined with a macrolide, or a fluoroquinolone with activity against Streptococcus pneumoniae. Of the major U.S. CAP practice guidelines, only one6 recommends doxycycline as an alternative to a macrolide for inpatients.

Doxycycline is an attractive alternative to macrolides. Similar to macrolides, doxycycline is active against a wide variety of organisms including atypical bacteria (Chlamydia pneumoniae, Legionella pneumophilus, and Mycoplasma pneumoniae) and is well tolerated.810 In addition, it is inexpensive (cost of $1.00/day [awp] for 100 mg p.o. bid), and rates of tetracycline/doxycycline resistance among S. pneumoniae isolates have remained low, in contrast to the increasing rates of resistance to macrolides and fluoroquinolones.11, 12 The most recent guidelines from the Infectious Diseases Society of America cited limited published clinical data on the effectiveness of doxycycline in CAP as a barrier to increased use.7 Only one study of hospitalized patients has been published in the era of penicillin‐resistant pneumococcus, and this study included only 43 low‐risk patients treated with doxycycline.13 At the university hospital affiliated with the University of California, San Francisco, ceftriaxone plus doxycycline is generally recommended as initial empiric antibiotic therapy for patients hospitalized with CAP, but significant variability in prescribing exists, allowing for comparisons between patients treated with different initial empiric antibiotic regimens. We compared outcomes of hospitalized patients with CAP treated with ceftriaxone plus doxycycline to those of patients treated with alternative initial empiric therapy at an academic medical center.

METHODS

RESULTS

DISCUSSION

In our hospital setting, the use of ceftriaxone plus doxycycline as the initial empiric antibiotic therapy for patients hospitalized with community‐acquired pneumonia was associated with significantly lower inpatient and 30‐day mortality, even after adjusting for clinical differences between groups. We did not find a difference between regimens in hospital length of stay or 30‐day readmission rate. In case the multivariable model was insufficient to account for the clinical differences (i.e., selection bias) between groups, we also performed an analysis of a subgroup of less severely ill patients by excluding those admitted from nursing homes, those admitted to the intensive care unit, and those with aspiration pneumonia. In this subset, use of ceftriaxone plus doxycycline remained associated with lower inpatient mortality but not with lower 30‐day mortality. Although, as an observational study, the results of our findings could still be a result of residual confounding, we believe the results provide valuable information regarding doxycycline.

Combination therapy with a macrolide, but not doxycycline, is advocated by the practice guidelines of several major U.S. professional societies,3, 4, 7 apparently because of a lack of data on the effectiveness of combination therapy with doxycycline.7 Only one randomized, unblinded study, in 87 low‐risk patients hospitalized with CAP, that compared monotherapy with IV doxycycline versus physician‐determined therapy has been conducted.13 This study found no differences between treatment groups in clinical outcomes but did find that use of doxycycline was associated with shorter hospital stays and reduced costs. Our results, achieved in a real‐world setting in relatively ill hospitalized patients (58% were in PSI risk class IV or V), provide further support for the use of combination therapy with doxycycline.

Hospitalized patients treated with a beta‐lactam in combination with a macrolide are often discharged on macrolide monotherapy. In our population most patients treated with ceftriaxone plus doxycycline were discharged on doxycycline if they required continued therapy (data not shown). In the current era of resistance of Streptococcus pneumoniae to antibiotics, there is good reason to believe doxycycline may perform as well, if not better, than macrolides when hospitalized patients with CAP are discharged on oral monotherapy. Macrolide resistance rates among invasive pneumococcal isolates in the United States doubled from 10% to 20% during a period in which prescriptions for macrolides increased by 13%.12 In addition, a large surveillance study of more than 1500 isolates collected in 1999 and 2000 found that 26% of the isolates were resistant to macrolides, whereas only 16% were resistant to tetracycline.16 In vitro testing against S. Pneumoniae has also suggested that tetracycline resistance overestimates doxycycline resistance.17, 18 More recently, Streptococcus pneumoniae susceptibility data from the SENTRY Antimicrobial Surveillance program reaffirmed doxycycline's in vitro superiority over macrolides.17

Our study had several limitations. The study design adopted precluded determining whether favorable results with the use of ceftriaxone plus doxycycline resulted from an effect unique to this combination of antibiotics, the possible anti‐inflammatory properties of doxycycline alone,19, 20 or unmeasured confounders. For example, processes of care that affect clinical outcomes for patients hospitalized with CAP, such as the timing of antibiotic delivery, the timing of blood cultures, and stability assessment on discharge were not measured in this study. To affect outcomes, these processes of care would need to be differentially distributed between our comparison groups. However, because this study was performed in a single institution during a single interval, it is likely that the performance of these processes of care would be similar for all patients.

In conclusion, ceftriaxone plus doxycycline appears to be an effective, and possibly superior, therapy for patients hospitalized with CAP. Randomized controlled trials of doxycycline‐containing regimens versus other regimens are warranted.

In the United States, community‐acquired pneumonia (CAP) leads to nearly 1 million hospitalizations annually, with aggregate costs of hospitalization approaching $9 billion.1, 2 In an effort to improve the appropriate, cost‐effective care for patients with CAP, several professional societies have developed clinical practice guidelines and pathways for pneumonia.37 Although the guidelines address all aspects of care, they devote substantial attention to antibiotic recommendations. Most U.S. guidelines recommend treatment of hospitalized patients with an intravenous beta‐lactam combined with a macrolide, or a fluoroquinolone with activity against Streptococcus pneumoniae. Of the major U.S. CAP practice guidelines, only one6 recommends doxycycline as an alternative to a macrolide for inpatients.

Doxycycline is an attractive alternative to macrolides. Similar to macrolides, doxycycline is active against a wide variety of organisms including atypical bacteria (Chlamydia pneumoniae, Legionella pneumophilus, and Mycoplasma pneumoniae) and is well tolerated.810 In addition, it is inexpensive (cost of $1.00/day [awp] for 100 mg p.o. bid), and rates of tetracycline/doxycycline resistance among S. pneumoniae isolates have remained low, in contrast to the increasing rates of resistance to macrolides and fluoroquinolones.11, 12 The most recent guidelines from the Infectious Diseases Society of America cited limited published clinical data on the effectiveness of doxycycline in CAP as a barrier to increased use.7 Only one study of hospitalized patients has been published in the era of penicillin‐resistant pneumococcus, and this study included only 43 low‐risk patients treated with doxycycline.13 At the university hospital affiliated with the University of California, San Francisco, ceftriaxone plus doxycycline is generally recommended as initial empiric antibiotic therapy for patients hospitalized with CAP, but significant variability in prescribing exists, allowing for comparisons between patients treated with different initial empiric antibiotic regimens. We compared outcomes of hospitalized patients with CAP treated with ceftriaxone plus doxycycline to those of patients treated with alternative initial empiric therapy at an academic medical center.

METHODS

RESULTS