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Melanie Cole (Host):  Many people mistakenly think that palliative medicine is the same as hospice care and so they may be reluctant to seek advice about it for their loved ones. However, it’s important medical care that focuses on people who are seriously ill. It’s meant to help patients get relief from their symptoms, pain and stress whatever their diagnosis.

Welcome to Check-up Chat with EvergreenHealth. I’m Melanie Cole and today, we’re discussing palliative medicine. Joining me in this panel are Dr. Hope Wechkin. She’s the Medical Director of EvergreenHealth Hospice and Palliative Medicine and Dr. Laura Johnson. She’s a physician at EvergreenHealth Palliative Medicine. Doctors, I’m so glad to have you with us today. and what a great topic. Dr. Wechkin, I’d like to start with you. Tell us a little bit this field of palliative medicine. Give us a definition. How did it come about and really, what does it do?

Hope Wechkin, MD (Guest):  I think I’ll start by answering your question by telling you the same thing that I tell every single patient who I meet for the first time in clinic. Most people who are referred to me, actually don’t really know quite what they’ve been referred for. And I explain to everybody that a lot of people who have either one major illness or a number of medical issues, can have the experience of being on the medical train. 

Palliative medicine is kind of like a train station. It’s just the chance to get off. What I say is go to the bathroom and get some lunch first by which I mean, paying attention first and foremost to whatever symptoms the person is having, whether that’s pain or fatigue or nausea or insomnia or anxiety or all of the above. Whatever combination of symptoms the person is having deserves a really deep dive to figure out what’s going on first and foremost. And then, after we’ve discussed that, then we kind of look at the map and figure out okay where are we, what’s the landscape, is there anything coming around the bend that we need to plan for. And importantly, is everybody on the same page. Is everybody reading the same map? By which I mean, a person’s doctors, their family members, their friends, anybody who is involved in their lives and helping them navigate this journey.

So, basically, palliative medicine is kind of like a train station on the way in this long journey.

Host:  Dr. Johnson, tell us a little bit about the difference because as I said in my intro, people always think hospice care and palliative medicine are the same thing. So, sometimes they are a little reluctant to seek that kind of care. They think, oh my gosh, it’s some kind of a death sentence. Tell us the difference between these two types of care.

Laura Johnson, MD (Guest):  Yes, that is a concern that we see very often in our patients. I work only in the hospital setting and when a referral is placed to us, for palliative care, patients often will very much think that that means that we’re referring to hospice care. So, the differences are several. First of all, palliative care is more consultative whereas hospice is a whole system of care. Palliative care is introduced earlier in the course of an illness. And in palliative care, we walk alongside patients as they are receiving curative treatments. The focus is as Hope mentioned, is very much on symptom management as well as on clarifying the goals of care.

And palliative medicine is like an extra layer of support within that traditional medical system versus hospice as I mentioned, is a system of care, it’s for patients whose doctors believe that the patient’s life expectancy may be within the next six months. Although certainly none of us have a crystal ball which is why hospice has periods of recertification and people can be on hospice much longer than that. But hospice is actually medical care provided in the home or wherever a patient is living focusing on symptoms. Hospice brings nursing care, medications and equipment to the patient and focuses their care on comfort. And it’s for patients who have decided they don’t want to continue coming back to the hospital over and over but rather want to focus their care at home.

Dr. Wechkin:  Yeah Laura, also one of the things that I’ve found is helpful for people to understand is that basically, in American medicine, there are two main systems of medical care. There is the regular system of care that most of us are in and that’s where basically, we go to the medical care whether it’s the doctor’s office or the infusion center or the ED or the hospital if we’re sick. In general, patients go to the medical care. And that is in the regular system of care. And palliative care is usually given in that setting, in that traditional system of care.

And then there’s a parallel track under Medicare that’s a very specific benefit in which everything pivots, and care comes to a person at home and comes to a person who has a prognosis, a life expectancy of six months or less. That’s hospice care. And they are parallel systems. So, you can’t be in both systems at the same time.

Palliative care is an approach that’s embedded into the traditional system of care and hospice care is a system that comes to people at their homes primarily when they have six months or less to live.

Host:  Well thank you ladies for clearly defining that and Dr. Wechkin, as you’re telling us who can benefit from palliative medicine and how long they can be on it, which you just were touching on and this is such an important question and most patients want to know this. Can they still work on curing their disease? Can they still take curative treatments whether it’s chemotherapy or radiation? Can they still work on curing cancer while they participate in palliative medicine?

Dr. Wechkin:  So, the short answer to that is yes, definitely. Many people who – I’ll take an example of a cancer patient. We have many, many cancer patients who are receiving chemotherapy, who are receiving radiation therapy, who are receiving immunotherapy and they are at the same time receiving palliative care. Usually, the people who are getting palliative care and curative treatments at the same time or I should say, disease modifying treatment, usually at that time, we’re not expecting a cure but we’re hoping to stave off disease for as long as possible which is what in advanced cancer for example, that’s what chemotherapy and radiation are often designed to do. Many of those patients are also receiving palliative medicine consultations with me in clinic. Many times we have somebody coming right from the infusion center into my office to see me or vice versa and people can continue for months or even years receiving both disease modifying treatment and palliative medicine treatment at the same time.

Host:  Let’s talk a little bit about what types of providers provide palliative medicine. Dr. Johnson, tell us about your team and the collaborative multidisciplinary approach to palliative medicine because as Dr. Wechkin was saying, they are working on curative treatments at the same time that they are working on some symptom and help for pain or stress or whatever these other symptoms that palliative medicine can help with. Tell us about your team and why it’s so important that the coordination of care transitions across those healthcare settings that Dr. Wechkin was talking about before.

Dr. Johnson:  We have chaplains here in the hospital, the social workers here on the floor, the hospitalist providers, primary care providers; they all ultimately are part of our larger team because we often will – we’re often the bridge in between all of these different groups and teams. So, we might meet with a patient in the hospital who is not really clear about their prognosis and they also may have worries about where they are going to live. We spend a lot of time with the patients, so we really get to know them and what their worries are and what their priorities are. So, even though technically our team may consist here in the hospital of social worker and a physician; we then will go to the larger team and share with them what the patient’s concerns are. Maybe they need some clarification about their prognosis, and we’ll bring them in and then often have a larger meeting including those other parts of the team.

The chaplains are also very integral members of our hospital support system and palliative care as well. Do you have anything more to add about that Hope?

Dr. Wechkin:  Yeah, I just as I’m hearing you talk Laura, it’s interesting to think that the team comes with the patient. When I see somebody in clinic, they may have three or four doctors whom they are seeing as outpatients and maybe a nutritionist or a therapist or a social worker; those people become the team and a lot of what we do, a lot of what I do, is honestly is picking up the phone and calling people. And making sure we’re all on the same page. There is even with electronic medical records and emails and texts and all that, there is nothing beats picking up the phone and talking to another provider on that person’s team to get at what they think is really going on, how – what questions they have and how we can all work together going in the same direction.

Host:  Dr. Wechkin, as we’ve talked about the multidisciplinary approach crossing the healthcare setting that they can get their curative treatments and palliative medicine; what types of treatments are used in palliative medicine? We haven’t really discussed what it is that you do as far as medication. You mentioned social work and mental health counseling I’m sure is a very big part of what you do. So, tell us how you have this expertise in managing complex physical, emotional symptoms, pain, shortness of breath, depression, nausea, lack of appetite; all of these things that can come into whatever disease state that the patient is in.

Dr. Wechkin:  There is a whole world of symptom management for whether it’s pain management, nausea, et cetera of tools and tricks that in the world of palliative medicine we have at our disposal just to help people feel better while they are getting treatments. There is an increasing literature on that and I have to say that I personally have learned a lot of what I bring to palliative medicine from the world of hospice actually. My work in hospice care has taught me a lot of things that I didn’t learn in medical school or the rest of my training. Ways to give medications, ways to – medications to use that aren’t typically used so often anymore. So, there’s a lot of just medical, pharmaceutical knowledge that I have learned over the years and then there’s also a part that isn’t in text books. And that is really listening and really being with the patient and their family and really having the time – taking the time, making the time to be present for whatever is going on. Nothing is off the table. And I feel like we have a little bit of a privilege in palliative medicine in that we do have more time than most traditional doctors visits. We don’t have ten minutes or fifteen minute visits. My initial visits with every new patient is an hour. By having the time to really listen and really attend to what a patient and his or her family members are saying; that’s a really critical part of palliative medicine that goes beyond just knowing some prescriptions that might help.

The time and the presence is part of the medicine.

Host:  Well it certainly is and Dr. Johnson, to expand on that, is it just the patient that you are lucky enough to spend this time with or can the family get involved in palliative medicine? Do they get involved in some of these treatment options or the counseling? And while you’re answering that, discuss whether or not patients get palliative care, palliative medicine at home. Is this only in hospital or does it happen at home as well?

Dr. Johnson:  Yeah good question. Certainly in the hospital and then also I know in the clinic setting most often a patient is with a family member or other proxy decision maker, caregiver. So, we in palliative medicine are focused on not jut the patient but the patient’s family and the patient’s support system. So, we aim to provide relief from the symptoms and stress of the illness and that’s for both the patient and the family. 

We actually don’t have palliative care providers who go out to the homes. We have palliative medicine clinic where Dr. Hope Wechkin sees patients and their families. And then we see patients here in the hospital. So, right now, our services don’t specifically extend into the home although certainly once patients are at home, and followed by Dr. Wechkin in clinic, they are in communication with her about their symptoms via phone.

Dr. Wechkin:  Yeah and one thing I will just add to that is that a lot of patients whom I’m seeing in clinic, are getting services at home often through Home Health services. I am often in communication with Home Health nurses, Home Health psychiatric nurses, Home Health social workers to try to coordinate the care that is being given at home. But for the most part, people receiving palliative care services are at the point in their lives where they are still coming into receive medical treatment and care.

Host:  This is such an important topic. And really such an interesting episode. So, Dr. Wechkin, the first – I’d like to give you the first last word as it were to tell patients what you would like them to know about exploring options in palliative medicine. Does insurance cover palliative medicine? Does it recognize this burgeoning field that’s so caring and so helpful to families and their loved ones? Tell us a little bit about insurance and offer your patients your best advice about palliative medicine.

Dr. Wechkin:  The short version about insurance is yes. Insurance covers palliative medicine consultation services, office visits, inpatient consultations just the way it does any other specialty. So, I see patients who have Medicare and Medicaid and all kinds of private insurances and basically people who are enrolled in getting care through a traditional medical system are able to access palliative care services.

I would say that the vast majority of patients I see for the first time come in scared. They’re not quite sure why they’ve been referred to palliative care. They have these associations with hospice. They’re not – nobody has really defined it for them and an hour later, the vast majority of people just feel a lot better. We come out of these visits with a plan, with clearer understanding. Oftentimes people hear what their family members are worried about for the first time. And usually, people shoulders a lot more relaxed by the time they leave than when they come in.

So, really, a palliative medicine referral is a chance to understand more clearly what’s going on and to make plans for starting to feel better.

Host:  Dr. Johnson, last word to you. What would you like listeners to know who may have loved ones that are having symptoms, that are having depression, that are having all of these issues because of the treatments that they are going through or because of the illness that they have; what would you like them to know about how to get involved in palliative medicine? How to find somebody to help them.

Dr. Johnson:  I would recommend they ask their doctor about a referral to palliative medicine and that might be their primary care physician or their cardiologist or their oncologist whoever is helping manage their medical problems that they are dealing with and that are causing them the most stress and symptoms. And from there, I think I would really recommend sometimes even just one visit to the palliative medicine clinic can make a huge difference as Hope was just saying in the levels of stress, between the family members and the patient and the providers. And it really helps providers as well. Our medical system the sort of default is just kind of do everything, go forward and not taking that time to stop and ask well what do you really want to do. What’s most important to you? Does this fit with your priorities and your life right now? And so, taking that time not only can make a huge difference for the patient, their symptoms and for their family but also can help their doctors know what they really want and then provide much better and right sized medical care for the patient.

Host:  Great information. Doctors, thank you so much for joining us today and telling us about this incredible form of medicine that helps so many people. To learn more about EvergreenHealth Palliative Medicine please visit www.everygreenhealth.com/palliative-care. That concludes this episode of Check-up Chat with EvergreenHealth. Please remember to subscribe, rate and review this podcast and all the other EvergreenHealth podcasts. I’m Melanie Cole.