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Palliative Care in Hospitals: Making the Case

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Title: Palliative Care in Hospitals: Making the Case


1
Palliative Care in HospitalsMaking the Case
  • Diane E. Meier, MD
  • Director
  • Center to Advance Palliative Care
  • in Hospitals and Health Systems
  • a Robert Wood Johnson Foundation - Mount Sinai
    School of Medicine initiative
  • 10.10.02

2
  • Center to Advance Palliative Care
  • Mount Sinai School of Medicine
  • 1255 5th Avenue, C-2
  • New York, NY 10029
  • 212-201-2670 office
  • 212-426-1369 fax
  • 212-201-2680 event line
  • www.capc.org

A national initiative supported by The Robert
Wood Johnson Foundation at the Mount Sinai School
of Medicine.
3
Palliative Care
  • Interdisciplinary care that aims to relieve
    suffering and improve quality of life for
    patients with advanced illness and their
    families.
  • It is offered simultaneous with all other
    appropriate medical treatment.

4
The Cure - Care Model The old system
D E A T H
Life Prolonging Care
Palliative/ Hospice Care
Disease Progression
5
(No Transcript)
6
Palliative Cares Place in the Course of Illness
Life Prolonging Therapy
Death
Diagnosis of serious illness
Palliative Care
Medicare Hospice Benefit
7
Palliative Care
8
Hospital-based palliative careThe 5 main
arguments
  • Clinical imperative
  • Concordance with patient and family preferences
  • Demographic imperative meets the needs of
    growing aging and chronically ill population
  • Educational imperative
  • Fiscal imperative cost avoidance, improved
    hospital capacity

9
Defining and Making the Case for Palliative Care
  • Different attributes of palliative care appeal to
    different audiences
  • Alignment of messages and mission is key to
    making the successful case for palliative care

10
Message alignment for palliative care The
patient perspective
  • For patients, palliative care is a key tool to
  • relieve symptom distress pain, nausea,
    breathlessness, anxiety, depression, fatigue,
    weakness
  • navigate a complex and confusing medical system
  • understand the plan of care
  • help coordinate and control care options
  • allow simultaneous palliation of suffering along
    with continued disease modifying treatments (no
    requirement to give up curative care)
  • provide practical and emotional support for
    exhausted family caregivers

11
Message alignment for palliative care The
clinician perspective
  • For clinicians, palliative care is a key tool to
  • handle repeated, intensive patient-family
    communications, coordination of care across
    settings, comprehensive discharge planning
  • manage day-to-day pain and distress of highly
    symptomatic and complex cases, 24/7, thus
    supporting the treatment plan of the primary
    physician
  • promote patient and family satisfaction with the
    quality of the care provided

12
Message alignment for palliative care The
hospital perspective
  • For hospitals, palliative care is a key tool to
  • effectively treat the growing number of people
    with complex advanced illness
  • provide service excellence, patient-centered care
  • increase patient and family satisfaction
  • improve staff satisfaction and retention
  • meet JCAHO quality standards
  • rationalize the use of hospital resources
  • increase capacity, reduce costs

13
Why palliative care?
  • 1. Clinical imperative
  • the quality of the care given to persons with
    serious and complex illnesses

14
Why hospital-based palliative care? The clinical
imperative
  • Hospitals are where the sickest people go and
    remain the site of death for many.
  • Patients feel a loss of control and unsafe in the
    medical system.
  • Numerous studies document unnecessary patient
    suffering.
  • Patients want and will demand better care.
  • Family caregiver burden
  • Hospitals and clinicians struggling to do better,
    meet JCAHO pain, quality standards

15
Site of death Time trends
  • 1989 1993__1997
  • Hospitals 65 56 53
  • Nursing homes 18 19 24
  • Home 17 21 23
  • (Teno et al, Brown Site of Death Atlas of the
    U.S www.chcr.brown.edu/dying/usa_statistic
    s.htm and
  • 1993 National Mortality Followback Survey )

16
Everybody with serious illness spends at least
some time in a hospital...
  • 98 of Medicare decedents spent at least some
    time in a hospital in the year before death.
  • 15-55 of decedents had at least one stay in an
    ICU in the 6 months before death.
  • Dartmouth Atlas of Health Care 1999

17
The Nature of Suffering and the Goals of Medicine
- Eric J. Cassell
  • The relief of suffering and the cure of
    disease must be seen as twin obligations of a
    medical profession that is truly dedicated to the
    care of the sick. Physicians failure to
    understand the nature of suffering can result in
    medical intervention that (though technically
    adequate) not only fails to relieve suffering but
    becomes a source of suffering itself.

18
Death in the hospital What do we know about it?
  • Physical suffering
  • Poor to non-existent communication about the
    goals of medical care
  • Lack of concordance of care with patient and
    family preferences
  • Huge financial, physical, and emotional burdens
    on family caregivers
  • Suffering in professional caregivers
  • Fiscal impact on hospitals

19
National data on the experience of dying in 5
tertiary care teaching hospitals
  • The SUPPORT Study
  • Controlled trial to improve care of seriously ill
    patients
  • Multi-center study funded by RWJ
  • 9000 patients with life threatening illness, 50
    died within 6 months of entry
  • JAMA 19952741591-98

20
SUPPORT Phase I Results
  • 46 of DNR orders were written within 2 days of
    death.
  • Of patients preferring DNR, lt50 of their MDs
    were aware of their wishes.
  • 38 of those who died spent gt10 days in ICU.
  • Half of patients had moderate-severe pain gt50 of
    last 3 days of life.

21
Pain data from SUPPORT
  • of 5176 patients reporting moderate to severe
    pain between days 8-12 of hospitalization
  • colon cancer 60
  • liver failure 60
  • lung cancer 57
  • MOSF cancer 53
  • MOSF sepsis 52
  • COPD 44
  • CHF 43
  • Desbiens Wu. JAGS 200048S183-186.

22
Why palliative care?
  • 2. Concordance with patient and family wishes
  • What is the impact of serious illness on
    patients families? And what do persons with
    serious illness say they want from our healthcare
    system?

23
Family caregivers and the SUPPORT study JAMA
19952721839
  • Patient needed large amount of family caregiving
    34
  • Lost most family savings 31
  • Lost major source of income 29
  • Major life change in family 20
  • Other family illness from stress 12
  • At least one of the above 55

24
Family caregiversThe numbers
  • 1996 United States estimates 25 million
    caregivers deliver care at home to a seriously
    ill relative
  • Mean hours caregiving per week 18
  • Cost equivalent of uncompensated care 194
    billion dollars (assume 8/hr)
  • Levine C. Loneliness of the long-term caregiver
    N Engl J Med 19993401587-90.

25
Caregiving needs among terminally ill persons
  • Interviews with 900 caregivers of terminally ill
    persons at 6 U.S. sites
  • need more help 87 of families
  • transportation 62
  • homemaking 55
  • nursing 28
  • personal care 26
  • Emanuel et al. Ann Intern Med2000132451

26
Caregiver characteristics
  • 900 family caregivers of terminally ill persons
    at 6 sites across the U.S.
  • Women 72
  • Close family member 96
  • Over age 65 33
  • In poor health 33
  • Emanuel et al. N Engl J Med 1999341956.

27
Caregiving increases mortality
  • Population based cohort study 400 in-home
    caregivers and 400 controls
  • Increased risk of death RR 1.6 among caregivers
    reporting emotional strain
  • Substantial increased risk of major depression
  • Depression associated in multiple studies with
    ischemic heart disease, cancer, and all-cause
    mortality
  • Schulz et al. JAMA 19992822215.

28
What Do Patients With Serious Illnesses Want?
  • Pain and symptom control
  • Avoid inappropriate prolongation of the dying
    process
  • Achieve a sense of control
  • Relieve burdens on family
  • Strengthen relationships with loved ones

Singer et al, JAMA 1999
29
What do family caregivers want?
  • Study of 475 family members 1-2 years after
    bereavement
  • Loved ones wishes honored
  • Inclusion in decision processes
  • Support/assistance at home
  • Practical help (transportation, medicines,
    equipment)
  • Personal care needs (bathing, feeding, toileting)
  • Honest information
  • 24/7 access
  • To be listened to
  • Privacy
  • To be remembered and contacted after the death
  • Tolle et al. Oregon report card.1999
    www.ohsu.edu/ethics

30
Why palliative care?
  • 3. The demographic imperative
  • Hospitals need palliative care to effectively
    treat the growing number of persons with serious,
    advanced and complex illnesses.

31
The demographic imperativeChronically ill,
aging population is growing
  • The 63 of Medicare patients with 2 or more
    chronic conditions account for 95 of Medicare
    spending (CDC)
  • The number of people over age 85 will double to 9
    million by the year 2030 (CDC)
  • Aging baby boomers will demand better care for
    their parents, then for themselves
  • Data show caregivers are severely burdened
    financially, emotionally, and physically (JAMA)
  • System patterns, silo payment incentives promote
    acute episodic care, but patients will need a
    continuum of care over years of illness

32
Average Life Expectancy
33
Who is dying in the U.S. in 2002?
  • Median age of death is 78 years, and rising
  • Among survivors to age 65, median age at death is
    82 years
  • Among survivors to age 80, median age at death is
    88 years

34
The demographic imperative Is this patient
terminally ill?
  • 94 y/o with moderate dementia, congestive heart
    failure, and recurrent infections. She is
    treated with spoon feeding, antipsychotic
    medications, an ACE inhibitor, a beta blocker,
    and judicious use of diuretics.
  • Is this patient terminally ill?
  • (slide courtesy of Joan Teno MD, Brown
    University)

35
The Demographic ImperativeThe Reality of the
Last Years of Life Death Is Not
Predictable(slide courtesy of Joanne Lynn, MD
Rand Corp.)
36
Leading Causes of Death in 1997 77 are not due
to cancer
  • Heart disease 33
  • Malignant neoplasm 23
  • Cerebrovascular disease 7
  • COPD 5
  • Accidents 4
  • Pneumonia 4
  • Account for 75 of all deaths
  • Natl. Ctr. Health Statistics, CDC,
    1998

37
Better care needed from the day of diagnosis of
any serious illness
  • People need better care throughout the multi-year
    course of advanced illness
  • Medicare Hospice Benefit developed to care for
    the dying regulations require 6 month prognosis
    and decision to forego coverage for life
    prolonging care.
  • Additional approaches are needed for much larger
    numbers of persons with chronic, progressive
    illness.

38
Why palliative care?
  • 4. The educational imperative
  • Every doctor and nurse-in-training learns in
    the hospital.

39
The educational imperative
  • Teaching hospitals are the site of training for
    most clinicians.
  • Acknowledged deficits in skills/knowledge and
    attitudinal barriers abound.
  • Medical school and residency curricula offer
    little to no teaching in palliative care.
  • Meier, Morrison Cassel. Ann Intern Med
    1997127225-30.

40
Deficiencies in medical education
  • 74 of residencies in U.S. offer no training in
    end of life care.
  • 83 of residencies offer no hospice rotation.
  • 41 of medical students never witnessed an
    attending talking with a dying person or his
    family, and 35 never discussed the care of a
    dying patient with a teaching attending.
    Billings Block JAMA 1997278733.

41
Physician Training in Pain Management
  • Oncologists self report
  • 86 of their patients undermedicated
  • 50 rated pain management in their own practice
    as fair to very poor
  • 73 evaluated their own training in pain
    management as fair to very poor

Von Roenn et al, Ann Intern Med, 1993
42
The Educational Imperative
  • Palliative care not part of medical training, but
    this is changing
  • LCME undergraduate medical education requirement
    as of 2000
  • ACGME residency training recommendation
  • JCAHO recommendations on educating staff
  • Message Palliative care best quality care for
    the seriously ill, not less care, not cheaper
    care, and not instead of life-prolonging care

43
Palliative care education
  • LCME requirement (2000)
  • Clinical instruction must include important
    aspects of end of life care.
  • ACGME requirements for internal medicine and
    internal medicine subspecialties (2000)
    Each resident should receive instruction in
    the principles of palliative careit is desirable
    that residents participate in hospice and home
    careThe program must evaluate residents
    technical proficiency,communication, humanistic
    qualities, and professional attitudes and
    behavior

44
Why palliative care?
  • 5. The fiscal imperative
  • Population aging, growth in effective
    technologies, and antiquated payment system
    financial crisis for healthcare

45
Why Palliative Care? The Fiscal Imperative
  • Exponentially rising costs with effective new
    technologies, aging population
  • 9.2 growth in hospital payments in 2001
  • 76 of projected 2002 Medicare budget will be
    spent on hospital care (198 billion)
  • Under DRG system long, high intensity hospital
    stays fiscal crisis for hospitals
  • Hospital and insurer of the future will have to
    efficiently and effectively treat serious and
    complex illness in order to survive

46
Medical Spending and Care of the Seriously Ill
1.3 trillion in 2001
  • 11 of U.S. health care dollar spent in last year
    of life, much of it on hospital services
  • 30 of Medicare costs to the 5 of enrollees with
    most serious and complex illness
  • (Emanuel et al. N Engl J Med 1994330540.)

47
Summary Care for serious illness at the turn of
this century
  • Unprecedented gains in life expectancy
    exponential rise in number and needs of the frail
    elderly
  • Cause of death shifted from acute sudden illness
    to chronic episodic disease
  • Untreated physical symptoms
  • Unmet patient/family needs
  • Future doctors and nurses untrained
  • Fragmentation, poor coordination and an
    unresponsive health care and payment system

48
How do we make it better?
  • Starting with first principles
  • Does our healthcare system respond to the needs
    of our sickest patients and their families?
  • What are the goals of medical care?
  • What should they be?

49
A different kind of care
  • Palliative care in hospitals aims to
  • Relieve physical and emotional suffering
  • Support family caregivers
  • Train future health professionals
  • Meet the needs of the growing population of
    elderly with complex and advanced illness
  • Coordinate and rationalize care-
  • the right care for the right patient at the right
    time in the right place
  • Begin to make the system responsive to the
    patients it intends to serve

50
Palliative Care...
  • To relieve suffering, improve quality of life
  • Affirms life, sees death as a personal and
    natural process
  • Many diagnoses
  • serious or life threatening illness
  • Appropriate early in course of illness
  • Patient and family preferences sought and
    respected
  • Should be combined with life prolonging therapies
    or may become the focus of care near the end of
    life
  • Interdisciplinary
  • Psychological, spiritual, social, bereavement
    support

51
Annie Jones What actually happened
  • 82-year-old with hypertension, diabetes, renal
    failure osteoporosis, vision loss.
  • Cycle of health crises- falls, fractures,
    pneumonia
  • Hospitalized two times in 9 months
  • Home with Medicare-CHHA, discharged from homecare
    after 4 weeks- new crisis- repeat
    hospitalization
  • In pain, symptoms not managed- long hospital
    stay, resulting in progressive deconditioning,
    weakness, functional decline
  • Not ready for hospice but in need of more support
    in hospital and ongoing transition management and
    care coordination at home

52
Annie Jones What should have happened
  • Palliative care consultation for
  • Pain and symptom relief- facilitates success of
    rehabilitation, reduces hospital length of stay
  • Patient/family discussions re needs/goals,
    advance care planning
  • Home needs assessment
  • Identification of on-going support services at
    home
  • Plan for coordination and monitoring after home
    care skilled need terminates
  • Support for gradual transition to hospice when
    illness progresses to terminal stage

53
Role of the hospital-based palliative care
consultation team
  • Advice and support to ward team on symptom
    control and psychosocial/existential issues
  • Support to families
  • Support and advice to staff
  • Education of hospital staff
  • Liaison between hospital and hospice/home care
    services or other institutions
  • Auditing and research
  • Dunlop and Hockley 1998

54
Clinical benefits of hospital-based palliative
care the evidence base
  • Evidence-based
  • Reduction in symptom burden
  • Improved patient and family satisfaction
  • Reduced costs

55
Palliative care improves quality
  • Data show hospital-based palliative care
  • Relieves pain and distressing symptoms
  • Supports on-going re-evaluations of goals of care
    and difficult decision-making
  • Improves quality of life, satisfaction for
    patients and their families
  • Eases burden on providers and caregivers
  • Helps patients complete life prolonging
    treatments
  • Improves transition management

Campbell et al, Heart Lung, 1991 Campbell et al,
Crit Care Med, 1997 UC Davis Health System News
2002 Carr et al, Vitas Healthcare, 1995
Franklin Health, 2001 Dartmouth Atlas, 2000
Micklethwaite, 2002 Du Pen et al, J Clin Oncol,
1999 Finn et al, ASCO, 2002 Francke, Pat Educ
Couns, 2000 Advisory Board, 2001 Portenoy,
Seminars in Oncol, 1995 Ireland Cancer Center,
2002 Von Roenn et al, Ann Intern Med, 1993 Finn
J et al ASCO abstract 2002.
56
Palliative care is a cost-saving change, supports
transitions to more appropriate care settings
  • Palliative care lowers costs (for hospitals and
    payers) by reducing hospital and ICU length of
    stay, and direct (such as pharmacy) costs.
  • Palliative care in hospitals improves continuity
    between settings and increases hospice/homecare/nu
    rsing home referral by supporting appropriate
    transition management.

Lilly et al, Am J Med, 2000 Dowdy et al, Crit
Care Med, 1998 Carlson et al, JAMA, 1988
Campbell et al, Heart Lung, 1991 Campbell et al,
Crit Care Med, 1997 Bruera et al, J Pall Med,
2000 Finn et al, ASCO, 2002 Goldstein et al,
Sup Care Cancer, 1996 Advisory Board 2002
Project Safe Conduct 2002, Smeenk et al Pat Educ
Couns 2000.
57
How Palliative Care Reduces Length of Stay
  • Palliative care
  • Clarifies goals of care with patients and
    families
  • Helps families to select medical treatments that
    meets their goals
  • Assists families in decisions to withhold or
    withdraw death-prolonging treatments that dont
    help to meet their goals

58
Implications of LOS Reduction
  • Patients with advanced illness have a long length
    of stay and high cost/admission
  • Palliative care results in
  • Reduction in length of stay
  • Reduction in total costs/admission
  • Opportunity for new admissions
  • Better quality care
  • Highly satisfied families

59
6 Case studies on the clinical and financial
impact of hospital-based palliative care services
  • Mount Sinai Hospital, New York City
  • Kaiser Permanente, California
  • St. Johns Regional Medical Center, Joplin MO
  • Ireland Cancer Center and Hospice of the Western
    Reserve, Cleveland
  • Virginia Commonwealth University, Richmond
  • University of Michigan and Hospice of Michigan,
    Ann Arbor

60
Case 1. Clinical and Financial Impact of
Palliative Care Service at Mount Sinai Hospital
  • Documentation of patient demographics
  • 723 consecutive patients prospectively studied
  • Recommendation and implementation rates recorded

61
Palliative Care Program Patient Characteristics
1997 2002 (N2080)
  • Median Age 71.4 (range 18 to 112)
  • 54 Women
  • 47 White, 23 African American, 23 Latino, 7
    Other
  • 64 Medicare
  • Performance status at time of consult
  • Moribund 18
  • Very sick requiring active supportive treatment
    32
  • Severely disabled 26
  • Disabled requiring assistance 13
  • Normal activity but requiring frequent medical
    care 11

Source Medical Records Patient/Proxy
Interviews
62
Palliative Care Service Diagnoses 4/97 3/02
Source Medical Record
63
Improvement in Symptoms for 1070 Mount Sinai
Hospital Patients Followed by the Palliative Care
Service (6/97-12/01)
Severe
Pain
Nausea
Moderate
Dyspnea
Mild
None
64
Percent of Palliative Care Families Satisfied or
Very Satisfied Following Their Loved Ones Death
With
  • Control of pain - 95
  • Control of non-pain symptoms - 92
  • Support of patients quality of life - 89
  • Support for family stress/anxiety - 84
  • Manner in which you were told of patients
    terminal illness - 88
  • Overall care provided by palliative care program-
    95

Source Post-Discharge/Death Family Satisfaction
Interviews, Mount Sinai Hospital, New York City
65
Mount Sinai Hospital, 2001 Financial analyses
in patients who died with and without palliative
care
  • Medicare data Palliative Care Patients Spent 360
    Fewer Days in Mount Sinai As Compared to
    DRG-Matched Patients Not Followed by Palliative
    Care
  • Cost savings from palliative care 757,555 per
    year for patients with LOS gt 14 days

66
Fiscal impact of Mount Sinai clinical palliative
care service length of stay analyses in 2001
  • 360 fewer days, gt750,000 direct costs saved
  • Savings do not include income from new admissions
    allowed by increase in bed capacity
  • Result hospital salary support for a doctor and
    2 nurses for the palliative care service
  • Meier, D. Planning a
    hospital-based palliative care program A
    primer for institutional leaders. www.capc.org

67
Case 2. Results of Palliative Care Evaluation by
Kaiser PermanenteGarfield Memorial Fund
  • Comparison trial
  • Two year study, 1999-2001
  • Multivariate analysis in subgroup of deceased
    patients (n300)

68
Change in Satisfaction with Services
P .01
P .6
69
Kaiser Permanente Study Cancer Mean Total Costs
p.001 F15.77
Covariates days on service, severity of illness
70
Kaiser Permanente Study COPD Mean Total Costs
p.02 F6.17
Covariates days on service, severity of illness
71
Kaiser Permanente Study CHF Mean Total Costs
p.31 F1.07
Covariates days on service, severity of illness
72
Total Service Costs
  • Average 6,580 (45) reduction in costs for PC
    patients
  • Locus of care shifted from inpatient to home,
    result is lower costs

plt.001 F35.93
73
Case 3. St. Johns Regional Medical Center,
Joplin, MOActual Direct Cost Per Patient
Analysis Before and After Palliative Care
Consultation
  • Direct Cost saved per patient
  • Cost Prior to Palliative Care
  • Less Cost After Start of Palliative Care
  • Equals Total Cost Savings

74
Annual Net Savings
Total net savings per year after program
expense 108,467
  • Direct Cost Savings Converts To A Sustainable
    Program
  • St. Johns Regional Med. Ctr., Joplin, MO

75
Case 4. Ireland Cancer Center and Hospice of the
Western Reserve Project Safe Conduct- RWJF
Promoting Excellence project
  • Palliative care delivered simultaneous with best
    quality cancer care
  • Highly significant reduction in pharmacy costs
    per day per patient (61 to 18)
  • Highly significant increase in referral to
    hospice during last months of life (13 to 80)

76
Case 5. Virginia Commonwealth University
Palliative Care Unit
  • Specialist run high-volume in-patient palliative
    care unit
  • Comparing 2 week periods before and after
    referral, costs and charges reduced by 66
    overall
  • Compared to non-palliative care control group,
    direct and total costs reduced 57.
  • Smith TJ, Coyne P, Cassel B et al. A high
    volume specialist palliative care unit and team
    may reduce in-hospital end of life care costs.
    2002. Tsmith_at_hsc.vcu.edu

77
Case 6. The University of Michigan- Hospice of
Michigan RWJF Promoting Excellence
Study
Target population Advanced breast, prostate,
lung, colon, bladder, pancreatic, melanoma
cancers meeting hospice criteria Intervention
RN Palliative Care Coordinator (RN-PCC)
78
Palliative Care Trial Cost Comparison (patients
with complete data as of July 1, 2002,at
Medicare prices, excludes prescription drugs)
79
Comparison of ER Admissions, Hospital Admissions
and Hospital Days
ER
HOSPITAL
HOSPITAL
Subjects
Admissions
Admissions
Days


per pt


per pt
per pt
STUDY
26
20
.8
43
1.65
200
7.7
CONTROL
29
31
1.07
53
1.83
288
9.9
80
The Palliative Care Trial Group is Living Longer
than the Usual Care Group
81
Summary
  • Hospital-based palliative care teams will play an
    essential role in improving end of life care
  • Common site of death
  • Universal site of medical care for seriously ill
  • Important teaching setting
  • Clinical evidence
  • Pain and symptom burden can be reduced
  • Satisfaction can be improved
  • Improves quality of care for patients and their
    families

82
Summary, continued
  • Educational evidence
  • Positive impact on knowledge/skills/attitudes
  • Palliative care is now a requirement for under-
    and postgraduate medical education
  • Fiscal evidence
  • Costly, prolonged hospital and ICU stays
    associated with serious illnesses that precede
    death
  • Multiple studies of varied palliative care
    interventions point to cost savings

83
Hospital-based palliative care Needed and
effective
  • Number of current palliative care programs over
    700
  • Number of U.S. hospitals approximately 7000
  • Challenge How to increase the number and
    quality of hospital-based palliative care
    programs?
  • Barriers Target audience needs more convincing,
    need more professional training and capacity,
    financing for new programs

84
So, how do we get there?
  • Stay tuned

85
Advice to local champions Just do it...
  • Here are some important messages for anyone
    getting started Each individual program begins
    in a unique place, with a unique history and a
    unique set of people that are there, and you
    start with what youve got. The second important
    message is persistence. You have to have this
    strong vision, and work at it persistently over
    time. Over time, through some serendipity and a
    lot of perseverance by a small group of involved,
    committed people, we built an effective program.
    Also remember, its better to beg forgiveness
    than to ask permission. Its not like there was
    this giant committee in the hospital that said
    Should we have this inpatient hospice unit in
    the hospital? When you begin you just start
    doing it.
  • von Gunten J Pal Med 20003115-122.
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