It was a bad December for Saskia Siderow and her family.
First, her mother-in-law was diagnosed with late-stage colon cancer. Then, as she was coming out of a procedure in the hospital, her father-in-law suffered a massive stroke.
“It was a nightmare,” said Siderow, a New York-based healthcare consultant.
Siderow helped other family members care for both husband and wife as they went through treatment starting in December 2011 and, finally, died. And for Siderow, one thing made a huge difference for both of her in-laws: palliative care.
“There was a big difference between before palliative care and after palliative care,” said Siderow.
“Before palliative care, no one really made sure that we understood the diagnosis. No one made sure that we understood the prognosis. No one made sure we understood what was going on,” she added.
“We had no sense that anyone was talking to each other, which is typical of the U.S. healthcare system.”
Her mother-in-law died within a few months, after first trying every treatment possible. Her father-in-law lived for four years. In both cases, Siderow feels the palliative care team gave her in-laws, whom she does not wish to name, comfort and dignity in their last weeks and months of life.
Palliative care is a team approach. “Care is usually provided by an interdisciplinary team of experts, including palliative care doctors, nurses, and social workers,” the American Academy of Hospice and Palliative Medicine says.
“Chaplains, counselors, massage therapists, pharmacists, nutritionists, and others might also be part of the team.”
It sounds expensive and complicated. But a new study published in the Journal of the American Medical Association’s JAMA Internal Medicine shows that palliative care teams can actually cut costs.
On average, hospital costs alone were more than $3,000 lower if patients were started on palliative care within three days of admission, the team, led by Dr. Peter May of Trinity College in Dublin, Ireland reported.
Palliative care — sometimes called comfort care — hit the headlines earlier this month when former first lady Barbara Bush said she was opting for comfort care just days before she died.
Dr. Sean Morrison of the Icahn School of Medicine at Mount Sinai, who worked on the study team, said people often misunderstand what palliative care is. They often fear that palliative care and hospice care mean giving up.
The approach includes treating a patient’s pain and symptoms such as breathlessness so they can better understand options, communicate and withstand the stress of medical treatment.
“Every single study that has compared palliative care to usual care — there has never been a study that shows people’s lives are shortened when they receive palliative care,” Morrison said.
“We know that there is a very, very strong database that demonstrates when palliative care is provided at the time of other appropriate treatment, patients feel better, their quality of life improves, their families feel better and, particularly in the case of cancer, they live longer.”
Morrison, May and colleagues did what’s called a meta-analysis — a study of studies. They pooled data from six other studies on palliative care covering more than 130,000 patients admitted to hospitals in the United States between 2001 and 2015. Just under 4 percent of them received palliative care.
Those who got palliative care ended up with hospital bills that were more than $3,200 lower than those who did not get palliative care, the study found. Cancer patients ended up spending more than $4,200 less if they got palliative care.
"This study proves that better care can go hand in hand with a better bottom line,” Morrison said.
“It’s a side-effect of providing high-quality care.”
Morrison chairs the department of geriatrics and palliative care medicine at Mt. Sinai and helped head the team that cared for Siderow’s mother- and father-in-law.
Siderow said the approach helped choose the best course of treatment while ensuring her mother-in-law stayed clear-headed and able to decide what she wanted to do.
“My mother-in-law said that it was transformational for her,” Siderow said. “They gave her peace of mind, that she was in the driver’s seat and there wouldn’t be this crazy circus of tests and treatments that she didn’t understand.”
At first, Siderow’s mother-in-law wanted every treatment possible for her stage 4 colon cancer, which had spread to her brain by the time it was diagnosed.
“She wanted to fight,” Siderow said.
“But she was very sick. She needed surgery,” she added. “Then she needed to get well enough, post-surgery, to do the chemotherapy. That took some time. By the time she was ready, the cancer had continued to progress.”
Siderow said the palliative care team helped through the process, making sure her mother-in-law didn’t get unnecessary tests and middle-of-the-night wakeup calls for non-urgent care.
Her father-in-law died four years later from complications of his stroke.
“He was able to live at home. He had round-the-clock care from family and from visiting doctor services that are part of the Mt. Sinai program,” Siderow said. “It kept him out of the ER. It kept him out of the hospital. Would his care have cost more had we pursued a different philosophy? Absolutely,” she said.
What Morrison believes works is the combination of strong healthcare, communication and choice.
“For example, for one of my patients, it may be extraordinarily important to live as long as possible or to make a major family event and they are willing to try a treatment that may be very, very burdensome,” Morrison said.
“For others, it may be that a five percent chance of a treatment meeting its goals, plus burdensome side-effects and indeed side effects that may hasten death, may seemless attractive. They may say to me ‘I would rather spend my time feeling better and spending better quality time at home’,” he added.
“Each of those decisions is right for that individual patient."
A second study shows the effects of not providing palliative care.
Dr. Melissa Wachterman of the Veterans Affairs Boston Healthcare System and colleagues looked at the records of more than 770,000 Medicare patients who were getting dialysis as part of their treatment.
About 20 percent of them enrolled in hospice but more than 40 percent of these patients got hospice care for three days or less, the team found.
Hospice helps keep patients out of intensive care, the team noted, and means fewer of these patients end up dying in the hospital. But three days of care isn’t enough, they noted.
“Those who enrolled in hospice within three days of death had similar costs and more intensive patterns of health care utilization than those not referred to hospice,” they wrote in their report, also published in JAMA Internal Medicine.