Innovations in End-of-Life Care
an international journal of leaders in end-of-life care

This issue of Innovations in End-of-Life Care addresses the challenges facing hospitals and hospice organizations seeking to expand their usual boundaries to meet the needs of patients for comprehensive palliative care. Here, we feature the work of the Palliative CareCenter & Hospice of the North Shore, a winner of the American Hospital Association's 2001 Circle of Life Award. This organization has expanded its services far beyond the provision of the Medicare Hospice Benefit and now offers a wide range of care characterized by an effort to let mission (rather than reimbursement structures) drive choices about what they can or will do. One unusual element is an interdisciplinary palliative care consultation service that includes the opportunity for home visits to patients who need palliative care, yet who do not "qualify" for home health or hospice care under Medicare. Dr. Martha Twaddle and Mary Sheehan, RN, describe this and other services at the Palliative CareCenter & Hospice of the North Shore and how they attempt to follow patients throughout the illness trajectory.

In her Editorial for this issue, Diane Meier, MD, director of the Center to Advance Palliative Care at Mt. Sinai Hospital in New York City, offers an overview of ways in which hospitals and hospices can partner to provide better care, including a review of how palliative care and hospice differ. Dr. Meier delineates the benefits and challenges of collaboration between hospices and hospitals. The Center to Advance Palliative Care has played a leading role as a technical assistance center to health care providers in hospitals seeking to expand their role in caring effectively for dying patients. As Dr. Meier suggests, one route to building such expertise is to partner with hospices. The construction of in-house palliative care services is another way to meet the needs of the sickest, most vulnerable patients, who until recently have not been well served by acute care hospitals.¹ Earlier issues of Innovations spotlight examples of hospitals that have created such services to expand their purview into palliative care.²

In a candid Personal Reflection, Dr. Eugenia L. Siegler comments on her efforts to initiate and sustain a nurse-centered palliative care service at Brooklyn Hospital. The service ended when two of its champions, including Dr. Siegler, left the hospital, but her experience will certainly be instructive to other health care providers working in community hospitals, who are seeking to include palliative care among their patient services. Dr. Siegler and her colleagues initiated this advanced practice nurse-led palliative care consult service without having any physicians with expertise in palliative medicine on their staff. This choice was courageous and worth noting, as such physicians are not often available at community hospitals. In the absence of such expertise, Dr. Siegler emphasizes instead that a willingness to read the literature, staff education, a nurse-initiated intervention, and institutional support were key ingredients in implementing their program. Her reflection on why this effort ultimately failed may help readers to avoid some of the pitfalls she identifies, and may lead them to contemplate the complexity of sustaining hospital-based change efforts to improve palliative care.

1. The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). A controlled trial to improve care for seriously ill hospitalized patients. Journal of the American Medical Association. 1995;274:1591-1597.[Return to Notes from the Editor]

2. See Featured Innovations with Dr. Portenoy, July 2001 or Dr. von Gunten, September 1999.
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