The Evolution of an Inpatient Palliative Care Consultation Service in an Urban Teaching Hospital

Background: Research on inpatient palliative medicine reports quality-of-life outcomes and selected hard outcomes including pain scores, survival, and readmissions. Objective: This case study reports the evolution of an inpatient palliative consultation (IPC) team to show how IPC induces culture change in a hospital that previously had no palliative care. Design: Retrospective chart review. Setting: A Catholic university-affiliated, inner-city hospital. Population: A total of 1700 consecutive adult inpatients from May 2009 to October 2013. Measures: Consultation records enumerated demographics, code status, powers of attorney, referring physician, reason for consultation, and discharge destination. Deidentified data were uploaded to a spreadsheet. Simple descriptive statistics were calculated. Results: Requests originated from internal medicine (24%), geriatrics (21%), neurology (including stroke and neurosurgery, 14.3%), medical intensive care unit (MICU, 12.2%), and hematology-oncology (10.3%). The MICU consults increased 17.6% over time. The numbers of consults nearly doubled after trainees began rounding with the service. Hospice discharges increased by 9.2%. Palliative management of in-hospital expirations increased 2- to 3-fold. The most common consultation requests were for pain and nonpain symptoms, establishing goals of care for patients experiencing clinical decline and convening family meetings in cases of divided judgment. Conclusion: We describe the evolution of palliative care in a safety-net hospital. Medicine services which are largely resident run adopted early. Specialty services that are attending driven adopted later. We believe house staff and nurses were the initial change agents. The number of consultations increased when house staff and students began rotating on the service suggesting unmet demand due to the limited supply of providers.