Study: Stroke Patients Lack Sufficient Access to Palliative Care

More hospice providers are seeking to diversify their services with palliative care to reach patients further upstream. Recent research has found a gap when it comes to improving access for patients hospitalized with severe ischemic stroke. Expanding education and awareness of these services could be key to building up utilization.

A study published this year in the Journal of Pain and Symptom Management gauged the experiences of nearly 1,300 patients across four hospitals who suffered a severe ischemic stroke between January 2016 and December 2019. Of these patients, only 20% received palliative care consultations while hospitalized. Additionally, less than half (or 43%) of those who passed from a severe stroke in the hospital were given these consultations.

Researchers sought to determine prevalence, predictors and outcomes associated with palliative care consultations. The study found that patients who received these consults had higher rates of moving to a care plan focused on comfort measures. They were also more likely to report receiving high quality end-of-life care.

“The most important finding of this study is first that palliative care is underutilized in patients who may benefit from it,” researcher Amber Comer told Hospice News. “The second important finding is that when patients receive palliative care, they have higher quality end-of-life treatment. They were transitioned to comfort measures only and not receiving aggressive interventions at the end of life that would otherwise be futile. They were able to die in a more peaceful way, surrounded by their loved ones.”

Comer is an associate professor at the Indiana University School of Health and Human Sciences. She indicated that the study reveals missed opportunities for spreading awareness and utilization of palliative care.

Palliative care consultations can change the way patients die, said Comer. Stroke patients who weren’t provided palliative consultations often received expensive and extensive care measures in life’s final stages — many of which they wouldn’t have chosen if consulted, according to Comer.

The prevalence of stroke is on the rise as the country’s population ages. The U.S. Centers for Disease Control and Prevention (CDC) reported last year that strokes are a leading cause of mortality nationwide, leading to one death every four minutes. Around 795,000 strokes occur annually, and nearly 1 in 4 of these patients have had a previous stroke, according to the CDC.

Stroke patients aren’t the only underserved population. Patients with other serious illnesses such as renal failure, chronic obstructive pulmonary disease (COPD) and heart disease are a few others, according to Melinda Egging, president of The Denver Hospice in Colorado. Looking at disease-specific patient populations could lead to bolstered utilization of palliative care services, Egging told Hospice News.

“Some of the successes we see in palliative care and where it can be advantageous for the patient is heart disease or heart failure,” said Egging. “We can look further upstream to when and where a person has been diagnosed. Looking at these and other markers means you’re really looking at who is accessing health care and how they’re needs are being met. We can look at what’s happening and how we can manage care better.”

A contributing factor to the underutilization of palliative care is that the overall health care workforce needs to be better prepared and trained to discuss comfort-oriented and end-of-life care, Comer stated.

Education and care coordination are essential to expanding access to palliative care among underserved populations. Some clinicians conflate these services with hospice, and families often fear losing their other health care options, though palliative care can be provided alongside curative care.

“To get palliative care, patient wishes have to be documented,” said Comer. “The number one reason why patients didn’t have a palliative care consult in the study is that it’s time-consuming and it’s a hard conversation. Physicians are trained to save lives, and now we’re asking them to engage in conversations about how a patient wants to die. It goes back to the whole health care system and how we’re trained to save lives, not trained to talk about death.”

Some attempts have been made in the public policy space to improve the availability of palliative care training.

First introduced in 2019, the Palliative Care and Hospice Education and Training Act (PCHETA) seeks to provide resources to support clinician training and establish fellowship programs within new palliative care and hospice education centers to provide short-term, intensive training on these services. The bill has since passed in the U.S. House of Representatives, but then stalled due to competing legislative priorities.

Exposure to palliative care early in clinical training allows for firsthand experiences. This would also allow for the ability for providers to develop deeper ties to patients who could benefit from these services, according to Egging.

The Denver Hospice has integrated palliative care specialists into part of its hospital and health system rounding teams to help providers in these settings identify patient markers and facilitate earlier conversations. The hospice aids in educating hospital staff of how and when to intervene, along with tools they can utilize to engage patients and families with palliative care.

“It is important to highlight how palliative care improves the quality of care,” Egging said. “Palliative care is a way of relieving the symptom and pain burden, but also the stress that serious illness can bring. When you know more about it, you can really hone in on managing expectations and being prepared to give great value to patients and families.”