Palliative Care?

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Angry Birds

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Anyone do palliative care here? Can you tell us about it? Did you do a fellowship? What's the lifestyle? How many hours/days per week do you do it? What's the pay cut? Etc.? If you work in an academic center does this buy down clinical time in the ER?

I've had a relative pass away of cancer recently, and it's got me interested in palliative care... It also ties in well with my outside interests.
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Angry Birds said:
Anyone do palliative care here? Can you tell us about it? Did you do a fellowship? What's the lifestyle? How many hours/days per week do you do it? What's the pay cut? Etc.? If you work in an academic center does this buy down clinical time in the ER?

I've had a relative pass away of cancer recently, and it's got me interested in palliative care... It also ties in well with my outside interests.
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Wasn't it @dchristismi that started doing palliative?
 
Veil said:
Wasn't it @dchristismi that started doing palliative?
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Yes it was.

To answer some questions, you can do it without a fellowship, but that's getting more rare. That said, there is a huge need for pall care docs so with some training, you can probably find someone to hire you. The pall care docs I know are mostly inpatient and work a straight 9-5, M-F schedule. Usually have 3-8 patients on their list and are obviously not primary on any of them. Lots of talking, not much doing. They all seem happy and are the docs I consult most in the hospital. Also the ones I learn the most from, even 7 years into my career.
 
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The median pay is a little under $200k. As Gutonc mentioned, HPCM docs have a pretty nice schedule and they vary from no call to a couple call nights/week. However it's almost uniformly home call and reported to be quite easy.

I don't know of anyone who has a buy down in EM, yet, but it seems totally doable to me. Probably going to be increasingly valued with our aging population.
 
Thanks for the valuable info! Probably too hard a trade-off due to the sub-200 salary for 5 days/wk. But alas, that's what I expected.

However, it's something I might consider later in life...
 
Angry Birds said:
Thanks for the valuable info! Probably too hard a trade-off due to the sub-200 salary for 5 days/wk. But alas, that's what I expected.

However, it's something I might consider later in life...
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Yeah, you could basically work 7 days a month in an ED and make the same if not more. I’ve thought about this as well but I would rather just work less and have more days off.
 
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Yep, that's me. Well, the hospice part. I don't do much palliative, unless the patient happens to be on hospice. There are plenty of hospice patients who aren't actively dying.

There are apparently many ways to go about it - I simply asked after they hinted that they wanted me. I didn't do a fellowship, and my director said I really didn't need one to do the clinical work - yes if I wanted to do administration, and I absolutely do not.

There's definitely a shortage here, and every other month she calls me very nicely and asks if I'm ready to come on full time, which would basically be the above-mentioned 9-5 M-F. I keep putting her off, as I am not quite ready to give up EM... although after the last 3 long shifts in a row I do contemplate it!

I round for them roughly 13-15 days a month at a single inpatient-level hospice house. I usually have anywhere between 4-10 patients and depending on how long I spend, how many families are there, how many new admissions I have, it's usually a half-day, give or take. There have certainly been days where I've put in a full 8 hours, but 4-6 is more common. I get paid by billing, which is RVU based. The coders do the actual coding, but it's pretty straightforward. If you want actual numbers, pm me.

Bottom line, I really enjoy it, but yes, it's a lot of talking and not much doing. Lots of little tweaking here and there... up the morphine PCA, add some decadron, certainly nothing that is beyond my skill set. I do occasionally need to calculate morphine equivalents to change drugs, but I will honestly say that 10+ years in EM have given me a pretty good feel for people and pain. That, and I do have a pharmacy I can consult. Also, I don't hesitate to ask questions - we had a guy on a ketamine drip not too long ago and it's the first time I've see it used beyond a few bolus doses, which of course, I do all the time.

It's sort of my EM exit strategy. I certainly don't feel drained or beat up when I leave... I look at it as a part time gig. While it does pay, I can easily make a hell of a lot more in EM, so for now, it's 50/50, but it's definitely slower paced, with a very low malpractice risk, and it's very fulfilling.
 
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dchristismi said:
Yep, that's me. Well, the hospice part. I don't do much palliative, unless the patient happens to be on hospice. There are plenty of hospice patients who aren't actively dying.

There are apparently many ways to go about it - I simply asked after they hinted that they wanted me. I didn't do a fellowship, and my director said I really didn't need one to do the clinical work - yes if I wanted to do administration, and I absolutely do not.

There's definitely a shortage here, and every other month she calls me very nicely and asks if I'm ready to come on full time, which would basically be the above-mentioned 9-5 M-F. I keep putting her off, as I am not quite ready to give up EM... although after the last 3 long shifts in a row I do contemplate it!

I round for them roughly 13-15 days a month at a single inpatient-level hospice house. I usually have anywhere between 4-10 patients and depending on how long I spend, how many families are there, how many new admissions I have, it's usually a half-day, give or take. There have certainly been days where I've put in a full 8 hours, but 4-6 is more common. I get paid by billing, which is RVU based. The coders do the actual coding, but it's pretty straightforward. If you want actual numbers, pm me.

Bottom line, I really enjoy it, but yes, it's a lot of talking and not much doing. Lots of little tweaking here and there... up the morphine PCA, add some decadron, certainly nothing that is beyond my skill set. I do occasionally need to calculate morphine equivalents to change drugs, but I will honestly say that 10+ years in EM have given me a pretty good feel for people and pain. That, and I do have a pharmacy I can consult. Also, I don't hesitate to ask questions - we had a guy on a ketamine drip not too long ago and it's the first time I've see it used beyond a few bolus doses, which of course, I do all the time.

It's sort of my EM exit strategy. I certainly don't feel drained or beat up when I leave... I look at it as a part time gig. While it does pay, I can easily make a hell of a lot more in EM, so for now, it's 50/50, but it's definitely slower paced, with a very low malpractice risk, and it's very fulfilling.
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I did a month of hospice/palliative in my Pain fellowship and I liked it. The stress level is essentially 95% less than EM.
 
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gutonc said:
Yes it was.

To answer some questions, you can do it without a fellowship, but that's getting more rare. That said, there is a huge need for pall care docs so with some training, you can probably find someone to hire you. The pall care docs I know are mostly inpatient and work a straight 9-5, M-F schedule. Usually have 3-8 patients on their list and are obviously not primary on any of them. Lots of talking, not much doing. They all seem happy and are the docs I consult most in the hospital. Also the ones I learn the most from, even 7 years into my career.
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Depends, our palliative folks can have rough weeks. Our MICU can be very busy with lots of palliative discussion, the consults for pain management. Our system is currently trying to find a sweet spot, as they have hired three NP's to go along with (I think) four docs. They have a clinic to run, and they have opened up a few beds suppose to "palliative beds" with them as primary. It is a work in progress. I really have no idea what they make, but again . . sometimes they can be quite busy, but they are rarely stressed, just pushed by the monster that is a large hospital.
 
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dchristismi said:
Yep, that's me. Well, the hospice part. I don't do much palliative, unless the patient happens to be on hospice. There are plenty of hospice patients who aren't actively dying.

There are apparently many ways to go about it - I simply asked after they hinted that they wanted me. I didn't do a fellowship, and my director said I really didn't need one to do the clinical work - yes if I wanted to do administration, and I absolutely do not.

There's definitely a shortage here, and every other month she calls me very nicely and asks if I'm ready to come on full time, which would basically be the above-mentioned 9-5 M-F. I keep putting her off, as I am not quite ready to give up EM... although after the last 3 long shifts in a row I do contemplate it!

I round for them roughly 13-15 days a month at a single inpatient-level hospice house. I usually have anywhere between 4-10 patients and depending on how long I spend, how many families are there, how many new admissions I have, it's usually a half-day, give or take. There have certainly been days where I've put in a full 8 hours, but 4-6 is more common. I get paid by billing, which is RVU based. The coders do the actual coding, but it's pretty straightforward. If you want actual numbers, pm me.

Bottom line, I really enjoy it, but yes, it's a lot of talking and not much doing. Lots of little tweaking here and there... up the morphine PCA, add some decadron, certainly nothing that is beyond my skill set. I do occasionally need to calculate morphine equivalents to change drugs, but I will honestly say that 10+ years in EM have given me a pretty good feel for people and pain. That, and I do have a pharmacy I can consult. Also, I don't hesitate to ask questions - we had a guy on a ketamine drip not too long ago and it's the first time I've see it used beyond a few bolus doses, which of course, I do all the time.

It's sort of my EM exit strategy. I certainly don't feel drained or beat up when I leave... I look at it as a part time gig. While it does pay, I can easily make a hell of a lot more in EM, so for now, it's 50/50, but it's definitely slower paced, with a very low malpractice risk, and it's very fulfilling.
Click to expand...

Dude, this was a super helpful post. Thank you!

I might end up contacting you in a couple years when and if I ever decide to go down this path. Where I live I suspect I'd have to do a fellowship, which I wouldn't necessarily mind...

I do have some additional questions:

1. So, is this usually 13-15 days per month of 4-6 hours per day?

2. Do you feel that there is a skill set and knowledge base specific to palliative care? In other words, are you providing a valuable service that the primary team cannot necessarily do well and therefore needs your expertise?

3. I take it that you feel that your contribution to patient care is significant and beneficial enough, which is why you say that it is rewarding?

I ask these questions only because you said there is a lot more talking than doing (the opposite of EM)... Is it just about adjusting pain meds, which seems to be something anyone can do?

I guess where I'm getting at is that on the one hand I'm looking for something less stressful than EM--which it seems it definitely is. On the other hand, I still want to feel useful, beneficial, and a "real doctor," if you know what I mean.

Last question:

4. Could I do something part-time, like one day a week, and an occasional call? Would the palliative care team want the extra little bit of help, or is there a higher minimum level of commitment needed?
 
I mean this as no disrespect to palliative care physicians, whose skills and knowledge are needed, valued, and in short supply, but doesn't this field seem ripe for almost complete NP takeover?
 
miacomet said:
I mean this as no disrespect to palliative care physicians, whose skills and knowledge are needed, valued, and in short supply, but doesn't this field seem ripe for almost complete NP takeover?
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There's a surprising amount of nuance to the field. I'm sure NPs could go after it once Medicare would let them, but I don't think it would be huge - especially given that it doesn't pay us great so it would pay them less.
 
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Angry Birds said:
Dude, this was a super helpful post. Thank you!

I might end up contacting you in a couple years when and if I ever decide to go down this path. Where I live I suspect I'd have to do a fellowship, which I wouldn't necessarily mind...

I do have some additional questions:

1. So, is this usually 13-15 days per month of 4-6 hours per day?

2. Do you feel that there is a skill set and knowledge base specific to palliative care? In other words, are you providing a valuable service that the primary team cannot necessarily do well and therefore needs your expertise?

3. I take it that you feel that your contribution to patient care is significant and beneficial enough, which is why you say that it is rewarding?

I ask these questions only because you said there is a lot more talking than doing (the opposite of EM)... Is it just about adjusting pain meds, which seems to be something anyone can do?

I guess where I'm getting at is that on the one hand I'm looking for something less stressful than EM--which it seems it definitely is. On the other hand, I still want to feel useful, beneficial, and a "real doctor," if you know what I mean.

Last question:

4. Could I do something part-time, like one day a week, and an occasional call? Would the palliative care team want the extra little bit of help, or is there a higher minimum level of commitment needed?
Click to expand...

1. So, for now, I'm doing that 13-15 days a month at roughly 4-6 hours per day at a dedicated hospice house, not a hospital. This could change. I spent 6 hours there today with a total of 9 patients and had 3 new admissions. The H&P is quite simple (as you all know) if the patient is unresponsive and you're just getting the history from the chart. I also spent a chunk of time on the phone with a husband of one of these because she was hallucinating and not reliable. I suspect each job is a little different, so I don't know that I can generalize.

2. I think EM's skill set carries over quite well... I mean, I've done plenty of terminal extubations in the ED and lord knows I've seen a lot of people die. I can explain what a hyperkalemic arrest looks like, and assure patients that it isn't painful and it's not a bad way to die. I have a good feeling for med titration because I've seen so many people in acute pain over the years and have experience with a large range of medicines. I'm comfortable with really high doses of morphine, dilaudid, fentanyl, and, surprisingly enough, haldol. I know what dystonia looks like. I know what air hunger looks like. In my case, there *is* no primary team, because I'm at a hospice house and I'm it. I'd imagine in the hospital setting, palliative care would be the ones to sit down and talk - more than most of the other specialties. Families have a lot of questions. Patients often have fear. I am Virgil leading Dante through hell, as it were. For me, the main things I've had to learn have been calculating morphine equivalents, learning the palliative performance scale and the Pain in Alzheimer's Dementia scale, which I now use every single day.

3. I definitely feel my contribution to my patients' care makes a difference. I get a lot of hugs. I have people cry on my shoulder. I get thank you notes. I don't fix people, but I certainly help them. It's a different kind of doctoring for sure. I don't get the adrenaline rush, but then again, it takes a hell of a lot to get that in the ED now anyway. It is however, a LOT more relaxed and, dare I say it, serene.

4. I'm certainly part time. I don't take call either, because I'm still learning the ropes and don't do certifications. Again, I'm *just* doing hospice - while there are patients who aren't dying, they all meet hospice criteria. I've found that if I'm rounding, having the continuity makes days 2-x much simpler because I know that I upped Mr Smith's morphine PCA to 3/hr yesterday, and if he uses x many boluses, I'll up it to 5. If I know that Ms Jones was really restless yesterday and I'd started her on a whiff of haldol, and she's unresponsive and starting to mottle today, I can give her family a little better idea of what to expect.

Honestly, the only way you would find out how you might get involved is to ask. They were thrilled to have me.
And yes, there are plenty of midlevels involved. The families still ask when the Doctor will be in. Mostly, our NPs do the home visits, at least as far as I know. I've never met any of them beyond emails or the occasional phone call. It's not like I'm signing their charts.

Hope that helps.
DC
 
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What would salary look like for a 50-50 split of em-palliative, doing part time for each? Is it difficult to negotiate these kind of arrangements?


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AlvinKamara said:
What would salary look like for a 50-50 split of em-palliative, doing part time for each? Is it difficult to negotiate these kind of arrangements?


Sent from my iPhone using SDN mobile
Click to expand...


Let's assume you'd make $190k/yr doing Palliative full time and $250k/yr doing EM full time. If you do 50-50 it'll probably be something like 190/2 + 250/2 = $220k/yr.

You should probably assume lower end, since you're most likely to be able to pull off a 50-50 split if you work in an academic institution.

Another approach is to work as a Palliative doc for your "real job" and then pick up locums shifts in EDs when you have extra time or need extra money.
 
If you're an independent contractor, your imagination is your only limit.
 
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Palliative care pays less but gives a predictable schedule M-F 8-5, less risk and most jobs no nights and no weekends.

Nothing will pay as much as working EM but by the time you’re considering leaving EM, the money is not your biggest concern. You just want out. It’s not a bad out considering you’re still getting to be a doctor and can still “help” people.
 
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Do you ever feel like you're murdering people when you give them more opiates for guppy breathing?
 
BAM! said:
Do you ever feel like you're murdering people when you give them more opiates for guppy breathing?
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I'm assuming by "guppy breathing" you mean the agonal respirations of dying, likely unconscious person. I realize this gets very complicated in hospice and palliative care settings, but assuming that definition, such a person, presumably feeling little if any pain in their unconscious near-death state, would not need any opiate at all. The opiate would be primarily treating the emotional pain of those observing the dying person.
 
Generally, my dying patients are either on an infusion or getting scheduled doses titrated specifically to their needs, which includes pain, air hunger and anxiety. I will give you a serious answer, although my first impulse was also a WTF.

From the Palliative Care Network of Wisconsin's Fast Fact Series: (one of my favorite places for HPM pearls)

FAST FACTS AND CONCEPTS #8

MORPHINE AND HASTENED DEATH

Charles F von Gunten MD

Question: What is the distinction between the use of morphine at the end of life to control symptoms and euthanasia/assisted suicide?

Case Scenario: An 83 year old former industrial worker has been hospitalized because of severe pain. He has pancreatic cancer with metastases to liver and lung. He has severe abdominal pain, and opioid therapy with morphine is recommended for pain relief.

Main Teaching Points
  1. Many physicians inaccurately believe that morphine has an unusually or unacceptably high risk of an adverse event that may cause death, particularly when the patient is frail or close to the end of his or her life. In fact, a large study of opioid use at the end of life from the US National Hospice Outcomes Project, as well as a systematic review of various other countries, found no difference in survival with absolute opioid dose or change in opioid dose. Furthermore, morphine-related toxicity will be evident in sequential development of drowsiness, confusion, then loss of consciousness before respiratory drive is significantly compromised.

  2. Many physicians inappropriately call this risk of a potentially adverse event, a double effect, when it is in fact a secondary, unintended consequence. The principle of double effect refers to the ethical construct where a physician uses a treatment, or gives medication, for an ethical intended effect where the potential outcome is good (eg, relief of a symptom), knowing that there will certainly be an undesired secondary effect (such as death). An example might be the separation of conjoined twins knowing that one twin will die so that the other will live. Although this principle of “double effect” is commonly cited with morphine, in fact, it does not apply, as the secondary adverse consequences are unlikely.

  3. When offering a therapy, it is the intent in offering a treatment that dictates whether it is ethical medical practice:
    1. if the intent in offering a treatment is desirable or helpful to the patient and the potential outcome good (such as relief of pain), but a potentially adverse secondary effect is undesired and the potential outcome bad (such as death), then the treatment is considered ethical

    2. If the intent is not desirable or will harm the patient and the potential outcome bad, the treatment is considered unethical
  4. All medical treatments have both intended effects and the risk of unintended, potentially adverse, secondary consequences, including death. Some examples are total parenteral nutrition, chemotherapy, surgery, amiodarone, etc.

  5. Assisted suicide and euthanasia are not examples of “double effect.” The intention in offering the treatment in assisted suicide and euthanasia is to end the patient’s life.

  6. If the intent for using morphine in the scenario is to relieve pain and not to cause death, and accepted dosing guidelines are followed:
    1. the treatment is considered ethical,

    2. the risk of a potentially dangerous adverse secondary effects particularly hastening death is minimal, and

    3. the risk of respiratory depression is vastly over-estimated.
References

  1. Emanuel LL, von Gunten CF, Ferris FD. The Education for Physicians on End-of-Life Care (EPEC) curriculum. Chicago, IL: American Medical Association, Chicago; 1999. : Education in Palliative and End-of-Life Care: Feinberg School of Medicine: Northwestern University.

  2. Morita T, et al. Effects of high dose opioids and sedatives on survival in terminally ill cancer patients. J Pain Sympt Manage. 2001; 21:282-9.

  3. Regnard D. Double effect is a myth leading a double life [letter]. BMJ. 2007; 334:440.

  4. Portenoy R, Sibirceva U, et al. Opioid use and survival at the end of life: a survey of a hospice population. J Pain Sympt Manage 2006; 32:532-40

  5. Sykes N, Thorns A. The use of opioids and sedatives at the end of life. Lancet Oncol 2003; 4:312-8.
 
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Apollyon said:
Russell Portenoy was the person who said that opiates were appropriate and non addicting. He, now, regrets his error.
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Appropriate in what context?


I have to agree with the poster above. In my experience palliative care is actually pretty thoughtful about their use of opiates and should be titrated to a patient's symptoms not breathing patterns alone. You can have tachypnea or cheyne stokes breathing without other non verbal signs of discomfort that wouldn't necessarily require medication. It's nuanced. And no I have never felt like I was killing a patient when giving morphine for air hunger. I've stressed more over using haldol in a dying patient with a long qt which is an anxiety that doesn't make a ton of sense either.
 
pkm296 said:
Appropriate in what context?


I have to agree with the poster above. In my experience palliative care is actually pretty thoughtful about their use of opiates and should be titrated to a patient's symptoms not breathing patterns alone. You can have tachypnea or cheyne stokes breathing without other non verbal signs of discomfort that wouldn't necessarily require medication. It's nuanced. And no I have never felt like I was killing a patient when giving morphine for air hunger. I've stressed more over using haldol in a dying patient with a long qt which is an anxiety that doesn't make a ton of sense either.
Click to expand...
For everything. CNCP (chronic non cancer pain) is one of the big ones. That genie is out of the bottle, and to see how well we are getting it back in (we're not).
 
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