Offering Palliative Care in Rural Communities

Offering Palliative Care in Rural Communities



(gentle music) – I'm Dr. Gregg Vandekieft. I'm a palliative care physician for Providence Health and Services. Work at St. Peter Hospital,
Providence Centralia Hospital, and also an outpatient clinic in Lacey. Palliative care is an aspect of medicine that really focuses on addressing problematic symptoms, suffering. Both anticipating, responding to, treating difficult situations and so our focus is physical. It's psychosocial and it's spiritual. Palliative care is delivered
by an interdisciplinary team. I provide the physician aspect of care but we work with nurses,
social workers, chaplains, pharmacists, occasionally
various types of therapists. To really look at the whole
person and address their needs. That includes their family,
their friends, their community. And especially because many
palliative care patients are seriously ill and may
be losing their ability to communicate their own
preferences and desires so we spend a lot of time
working with medical surrogates. Spouses, children, others,
trying to figure out what is the next best step? Delivering high quality palliative care in the rural setting is
primarily a challenge because of staffing. Number one, they're already challenged to meet the staffing needs
of just basic primary care and any sub-specialty. Secondly, how do you recruit a specialized palliative care provider in any discipline into a rural setting if you don't have the volume of
patients to really justify the salary and all of that? So we're seeing a lot
of innovative things. In many rural communities,
the palliative care champion might be a hospice social worker. It might be a hospital chaplain. Often it's a nurse or
a nurse practitioner. It may be a family doctor who also does hospice medical directorship. And so they're kind of finding ways to cobble together the components of the palliative care team. So, much of palliative
care is actually delivered in the primary care setting. If I think of palliative
care in the broadest sense of the term, symptom management,
determining goals of care, matching a patient's values,
priorities, preferences with the treatments that are offered. That's something primary care
providers do every single day. Palliative care is more
specialized and also palliative care is generally consultative rather than taking over
the total management. So at primary care you need to be able to do the preventative care. The immunizations and other
health screening services. Palliative care is more
focused on addressing the bigger picture, but not
getting into the nitty gritty of a lot of the preventive needs that a primary care provider would do. So palliative care is a
broader concept of care that's focused on comfort
and quality of life. Hospice is one specific
model of palliative care. But hospice is really
limited to end of life care. Historically medicine is thought in more of an either or mindset. And what I mean by that
is either we're pursuing, hopefully curative or life
prolonging treatments, or we're doing comfort care. People would always say,
oh they're not ready for palliative care yet. Meaning, they're not
sufficiently end of life. Now, they're recognizing, why wait until they're end of life to get 'em comfort focus therapies? So I'm seeing many more patients now who are actively undergoing
radiation therapy, chemotherapy, cardiac management. While they're receiving those treatments they're also getting palliative care. When we first opened our clinic we got a gentleman who
had gone through head and neck cancer treatments. He was completely through
his cancer therapies. He was miserable. The radiation, the
surgery, the cancer itself had all left him with a
pretty substantial amount of pain, nausea, malnutrition. He was still getting nutrition
through a feeding tube because he couldn't swallow and so we spent months working with him to stabilize his physical symptoms. To address a lot of
his psychosocial needs. He'd become very isolated and depressed. And after about six months, he actually came into our clinic and said, "I don't think I
need my appointment today. I actually think I'm
ready to stop coming in and I want to open the
space up in your schedule for others, but I wanted
to come in and thank you because you changed my life." And you know, needless to
say, everybody in the clinic is crying, feeling like wow. But this is a gentleman
who would never qualify for hospice at this point. You know, he's free of his cancer. He's not end of life. He presumably has decades of life ahead. But between his physical
and emotional symptom burden he was able to come in and have
a dramatic difference made. (gentle music)

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