Physician assistant and researcher Nathan Boucher discussed current directions in palliative care and hospice implementation at an event Monday.

Boucher, visiting assistant professor in the Sanford School of Public Policy, showcased three of his prior and current research projects during his talk for the Duke Healthcare Policy Forum. As a key takeaway, he encouraged the audience to consider how his major findings might direct future health policy. He advocated for more conversations between the patient and the provider on making plans for end-of-life care and better advocacy for the hospice system. 

"I think what we're not doing enough of is asking the patient what they would like, having [better] communication with the surrogate decision maker or the patient with regard to what their goals of care are," Boucher said.

Hospice, he explained, is a coordinated care system primarily funded by the federal government through its Medicare health insurance program. In general, patients with less than six months to live can choose to receive its services, which include pain management, end-of-life planning for the patient and bereavement services for their families.

Although the hospice system has been in place since 1986, the medical community and its patients have not yet fully embraced its services, Boucher argued. He added that the predominant reason comes from the culture of medicine, which is focused more on curing disease as opposed to emphasizing patient comfort.

"There is a little bit more noble but misguided problem, and that is that we don't want to give up on our patients. We don't want to say 'Okay, well die,'" he said. "We want to see what we can do, even if there is so little [effect] on their outcomes. Our health system is built on cure, payment systems are built on cure, but also our [medical] training is by and large built on cures."

Issues faced by minorities

Racial and ethnic minorities often have the least access to hospice services, both due to cultural differences and less awareness within their communities of proper procedures for end-of-life management. 

This was highlighted through a study Boucher presented examining attitudes toward end-of-life management across Puerto Ricans and Dominicans in New York. Across his interviews, Boucher said he found that these individuals would draw on multiple sources in considering how they would want to live their last days, including advice from their medical providers, their families and their church communities.

This was counter to what Boucher said he perceived as being more common in medical practice—where the physicians and their teams are the primary groups guiding terminal patients in thinking about dying. 

"Think of holistic care as multifaceted and not just medical advice," he said. "Involve the family. Some patients would want their families involved in their medical decision making. In fact, patient autonomy, for some patients, might mean all 20 members of the patient's family in the room making the decision."

Talking to veterans

In his second study, Boucher and his team interviewed veterans at the Durham Veterans Affairs Medical Center and asked them about their attitudes toward religious and spiritual services. He said that since chaplains are usually part of the military and stationed with soldiers, having continuity with religious services back at home with patients makes sense and does not encroach on the separation of church and state.

Boucher found, however, that many of the patients he studied were unaware of the breadth of religious and spiritual services offered by the VA system. The patients and Boucher attributed this both to the setup of Durham's VA hospital, where such services are not prominently displayed, as well as to delayed conversations about end-of-life care by the medical team.

"So you walk around the back of the elevator and you see what's on the other side. There's the chaplain's office. I don't think it's been put out for availability the way it should," read one quote from a veteran that Boucher emphasized.

The major findings of Boucher and his team's research with the VA were well-received by the Durham VA administration, which plans to incorporate some of their suggestions, he said.

Other findings and questions

In his final case study, Boucher commented on the advantages of palliative care for leukemia patients, a topic which he noted has received little attention in prior research. Although palliative care and hospice are both geared toward maximizing patient comfort and pain management, the two differ in that palliative care is open to anyone suffering from an illness and is not exclusive to terminal patients, unlike hospice. 

His study showed that making palliative care more coordinated and accessible to patients could improve their experiences. 

Audience members asked Boucher about how federal and local policies toward hospice and palliative care have shifted in recent years, especially during the administration of President Donald Trump. In addition to a federal bill that is aimed at making the public more aware of hospice services, Medicare has also recently begun to offer reimbursement to physicians for having a discussion on end-of-life care with their patients, Boucher said.

In addition, Medicare has recently increased its daily reimbursement for each patient with hospice services—its first time doing so since the inception of the program. 

"When the hospice came around in the mid-80s, the daily rates that get paid to the hospice organization hadn't changed since," he said. "It's like $150 to $190 that's supposed to cover a hospice patient's stay per day, and we're talking about nursing, social workers, spiritual care support, all required elements. No one really makes money on hospice, it's kind of like breaking even."

Junior Dottie Kontopoulos, who said she is not pre-med but is interested in healthcare delivery and policy, found that the event influenced her understanding of medical support systems.

"Hearing about how the profession can be used in education and policy was really informative for me in thinking about what I want to do in the future," Kontopoulos said. "What I think so much of training and discourse—especially as undergraduates at Duke—tends to be around the pre-med track and becoming a practicing physician, so I think it's great to hear how that information can be used to support physicians and the medical system, not necessarily through that direct route."

Correction: An earlier version of this article included a quote from Boucher stating that $120 are allocated to hospices every day, instead of $150-190.