Palliative Care in the U.S. Military Health System

InMay 2014, the Secretary of Defense ordered a comprehensive review of the Military Health System (MHS), which was published in August 2014. In brief, the MHS includes over 50 inpatient medical treatment facilities and provides care for 9.6 million beneficiaries, spending more than $50 billion per year. Approximately 22% of the MHS beneficiaries are over the age of 65, which parallels the civilian sector. The review focused on issues including quality of care and patient satisfaction in hopes of providing direction on how to improve the MHS. Although not mentioned in the report, providing inpatient and outpatient palliative care services is one important way to improve the MHS. Palliative care is specialized medical care with the goal to improve a person’s quality of life by relieving pain, symptoms, and the stress associated with serious illness. According to the World Health Organization, “Palliative care is a [team based] approach that improves the quality of life of patients and their families facing the problem[s] associated with lifethreatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.” Currently, the MHS has only two palliative care teams across all of its 56 facilities: one at Walter Reed National Military Medical Center and the other at Madigan Army Medical Center. Although the MHS is a leader in trauma and point of injury care, we are lagging far behind the Veterans Health Administration (VHA) and the civilian sector in providing essential palliative care services to our patients. The Veterans Healthcare Eligibility Reform Act of 1996 mandated that the VHA offer hospice and palliative care services to all veterans. Subsequently, in 2003, the VHA released a directive instructing all VHA facilities to formmultidisciplinary palliative care consult teams. Since 2003, the VHA has been providing robust palliative care services to our veterans, and by 2007, 42% of all veterans who died as VHA inpatients had received a palliative care consultation. Nationwide in the civilian sector, approximately 61% of hospitals with 50 or more beds provided hospital-based palliative care in 2012. Quality of life is paramount in palliative care, with an emphasis on symptom management, as well as spiritual and psychosocial well-being. Palliative care services are appropriate for patients of any age with a chronic or life-limiting illness. Most health professionals erroneously equate palliative care with hospice, believing it is synonymous with end-of-life care; however, it can and should be provided in conjunction with curative therapy at any point in an illness. To improve the quality of care and patient satisfaction, while reducing total cost, it is imperative for the MHS to incorporate palliative care services into its medical treatment facilities. Palliative care is interdisciplinary, with teams comprised of physicians, nurses, social workers, and chaplains as well as other disciplines. The interdisciplinary team supports patientcentered care, and fosters informed patient and family decision making. The team also assists in the coordination of services across care settings, such as home care and hospice. With more and more beneficiaries living with chronic and life-limiting diseases, the need for palliative care is only going to become more pressing. These patients will need palliative care clinicians with specialized training in pain and symptom management. Poor symptom management is associated with poor quality of life, and in turn, poor patient and family satisfaction. Hospital-based palliative care programs have been shown to improve symptoms and patient satisfaction, decrease total hospital costs, and, in some diseases, improve survival. Patients with metastatic non-small cell lung cancer given standard oncologic care plus early palliative care lived approximately 2 months longer than patients only given the standard oncologic care. A review done by El-Jawahri et al. examined 22 randomized controlled trials and concluded that palliative care services were associated with improvements in patients’ quality of life, family caregiver outcomes, satisfaction with care, and quality of care delivered at the end of life. Other research has shown that patients who receive palliative care report improved symptom management, improved prognostic understanding, and are less likely to receive chemotherapy near the end of life when chemotherapy is most risky and least beneficial. Lower rates of hospital admissions and decreased Department of Medicine, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20814. The views expressed in this article are those of the author and do not reflect the official policy of the Departments of the Army/Navy/Air Force, the Department of Defense, or the U.S. Government. doi: 10.7205/MILMED-D-15-00047