Meeting the Psychosocial Needs of Seriously Ill Patients through Embedded Palliative Care Programs: Single Discipline Approaches Are Not Enough

Dear Editor:

Embedded palliative care (EPC) programs are a strategy for improving the quality of care to patients with serious illness. ¹ Many EPC programs start with one physician or advanced practice nurse (APN) who provides specialty palliative care (PC) in a setting colocated with a primary team (e.g., cancer center). Primary teams often look to these solo EPC clinicians to provide “full spectrum” PC, including the emotional and spiritual support that is more expertly provided by members of the interdisciplinary teams (IDTs), for example, social workers (SW), psychologists, chaplains, and psychiatrists. Solo EPC clinicians are expected to “do a little bit of everything,” despite the fact that the concept of the IDT as integral to PC emerged several decades ago. Studies suggest psychosocial care is a shared responsibility across IDT members. Multidisciplinary team-based specialty PC is associated with improved goal-concordant care, symptom control, and quality of life. ² To minimize the expense of hiring full teams, primary teams typically hire prescribers who can also provide nonpharmacological management. However, PC fellowships train physicians to meet psychosocial and spiritual needs in conjunction with IDTs, not alone. To demonstrate competency, PC fellows are expected to “promote comprehensive psychosocial and spiritual assessment across patient teams.” ³ These skills are typically taught by IDT faculty, but are rarely mastered by PC fellows in one year. Similarly, to achieve board certification in PC, APNs must pass a certification examination evaluating their ability to address patients' and families' psychiatric/psychological and spiritual/existential problems. ⁴ However, fellowship training is not yet routine for APNs, resulting in variability in practice and skill.

We believe that most EPC clinicians want to practice as part of an IDT, which is the gold standard of PC practice. However, they should be able to provide at least a basic level of support to patients/families in the short term, as a longer-term strategy to add IDT members is formulated. We propose that EPC clinicians cultivate basic psychiatric skills to manage acute crises, provide brief behavioral interventions, and practice motivational interviewing. We recommend enlisting palliative psychologists, psychiatrists, SWs, and chaplains to teach didactics to the EPC clinician, with financial and administrative support provided by primary teams. In addition, with guidance from the experts, EPC clinicians should compile a list of essential community resources for patients/families.

We suggest trying to align stakeholder interests at the systems level. Although it may be unrealistic to expect primary teams to support full IDTs as an embedded program is launched, they should, with the help of EPCs, determine whether the documented benefits of IDT-based care outweigh the upfront financial burden. Embedded programs staffed by solo clinicians should also meticulously track the psychosocial work they do. A time motion study to evaluate the content of the clinician's workday can help determine the degree to which visits are spent providing counseling or emotional/spiritual support that could be provided more expertly by a palliative-trained SW or chaplain. This data may provide the financial justification over time for adding these highly skilled IDT members.