HealthLawProf Blog

Editor: Katharine Van Tassel
Case Western Reserve University School of Law

Wednesday, October 12, 2011

Guest Blogger Elizabeth Sepper: Geography as Destiny for the Seriously Ill

SepperphotoThe Center to Advance Palliative Care has just released a new report on access to palliative care state-by-state.  Although the findings showed improvement in access nationwide, they nonetheless highlight stark divisions between geographic areas.

The disparities cut along the now-too-familiar axes – red state versus blue state, rural versus urban, and poor versus well-insured.  In particular, the study found 73 % of hospitals with fifty or more beds have a palliative care team, compared to 51% in the South.  In smaller hospitals in the South, palliative care is extremely limited (Louisiana and Mississippi have no palliative care at all in small hospitals).   The 47 million Americans who are uninsured or live in isolated places are further disadvantaged by the low rates of palliative care at both public and sole community provider hospitals.

In palliative care, a team (usually a doctor, nurse, social worker, and others, sometimes a chaplain) focus on communication, coordination of care, and treatment that accords with and meets the spiritual needs and emotional wishes of a seriously ill patient.  It is a rare area of medicine that explicitly acknowledges the centrality of emotional and spiritual needs of sick people to their quality of life. 

For poor, rural, and red state patients, lack of hospital access to palliative care likely means inadequate treatment of pain, education, and follow-up after hospital care.  Unfortunately, for these patient populations, this is hardly new.  Indeed, there are a number of parallels to access to reproductive healthcare.  Red states have higher rates of unintended pregnancies and lower access to abortion.  Geography largely determines women’s access to and experience of medical care.  Some of the root causes of the disparities seem alike as well—for instance, few training programs for physicians and lack of reimbursement (with regard to palliative care, for advanced practice nurses in some states and social workers). 

It’s clear that meeting the palliative care needs of our aging population will require a new approach to availability and access.  The report makes numerous recommendations—like physician training, fellowships, and more consistent compensation of advanced practice nurses.  But I was struck by the absence of one proposal often seen in the reproductive health literature—namely, expanding the role of nurse practitioners. 

Given paucity of trained physicians, allowing advanced practice nurses to lead palliative care seems like a natural solution.  Nursing emphasizes advocacy and caring.  Nurses spend more time with patients than physicians do.  They also experience greater distress at the overtreatment of dying patients and the undertreatment of pain.  So why not expand nursing practice in this area?  How could compensation structures be revised to encourage nurse-led palliative teams?  How could legislatures create incentives to increase access to palliative care?  And, more importantly, how much opposition would they face from the physicians’ lobby?

The views expressed in this post are those of the author and should not be attributed to the Center for Reproductive Rights or the Health Law Prof Blog.

- Elizabeth Sepper

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