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January 2017

Physiatrists Possess Palliative Promise

Raiser_Sara picSara Raiser, MD
PGY3, University of Virginia

 

Palliative care is an underutilized commodity in health care, and physiatrists harbor a unique set of skills in neurological and musculoskeletal medicine to offer the patient undergoing palliation. Palliative care is the epitome of holistic health care in a number of ways: physiatry shares many of these same goals including addressing the person as a whole, deciphering goals of care, coordinating interdisciplinary care, and managing patient treatments with multiple modalities. Physiatrists offer numerous complementary skills including expertise in rehabilitation for numerous conditions.

Most distinctly, physiatrists are experts in managing neurological and musculoskeletal conditions and can notably offer specialized palliation for pain, suffering, and dysfunction due to such etiologies. Cancer is by far, the most common patient diagnosis in those receiving inpatient palliative care services, followed by neurological and neurosurgical diagnoses, most often stroke.1 One study conducted at the University of Colorado reported that the reason for palliative care consult was typically for eliciting goals of care (82%)2; however, these patients have significant potential to benefit from physiatric recommendations regarding neurological- and musculoskeletal-based symptom management. This may include spasticity management with medications; Botox injections; specific hands-on therapy recommendations; referral for prosthetics and orthotics (i.e., for ankle-foot-orthoses for foot drop or specific shoe to provide relief to certain ailments in the lower extremity for improved mobility); conservative symptomatic treatment for musculoskeletal complaints such as medications, positional relief, steroid injections or self massage.

Illness does not have to be terminal to warrant involvement of palliation; rather, any illness or injury resulting in significant pain, suffering or dysfunction warrants palliative management. Physiatrists essentially provide palliative care on a daily basis, whether in the acute care hospital setting, the acute or subacute inpatient rehabilitation unit or in the outpatient clinic. A typical physiatric visit includes not only management of curative disease treatments, but also management of patients’ symptoms and suffering.

In many parts of the country, physiatry remains an elusive field, of which many people, patients, and physicians alike, lack an understanding. Perhaps, this is due, in part, to the wide variety of services and skills offered by physiatrists as well as the many specialized niches they fill. Palliative care is yet another area where physiatrists are underutilized and have an important skill to offer with their neurological and musculoskeletal expertise. Physiatric involvement in palliative management might be employed in various settings: consider a joint venture along with the inpatient palliative care consult service to address neurological and musculoskeletal conditions, or a specialized interdisciplinary clinic that includes palliative care specialty physicians and additional resources such as hospice care. This is not to say that physiatrists should replace palliative care specialists, but rather that palliative care is yet another area that could benefit from physiatric expertise woven into its interdisciplinary care model through the next generation of rising physiatrists.

  1. Chahine LM, Malik B, Davis M. Palliative care needs of patients with neurologic or neurosurgical conditions. Eur J Neurol. 2008;15(12):1265-1272. doi:10.1111/j.1468-1331.2008.02319.x.
  2. Liu Y, Kline D, Aerts S, et al. Inpatient Palliative Care for Neurological Disorders: Lessons from a Large Retrospective Series. Journal of Palliative Medicine. November 2016:jpm.2016.0240. doi:10.1089/jpm.2016.0240.