Palliative Care Helps with One
Family’s Journey: Medicare Program to Improve Care, Reduce Costs
Palliative care focuses on improving
the quality of life for patients with serious illnesses, relieving
symptoms, pain and stress - It’s not hospice
By Jenny Gold, KHN Staff Writer
Palliative Care physician Tim Ihrig talks with patient Augie Avelleyra,
93, in the living room of the family’s home in Fort Dodge, Iowa (Photo
by Paula Avelleyra).
Jan. 2, 2014 - When palliative care specialist Dr.
Tim Ihrig crosses the threshold of the Avelleyras home, he steps over a
doormat that says, "One nice person and one old grouch live here."
It doesn’t take long to figure out
who the nice person is.
Phyllis Avelleyra grew up on a farm
in western Iowa and met her husband Augie in "the big city," which is
what she calls Fort Dodge, with a population of 25,000. The couple,
married for 60 years, has five daughters, the oldest of whom is already
a grandmother herself.
Ihrig met the Avelleyras family
last year at UnityPoint hospital in Fort Dodge, where Phyllis was given
a diagnosis of congestive heart failure, which is often fatal. As all of
the other physicians at the hospital were running tests and drawing
blood, Ihrig had another kind of inquiry: what did Phyllis want from the
rest of her life?
"He asked my mom 'what are the
three most important' things for her," remembers Patty Aslesen, the
Avelleyras' oldest daughter. "She said, 'My girls, playing cards on
Wednesdays, and counting money for the church once a month.' And Dr. Tim
said, 'Well, then our goal is to let you do those things as long as you
Palliative care focuses on
improving the quality of life for patients with serious illnesses, and
relieving symptoms, pain and stress. It’s not hospice; it can happen at
any point during a patient’s illness, and often accompanies other kinds
of treatment. But it’s a contrast to the usual rush to provide all of
the advanced medical care possible.
'They're The Boss'
“As an internal-medicine-grounded
physician, I was steeped in the litany of ‘Here’s what we do to people
because we can,’” says Ihrig. “With palliative care you sit and you help
people understand where they’re at. This is their life. They’re the
boss. We’re stealing from them if we don’t give them the opportunity to
decide yes, no or maybe.”
In 2011, just under a third of U.S.
hospitals offered palliative care, though that number is growing
quickly, according to the American Hospital Association. Among hospitals
with more than 50 beds, more than two-thirds offer palliative care,
according to the Center to Advance Palliative Care at Mount Sinai School
UnityPoint added the specialty just
last year, as part of a Medicare program to improve care and reduce
costs. Ihrig says he never encourages a patient to skip any care, but
when patients truly understand all of the options and the accompanying
risks, they often choose less. And the result is not only a better
quality and even length of life — it also saves money.
Patients in the palliative care
program at UnityPoint cost the health care system 70 percent less than
other patients at the hospital with similar diagnoses. Palliative care
patients receive more care at home and more proactive management of
chronic issues, which means they require fewer expensive hospital
visits. It’s also the top rated program within the UnityPoint system for
patient satisfaction and the program most likely to be referred to
With palliative care, says Ihrig,
"the patient experience is heightened, and the nice bonus is by doing
the right thing, you essentially save the system."
morning in August, Phyllis, 85, and Augie, 93, sat together in their
living room, along with three of their daughters and the man they think
of as the newest member of their family. Everyone calls him Dr. Tim
(Photo by Paula Avelleyra).
It's About Quality - Not Length
- Of Life
At his first meeting with the
Avelleyra family, daughter Patty remembers, Ihrig "explained to all of
us that were there exactly what was going on with mom’s heart muscle,
and by explaining that to us it helped us to understand that a lot of
medical intervention would really be pointless, because this is
something that doesn’t really have a fix."
Patty says, surprisingly, that
wasn’t such a hard thing to hear. "I was kind of relieved because my
parents are older, and they don’t like being in the hospital. They don’t
like having people come up to them and poke them and prod them and say
that ‘We’re gonna do this and that’ and not understand what’s going on
at all. So to realize that this is just a part of their normal
progression of life," she explains.
A few months ago, Phyllis’ kidney
disease started to get worse, and the idea of dialysis came up. To talk
about the pros and cons, Ihrig gathered the family together again, along
with a kidney specialist, to help Phyllis make her decision.
"I have seen some people who were
on dialysis and they looked so sad," Phyllis says. "And they aren’t able
to do what they wanted to do in their life. Their quality of life was
absolutely not at all what they would want." In the end, Phyllis decided
to forgo dialysis.
While on palliative care, Phyllis
has been able to stay in her own home. A nurse stops by to check on her
and her husband Augie, who has dementia, every few weeks, and Ihrig
makes the occasional house call.
"It’s just taking one day at a
time,” says Ihrig. "It’s not just there’s some dementia or heart
disease," he adds. It’s about honoring Phyllis and Augie as a couple and
asking, “How do we take it another day, another week or however longer
we have? It’s an honor to be on this journey.
Afraid Of 'Gettin Dead'
Ihrig says in the end, most of his
patients like Augie and Phyllis aren’t afraid of dying—they know it’s
part of life. But they are afraid of "gettin’ dead" – the often painful
and drawn-out period at the very end. And that he can help with that
"He also mentioned that they would
be around – I mean people would be there to help me to get through to
the eventual death. And we talked about that. And he mentioned that they
would never let me suffer, that there would always be some care there
for me," she says, choking back a tear. "That meant a lot."
A few weeks after we spoke in the
Avellyras living room, Augie suffered a heart attack. He did not go back
to the hospital, but was instead moved into a hospice home. Ihrig
visited every Friday afternoon to share a beer and make sure he was
At the end of October, with Phyllis
by his side, Augie passed away.
article was produced by Kaiser Health News with support from
The SCAN Foundation. It was
originally published on Dec. 16, 2013 by KHN.
of this information is reprinted from
kaiserhealthnews.org with permission from the Henry
J. Kaiser Family Foundation. You can view the entire Kaiser
Daily Health Policy Report, search the archives and sign up
for email delivery. © Henry J. Kaiser Family Foundation. All
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