Q&A with Sean Morrison, MD: Palliative Care Becoming Part of the Health Care Genome

In his office overlooking Central Park, Sean Morrison, MD, keeps a picture of a young woman who suffered from leukemia. She died more than a decade ago after two failed bone marrow transplants, several months of isolation in a hospital room and scores of terrible pain crises during her fight with the disease.

“I think she has stayed with me because she taught me much more about caring for the seriously ill than I could ever learn in medical school,” he says. “Her case really epitomized what we try to do here. The goal was always to cure her disease and to this day, her family says that what allowed her to continue to fight was the support that palliative care gave her.”

Dr. Morrison is the director of the Lilian and Benjamin Hertzberg Palliative Care Institute at the Mount Sinai Health System. Together with the HPCI’s former director Dr. Diane Meier, Dr. Morrison helped to start Mount Sinai’s palliative care program in the mid-90s and has since worked determinedly to nurture its growth. Throughout his career, Dr. Morrison has received more than $35 million in research funding, published more than 120 articles in many major peer-reviewed medical journals, and contributed to 15 books on the subject of geriatrics and palliative care.

What is palliative care?

Palliative care is a relatively new medical specialty that focuses on improving quality of life for people living with serious illness. It does so by addressing symptoms such as pain or nausea, by helping patients and families identify their goals of care and matching treatments to those goals, and lastly by helping to coordinate a terribly fragmented health care system.

The way I think about it, palliative care provides an added layer of support for persons with serious illness and their families in the setting of routine medical care. Most importantly, it is provided at the same time as all other medical treatments, including those to cure disease and those to prolong life.

What are some common misconceptions of palliative care?

The biggest misconception is that palliative care is what we do when there is nothing else to be done – that it is only focused on care for the dying. If I could get one message out it would be that palliative care is appropriate for anyone with a serious illness regardless of life expectancy, regardless of what we think the outcome is.

The second misconception is that it is the same thing as hospice. Hospice is a specialized form of care that is focused on improving quality of life for people in the last six months of life. Palliative care is a natural bridge to hospice for many patients, but many patients who are cared for with palliative care will never need hospice.

The third misconception is that it is expensive and not covered by Medicare or other insurance programs. That is not the case. It is covered by Medicare and Medicaid and by all third party payer insurance.

What are your priorities when you sit down with a patient and their family to discuss their goals?

The first thing part of any good clinician-patient encounter is to ask questions. We all have different values and goals, different hopes, different understandings of illness and different views of what the future is going to look like. So we ask a lot of open-ended questions and then we work out what the patient’s goals are and how we can help them achieve those goals. You can’t help people through a serious illness unless you understand who they are and it is not a one size fits all.

How have you seen the clinical practice of palliative care change over the last decade and which of those developments would you say is most important?

I think there have been three key changes over the past decade. The first is the rapid growth in hospital palliative care teams, where we went from less than 5 per cent of American hospitals to over 85 per cent of mid to large size hospitals with palliative care teams now. That’s very much improved access.

The second big change in clinical care was the recognition of palliative medicine as an official medical subspecialty in 2006. That gave it legitimacy because for the first time there was a real quality metric for physicians practicing palliative medicine – your doctor has to have specific training and standards.

The third most important development was agreement on quality guidelines for palliative care from first the National Consensus Project and then the National Quality Forum. That is, what do palliative care teams need to be doing in order to provide high quality palliative care? This is a standardization that helps patients and families recognize quality programs.

What do you think are the most exciting developments underway at the moment?

For the first time, the financial incentives in the reimbursement system favor palliative care. The passage of the Affordable Care Act has provided a universal focus on reimbursement for quality and efforts to take care of patients and families where they want to be taken care of, which is not in the hospital.

That has led to new developments in community palliative care. This is the idea that we can take care of seriously ill patients and their families in their homes rather than using the hospital as the sole focus of care. I think that is very exciting.

Another important development is that the public is becoming more aware of what palliative care is. We are far from someone being diagnosed with a serious illness and and asking immediately for palliative care, but we are getting there. The media is beginning to pick it up, there are starting to be stories about it and the language is starting to be right.

The third area which I am excited about is that we now have a new cadre of researchers that are beginning to address the research problems that are of the upmost importance to patients and families – how to better treat pain, how do we treat fatigue, how do we care for families at home, what are the models of care? It’s not yet where it needs to be, but we now have a substantially improved knowledge base and a strong cohort of investigators throughout the country actively working to push the evidence base forward.

What do you think is special about palliative care at Mount Sinai?

What is special here is the team culture. There is a shared sense of mission that is remarkable in the way that people work seamlessly together across disciplines with their entire focus on what is best for patients and families.

What are your goals and priorities for the Hertzberg Palliative Care Institute?

I would like to really integrate palliative care into the genome of the hospital, so that patients and families don’t necessarily need a specialized palliative care consultation because primary palliative care will become a part of routine care. This would include addressing pain, talking about goals of care, and talking about what patients and families want to do when they leave the hospital.

I would also like to see palliative care teams move out into the community so that rather than patients having to come to us, we could go to them.

And the final piece, which I think we desperately need as a field, is to build the evidence base through research. It is unacceptable that when you come in to see me with severe pain, I have one class of drugs to treat you, which is opioids, and they all have significant side effects. And if you come in with nerve pain, the best I have is a drug that works a third of the time, and a third of the time that works well. We need to do better. Our patients deserve that.

What’s on your wish list for palliative care as a specialty in the next 5-10 years?

I would like every person in the U.S. to know to request palliative care in the setting of a serious illness, every health care professional to have the knowledge and skills to provide palliative care and every site of health care in the US to be equipped to provide it. So that wherever you are, whether it’s a hospital or a nursing home, assisted living, at home, you have access to quality palliative care. And I think we can do that by 2020.

I would like our program to be leading the way in all three of those goals by serving as the model of how to deliver clinical care, providing high quality care to our community, by doing the research and the teaching, and by doing the right outreach both within our Sinai community, locally within NYC, and nationally so that people understand what it is that we do and why it is important.