Palliative medicine addresses these questions at any point in a patient’s serious illness. Hospice,
which is one mode of palliative care and dates to the 1960s, is covered by Medicare specifically for
people who have six months or less to live and decide to forgo further treatment efforts.
Gramling and his colleagues often consult with patients, both in and outside of the hospital, as they
continue therapy. This is expanding the reach of palliative medicine to more people and “responding to the fact that a lot of people wouldn’t seek this help
until they’re days to weeks from dying,” he says.
“You still may have a year or more to live,”
Gramling explains. “But you’re sick and there’s
a lot going on, and the treatments you’re facing
might have trade-offs for you.”
Embracing the chance to broaden such
care to more patients, UVM’s palliative
specialist team is growing. It currently includes
two registered nurses, four nurse practitioners,
four physicians and a social worker, plus several
chaplains working outside but collaborating
with the division. Another nurse and physician
are scheduled to join them soon, and Gramling
plans to hire a sixth doctor.
“I can’t overstate the importance of
understanding and trying to eliminate
suffering,” says Thomas Peterson, M.D.,
professor and chair of family medicine at
Larner. “And at some point, that’s going to be
most important to each and every one of us.”
In the next five years, the portion of
Vermonters over age 65 will grow by 15 percent,
Peterson says. Nationally, the youngest Baby
Boomers will reach age 65 by 2029, when they
and older individuals will represent more than
20 percent of the total U.S. population, according
to the U.S. Census Bureau, which also estimates
the number of Americans who are at least age
65 will nearly double between 2016 and 2050.
Holly Miller says her gift to UVM highlights the crucial role of palliative medicine at the onset
of a serious illness. After watching both of her parents die at home — with little oversight from
professionals — Miller grew convinced that people must have the chance to choose the kind of
death they want and the care that makes them as comfortable as possible.
“We can’t always be cured, but we can be healed,” she says. “We want to cure everyone, but we
can’t. We need to give them some time to find some meaningful days before they die.”
With advances in medicine and technology, Americans are living longer with illness, even
serious illness — requiring ongoing or repeated periods of palliative care. Meanwhile, the number of
specialists in palliative medicine — those who have completed fellowships and dedicated training
— isn’t expanding fast enough to keep up with demand. Each year, fewer than 300 fellowship slots
are available to medical school graduates who want to focus on palliative medicine, Gramling says.
A 2010 study funded by the American Academy of Hospice and Palliative Medicine cited an
“acute shortage” of specialists and estimated the gap between expected need and available supply
at 6,000 to 18,000 physicians, depending on how much time each devotes to palliative practice. The
World Health Organization projected in 2015 that 40 million people worldwide need palliative care
each year, but only 14 percent of those in need receive such treatment.
To offset the shortage, UVM now is working to spread conversational proficiency to more
clinicians. Using tools developed by VitalTalk, a nonprofit training organization, 30 palliative care
experts at UVM have started courses to learn how to convey their knowledge to others.
“We’re creating our own army of communication coaches,” Gramling says.
Those coaches will receive certification to teach “Mastering Tough Conversations,” a oneday
VitalTalk workshop, every month or so for the next three years, starting this fall, for UVM
physicians and others who want to hone their dexterity at dialogue.
Medical schools emphasize good patient-doctor relations, but in practice, that can fade into the
background as advances in therapeutics push to the forefront, Gramling says. “In the modern era of
medicine we’ve gotten good at diagnosing and curing disease,” he says. “And because of that, we’ve
spent more of our efforts towards those ends — which are important — and less on communication
about what to expect and prognosis in case we can’t cure those things.”
These are difficult discussions involving fear, emotional distress and often family conflict. The
ability to broach these subjects and get to the crux of a patient’s concerns requires a delicate touch.
It’s more than a good bedside manner or inclination to chat.
“There’s skill to this,” Peterson says. “And those skills are developed. They’re not innate.”
VitalTalk brings in “scaffolding” to develop these skills, says Stephen Berns, M.D., a VitalTalk
instructor and education director of palliative care at Mount Sinai Beth Israel Health System in New York City. The course covers a “talking map”
of steps and goals, guidance on word choice
and question patterns, and ways to verbally
and nonverbally show empathy. If a patient is
overwhelmed, and the doctor begins talking
about treatment options, the patient likely will
miss that part of the conversation, Berns says.
“As clinicians, we have things to share,
and then the patient has things to share, but
we need to create space for each other,”
says Berns, who joined the UVM Division of
Palliative Medicine and Larner College faculty
the summer of 2017.
Care providers who do this well can
make a significant difference for patients.
Research indicates that palliative medicine can
reduce anxiety and pain, relieve symptoms
and improve quality of life and mood. A 2010
study of patients with advanced lung cancer
found that those who received early palliative
care had less aggressive treatment at the end
of their lives but survived longer than those
who underwent standard care. Researchers
also have quantified a cost benefit to palliative
medicine, because it decreases the use of
invasive measures that tend to add little benefit
and cause discomfort and that patients often
choose to decline in their remaining time.
For palliative care specialists, the ability
to uplift patients balances the intensity of
immersing themselves in someone’s grave and
“These things are happening to people
even if we’re not involved,” says Lindsay
Gagnon, a nurse practitioner in the UVM
palliative care division. And once the efficacy
of drugs and other therapy wanes, “there’s
always more that we can do to provide care
and relieve suffering.”