The case of the disappearing clinical nurse specialist

March 10, 2004 -- Today's Wall Street Journal includes a lengthy article by Gautam Naik about the potential cost benefits of palliative care units, focusing on one set up at a Virginia hospital by clinical nurse specialist Patrick Coyne and oncologist Tom Smith. Unfortunately, despite some positive elements, much of the piece provides a distorted, physician-centric vision of palliative care, a field in which nurses actually play a central role.

The basic hook of the piece is that palliative care units, which are popular in the United Kingdom but have only recently been spreading in the U.S., not only are potentially more "humane" but can actually cut hospital costs, especially during a terminal patient's expensive last days. By focusing on "comfort, not cure," palliative units can save money that would otherwise be spent on "drugs, diagnostics, tests and last-ditch treatments." Curiously, though the article notes that palliative care grew out of the hospice movement and explains a couple key differences between the two options, it fails to note that many patients and their families would likely have a better quality end-of-life experience in even less expensive home-based hospice care. Of course, hospice is a nurse-dominated care option in which physicians barely play a role, and so it may be difficult for some journalists to take it seriously.

The palliative-care unit at Virginia Commonwealth University (VCU) hospital, started by Coyne and Smith, is reportedly considered a model for others. The piece tells how the "seeds" of the unit were sown when Coyne and Smith, who both had an interest in palliative care, briefly taught at a Tanzanian cancer hospital in 1992. Upon their return, Smith reportedly advanced the idea of a palliative care unit at VCU, but was told to demonstrate that it was needed. Apparently in response, Coyne did a study at the hospital that found that terminal patients were not getting the care required to control their symptoms, but physicians were reluctant to get actively involved in a palliative care project to remedy the situation. The hospital told Coyne and Smith that it would back their project if they could find the initial money to make the new unit work, and the two started fundraising.

At this point in the piece, physician Smith appears in one of the Wall Street Journal's distinctive head drawings. His colleague, CNS Coyne, gets no such drawing, and instead starts to disappear from the article. In 1997, the article notes, when a startup grant was received, "Dr. Smith knew his luck had truly turned." The funders had heard about "Dr. Smith's palliative care project." The hospital gave "Dr. Smith the green light" in 1999. An extended quote from Smith describes end-of-life care decision making. Then Coyne makes his final appearance, with a brief quote about how some physicians still hesitate to refer terminal patients to the unit, because they "see us as the death squad."

Meanwhile, the article claims that Smith "now heads the palliative-care unit." In reality, Smith may supervise the physicians, but nurses report to nursing managers. This is a common problem in the media, which often reinforces the misimpression that physicians supervise all health care. The article then describes nurses on the unit following agitation algorithms "drawn up by the unit's doctors"--as if nurses would not have input on any such guidelines, and as if they follow these algorithms without assessing their appropriateness for the patient. To its credit, the piece then provides an illustrative anecdote by VCU social worker Valerie Cauthorne. But then it's back to Dr. Smith, who in several paragraphs discusses the model unit's drug administration policies and its hosting of visiting physicians and hospital administrators.

In short, Smith dominates the latter half of the article, as if the unit belonged to him. This is ironic given the central role nurses have always played in palliative care, a role that has included advocating for adequate symptom relief in the face of physician resistance or indifference--a problem that the three short quotes from Coyne actually illustrate. Sadly, much of the media seems to believe that health approaches (such as palliative care) do not exist until physicians notice them.

Take Action!
Please send your concerns about the treatment of nursing in the March 10, 2004 article "Final Days: Unlikely way to cut hospital costs: Comfort the dying" to author Mr. Gautam Naik, and the editor of the Wall Street Journal.

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