When internist Stephen Bekanich, M.D., was in medical school, he wasn't interested in palliative care. But when his grandmother endured a troubling death from metastatic breast cancer nearly a decade later, he redirected his career to the burgeoning field dedicated to relieving physical symptoms and emotional distress of seriously ill patients.
"There was a lot of aggressive care that wasn't appropriate to the stage of her illness,'' Bekanich recalls. "During that end-of-life phase, her symptoms were not managed and the goals of care were not addressed. I felt like there was a lot of unnecessary suffering. That really changed the focus of my career.''
Indeed, his grandmother's experience transformed Bekanich into a national authority in palliative care and, last month, brought him from the snowy mountains of Utah to the sunny flatlands of South Florida to serve as medical director of the new Palliative Care Services at University of Miami Hospital and Sylvester Comprehensive Cancer Center.
A joint venture between the Division of Hospital Medicine, headed by chief Amir Jaffer, M.D., and the Department of Family Medicine, under the leadership of chair Robert Schwartz, M.D., the new program includes an inpatient consultation service, available at the request of attending physicians, a 10-bed hospice unit established at UMH by VITAS Innovative Hospice Care, a future clinic at Sylvester, and a VITAS-sponsored fellowship program to train the next generation of hospice and palliative care specialists.
The first fellow started this month, joining an interdisciplinary team of three other hospitalists, an oncologist, nurses and a corps of VITAS social workers and support staff. Physicians from the Division of Hospital Medicine also plan to rotate through the clinical service to gain experience and earn their board certification in palliative care; Bekanich hopes oncology fellows and fellows from other disciplines will rotate as well.
Given the array of resources already in place, Bekanich, associate professor of medicine who holds a dual appointment in family medicine, can hardly believe his - and South Florida's - good fortune.
"The idea of starting off with a 10-bed unit in an academic hospital is unheard of,'' says Bekanich, whose shaved pate and sartorial flair (think striped purple socks and matching cufflinks) enhance his upbeat air. "Usually, you start off with part-time, bare-bones staff and, as the value of the program becomes clearer, you get more resources.''
Bekanich has no doubt UM's new service will prove its worth. After all, palliative care is known to decrease costs and increase patient satisfaction because patients who receive it often opt for interventions that help them feel better, but forego tests and treatments that will not improve outcomes.
The key, says Bekanich, who was named teacher of the year while serving as medical director of Palliative Care Services at the University of Utah School of Medicine, is education and conversation. Palliative care specialists help patients and their families clarify treatment goals and make decisions that maximize quality of life through the progression of disease or disability. Unlike hospice care, which is geared to terminally ill patients who have less than six months to live and for whom life-prolonging treatments are no longer effective, palliative care can be appropriate at any stage of illness, for any diagnosis.
"You do not need to be actively dying or need to abandon life-prolonging therapy to be one of our patients,'' Bekanich says. "We're not looking to be called in at the 11th hour. We like to see patients upstream in their illness so they have peace of mind that their symptoms are going to be paid attention to, that their family will be listened to, that their goals of care will be reviewed.''
When Bekanich's paternal grandmother died in 2005, and he pursued training in palliative care, it was not yet a board-certified specialty. That happened a year later. Now, with people living longer and dying from cardiovascular disease and other illnesses with debilitating emotional and physical symptoms, Bekanich hopes the field will continue to grow - and change the traditional model of patient care.
"The traditional model has always been diseased-centered, not patient-centered. It's about treating and curing the disease, and the patient just goes along for the ride,'' says Bekanich, who also serves as associate editor of Fast Article Critical Summaries for Clinicians in Palliative Care, or PC-FACS, an electronic publication of the American Academy of Hospice and Palliative Medicine. "We've left the era where people die of trauma and infections; now they die from long-term illnesses with enormous symptom burdens, and the patient and family have to be incorporated into the way we look at the illness.''
He notes, for example, that cardiologists who treat congestive heart failure typically focus on their patients' injection fractions, artery blockages and arrhythmias, but not on their shortness of breath, diseased-related fatigue and anxiety related to their prognoses. That's where palliative care specialists come in.
"The cardiologist can make sure the plumbing is clear and the electrical system is working, and we can look at the patient and say, ‘OK, these are the things you are feeling, let's work on them,''' he says. "My job is not to promote miracles, but to redirect hope in a way that is constructive and realistic.''
Had his "Ama'' had such help navigating her illness, Bekanich believes she would have spent her last four or five months suffering less and enjoying her family more. And that is her legacy: Today, her grandson is driven to help seriously ill patients in South Florida maximize the quality of their lives and, if the time comes, have satisfying deaths.
"People say this is a depressing field, but it's not,'' the father of two says. "If you do well for patients and families, it's incredibly rewarding. What would be depressing is if I come to work tomorrow and am told, ‘The patient in bed 50 had a really bad death.' That's depressing.''
