To what extent must generalists be expert in palliative care?

The rapid growth of Palliative Medicine and its recent recognition by the American Board of Medical Specialties are clear signals that this field has provided at least a partial solution to what may be THE quintessential problem in contemporary healthcare: how do we assure that in a hyper-complex and often disjointed healthcare delivery model someone is attending to the totality of the patient's needs, dialoguing with family, assuring symptom control and, as death approaches, re-prioritizing our interventions toward those that support the patients' comfort and dignity consistent with the their preferences and values?

Through the research efforts of Fischer, Wennberg et al, the last decade has seen a new understanding of the problem.  For example, we know that when asked the majority of patients state that they would prefer to die at home, but most (about 55%) do not.  ICU days and physician contacts in the last six months of life vary markedly by region, though the evidence does not support the idea that this is the result of patient preference.  

On the other hand, from 2003 to 2007, the percentage of chronically ill Medicare patients dying in hospitals and the average number of days they spent in the hospital before their deaths declined in most regions of the country and at most academic medical centers. The percentage of deaths associated with a stay in intensive care also decreased in most regions and at about half of academic medical centers (Goodman, et al 2011).  These are encouraging trends.  

These improvements have occurred concurrently with the emergence of Palliative Medicine as a specialty.  Certainly our own experience is that physicians - both generalists and other specialists - have come to recognize the value of the Palliative Care service and "voted with their feet" resulting in over 1000 consultations at our hospital during 2013.  And this has been a very good thing for caregivers, patients and families.

And yet, there are concerns.

As noted by Quill and Abernathy (NEJM 368;13:1173 March 2013), as we integrate experts in Palliative Medicine into the care team there is the possibility that primary physicians and consultants may "begin to believe that basic symptom management and psychosocial support are not their responsibility, and care may become further fragmented."  I would go further.  There is a risk that talking about advance directives, goals of care and the merits of many interventions, from dialysis to PEG tubes, will be seen as the (sole) province of the Palliative specialist.  Not only is such a model of care not sustainable from a resource perspective.  More fundamentally, this would result in the "outsourcing" of a core clinical skill set, much to the detriment of professionals and patients alike.

What is the alternative?  We need to make a high priority of excellence in communication and shared decision-making - for all patients, to be sure, but in particular for those approaching the end of life.  To use the framework of education, this will require knowledge, skills and attitudes - knowledge about the risks, benefits and expected outcomes of specific interventions, including CPR; skills in communicating so as to meet the needs of our patients, and an attitudinal relationship with this domain such that clinicians see expertise in this area as equally important to patient care as the ability to insert a central line.  

I heard an example of expert communication recently from one of our thought leaders in end-of-life care.  Rather than talk to patients or families about what we propose NOT to do, or to withhold, she suggested that we say something like this:  "Mrs. Jones, we have talked a lot about what your husband has said he wanted when he is dying.  With that in mind, when his heart stops, I think we should protect him from CPR, which I do not believe will help him.  We can do that by putting an order in the chart."  This is of course, just one example.  But it shows us what is possible.  

You are the experts in this.  What do you think?