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© 2003 American Society for Clinical Oncology
House Calls by Oncologists: A Home-Visit PrimerFrom the Division of Hematology-Oncology, James H. Quillen College of Medicine and Veterans Affairs Medical Center, East Tennessee State University, Johnson City, TN. Address reprint requests to Anand B. Karnad, MD, Division of Hematology-Oncology, Department of Internal Medicine, Box 70622, James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN 37614-0622; email: karnad{at}etsu.edu.
AS WE drove off, the oncology fellow accompanying me to her first house call read off the directions that were faxed to us by the hospice nurse: "Take 11E through Jonesborough and Limestone. As you cross the river, turn right next to the sign for the Methodist Church. Pass a small white-frame church to the top of the hill. There should be two mailboxes side by side. Turn left onto the gravel driveway at the mailboxes, then turn right off the gravel drive through a grove of trees. House is straight ahead—lots of windows, junk cars, and airplanes in yard." We were there to see a 62-year-old retired pilot dying of progressive glioblastoma multiforme. His wife met us at the door and took us to his bedside. Paroxysms of cough shook him as he lay on his paralyzed side. He smiled through this, and between spells barely managed to say, "Good to see you. It’s this cough . . . ." "Don’t say another word. We’re here to see how we can help you. This is Becky. She is an oncology fellow working with me and she’s going to help us come up with a plan to get you more comfortable." Becky listened to his rattling chest as I walked over to his wife to review the bottles of pills laid out on the windowsill. "I suction him out real good," she notes. "He’s taken all these different antibiotics and cough syrups." Her eyes welled up with tears as she looked away. Becky and I talked in low tones about what we’d do: by-the-clock codeine to suppress his cough, and if that did not work, sedation. Walking back to him Becky held his hand and said firmly, "We’ve got some good medicines fixed up, and we’re going to hang in there with you and get this cough under control and check on you to make sure you’re okay. Can you think of anything else we can do for you now?" He squeezed my hand in parting. His wife met us again in the foyer with a bay window overlooking the Nolichucky River. She was quiet as she held the door open. We stood in the stillness of the evening for a while not saying a word. "Thank you. Thank you for coming," she said, as we walked to the car.
A 1997 report on house calls using Medicare claims data showed that home visits by physicians are rare: only 8.8 of every 1,000 Americans 65 years of age and older received a house call (mean age, 82 years).1 Most of the physicians making house calls were primary-care physicians; surveys show that only half of internists and family physicians say they make at least one visit a year to a patient at home.2 There are several benefits to making house calls (Table 1  ). Especially for patients who are terminally ill, house calls can be an effective component of care.3 There are no data on house calls by oncologists or on the impact of such visits on end-of-life care at home. But oncologists do make house calls, and anecdotal reports suggest that it is a rewarding experience for the physician as well as for the patient and family.4–6
For those who have never done it, it is recommended that the first visit be made with a hospice nurse. Hospice nurses are especially gifted at caring for the terminally ill in the home environment and can help reduce the stress and anxiety of making a first home visit. Choose a convenient spot to rendezvous with the nurse, especially when visiting patients who live in areas that are remote or difficult to locate. Choosing a patient to visit may not always be easy. One need not always choose to visit patients with refractory pain and symptoms; patients who fear abandonment, caregivers who are near burnout, or patients who have caused hospice-team burnout may be ideal for first visits. Visiting patients who are pain-free and comfortable can also be rewarding. Ask the patient’s permission to make a house call. Make sure that the patient and caregivers are receptive. While most patients and caregivers are deeply appreciative of even the offer of a house call, they may not be ready for this. Arrange for a mutually convenient time (usually after office hours or on weekends) and be punctual (call to reschedule the time or the visit if plans change). For me, the gratification that comes from a sense of fulfilling an obligation of caring that continues to the patient’s death has been profound, and I personally do not bill for the house call. It should be noted, however, that Medicare and other insurers do reimburse for house calls.
The black bag can carry your stethoscope, prescriptions, equianalgesic conversion tables, and palliative care cheat-sheets (essential drug information, favorite algorithms), or it can simply be used as a prop, a symbol of our profession. In the past, this had served to help allay my own anxieties about making a house call. Lately, however, I have made house calls without any of the accoutrements of our profession, and I’ve felt just as comfortable making an effective house call. It seems that simply being there means as much to the patient as does the physician’s ability to relieve pain and suffering.
Reviewing goals of pain and symptom control and outlining the plan of care for each problem is an important part of the visit. Medications may need to be pruned and the timing of doses adjusted to patient comfort. Caregivers will need reinforcement that their role in giving the scheduled dose narcotic as recommended is crucial to good care. If the physician is making the house call alone, it is good to leave written instructions regarding the change in palliative care plans for other members of the hospice team. If the patient is comfortable and does not have much to say, spending quiet moments at the bedside may be treasured by the patient. Difficult as this might be, one should work at the ability to respect the power of silence.7 If you choose to make conversation, the bedside table and the room will always be a source of useful conversation starters: books, photographs, art, furniture, music, pets, and so on.
A substantial portion of the visit should be devoted to paying attention to the caregiver. Caregivers need support, and having a conversation with them away from the patient, eg, at the kitchen table, porch, or living room, provides an opportunity for them to discuss their fears openly and allows for the doctor to provide encouragement and positive feedback regarding their role in caring for their loved one.
Home visits have been integrated into the oncology curriculum for medical students with encouraging results.8 Visiting a patient who is dying at home provides an opportunity for students, residents, and fellows to learn the principles of hospice and palliative care firsthand. House calls in this setting provide an ideal opportunity to observe and develop empathy and communication skills. In conclusion, house calls embody the spirit of one of a physician’s central ethical obligations: nonabandonment.9 The impact of having the oncologist at home has immeasurable and profound benefits for the patient who is dying of cancer, as well as for the family and caregivers. Making effective house calls is a skill for oncologists that demonstrates a continuing commitment to caring for the patient.
1. Meyers GS, Gibbons RV: House calls to the elderly: A vanishing practice among physicians. N Engl J Med 337:1815–1820, 1997 2. Keenan JM, Boling PE, Schwartzberg JG, et al: A national survey of the home visiting practice and attitudes of family physicians and internists. Arch Intern Med 152:2025–2032, 1992[Abstract]
3. Campion EW: Can house calls survive? N Engl J Med 337:1840–1841, 1997 4. Lands RH: A piece of my mind: The house call. JAMA 278:976, 1997[CrossRef][Medline] 5. Karnad AB: An oncologist in the house: Home visit vignettes. J Palliative Med 3:201–202, 2000 6. Making house calls through a pilot program called HOME (Home Oncology Medical Extension). Med World News 20:108, 1979[Medline]
7. Himelstein BP, Jackson NL, Pegram L: The power of silence. J Clin Oncol 19:3996, 2001 8. Richards JG, Jass JR, Probert JC, et al: Teaching oncology: A longitudinal approach. N Z Med J 107:335–336, 1994[Medline]
9. Quill TE, Cassel CK: Nonabandonment: A central obligation for physicians. Ann Intern Med 122:368–374, 1995
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Copyright © 2003 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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