Dr. Laura Mavity sees the hospital’s sickest patients.

A few weeks ago she met with Ralph Garibay, a 91-year-old man in dire condition. He had a gallstone that caused a gall bladder infection and near kidney failure. After surgery, his prognosis was bad. At one point, hospital staff did not think he was going to make it through the night, and the family had a priest administer last rites.

Mavity, a palliative care specialist, was there to explain the situation to his family. “She told us he would be in the hospital for a while,” said Larry Garibay, Ralph’s son. As his father’s condition improved, the younger Garibay said Mavity checked in each day. “She made it a lot more understandable of what is taking place and the different avenues that we can take if something doesn’t go right.”

In the end, Ralph was transferred to a nursing home in Bend, where he is now. Throughout the ordeal, Larry said, Mavity’s presence made the hospital stay much less scary for all of them. “I really do love that lady. She’s wonderful.”

As hospital care becomes more complex, patients are increasingly subjected to a parade of specialists willing to try anything to extend life. Treatments are often tried, even if they have little chance of success. More care is the default practice.

Palliative care has grown on the premise that not everyone wants these heroic measures taken, particularly if they are suffering because of them. In contrast to the paradigm of more care being better care, palliative care specialists try to ask what will be best for a patient’s quality of life.

Mavity’s primary role at St. Charles Bend is to help patients step back and see the big picture so they can make educated decisions about their treatment. She is called in to discuss the options for people with serious, often terminal, illnesses.

Describing herself as a “quality-of-life doctor,” Mavity fills a unique niche in hospital care. Palliative care specialists take on patients that other doctors often avoid, those near the end of life or who have exhausted all of their treatment options. Unlike most physicians, Mavity spends the bulk of her time talking with patients and families and very little time conducting tests or procedures. Her goal, she said, is to help patients come to terms with their illness, make them comfortable and guide them through treatment decisions.

“Your mortality is smacked in your face when you get a really bad diagnosis,” she said. “That’s what palliative care tries to do is pause and talk with patients and families about (physical, emotional and spiritual) issues to be sure that we’re not missing ways that we could help them feel better.”

Growing specialty

Early in her career, Mavity, now 37, found herself drawn to complex situations. When doctors divided up hospital patients who needed to be seen, “they’d say, ‘There’s this one really bad case. They need a family conference to figure out what’s going to happen next,’” she recalled. “I found myself volunteering to do those, and most people don’t.”

Mavity also had personal experience dealing with death. Her mother died at age 48 of cancer. “I felt like that was something I could bring some personal experience (in), to make me better at my work.”

After practicing for several years as an internal medicine physician, she received specialized training in palliative care through a fellowship sponsored by Veterans Affairs and OHSU.

“I’ve always enjoyed interacting with patients and families and really trying to focus their care on what they want,” she said.

Several years ago, she called Dr. Alan Ertle, senior vice president of medical affairs at Cascade Healthcare Community, St Charles Bend’s parent company, and talked to him about palliative care in Central Oregon.

“We were one of the last big hospitals in Oregon that didn’t have an inpatient palliative care program,” said Ertle. “It was one of those things where we thought we were doing good enough.”

Mavity started at the hospital in the spring of 2009 with the mission to head a formal program. Today, in addition to Mavity, St. Charles Bend’s palliative care program includes nurses, social workers and case managers.

So far, CHC offers the palliative care program only in Bend; the hospitals in Redmond, Prineville and Madras do not yet have formal programs.

Before Mavity arrived, “there was always this piece missing,” said Colleen Greene, a case manager for the Comfort Care program at St. Charles Bend. “The patients were always kind of left on their own to decide what they wanted to do. I think palliative care can step in and help patients make some of those decisions. I think it’s just what we’ve needed.”

Many other hospitals have decided it’s what they need as well. A decade ago there were few doctors who specialized in palliative care and few hospitals with palliative care programs. Today, most large hospitals have a formal program, according to Dr. Porter Storey, the executive vice president of the American Academy of Hospice and Palliative Medicine, a professional society.

Though Mavity is the only specialist doing formal inpatient palliative care in Central Oregon, there are at least three other doctors who are certified in the specialty. Dr. Lisa Lewis is the medical director at Partners in Care, a Bend hospice and home health agency. Dr. David Tretheway is medical director at Redmond-Sisters Hospice. Dr. Michael Knower is a primary care physician in Prineville.

Palliative care was recognized as a formal medical specialty in 2008. Storey said that recognition was “huge” for the field because doctors now look at palliative care specialists as experts in a particular area of medicine. “For years hospice doctors knew that we knew things that other doctors didn’t know,” he said, “but other doctors didn’t know that. So we often were not brought in.”

Death panels or discussion?

The growth in palliative care has not been without controversy. While the availability of palliative care is lauded by many doctors and hospitals as an essential patient service, it has generated debate in other areas.

When Sarah Palin and other conservatives spoke of “death panels” created by proposed health reform legislation, the comments were largely taken as an indictment of the specialty. Palliative and hospice care providers were left explaining that they encourage discussion about death, not death itself.

Even among physicians, there are misconceptions about what palliative care doctors do. “I get really defensive when I’m expected to go into a room and make sure the patient understands that we’re not going to do anything for you anymore and it’s time for you to die,” said Mavity. “That’s not what I do.”

Mavity said she spends a lot of time explaining herself and her specialty. “Just saying palliative care or hospice has connotations in our culture,” she said. “Some of us have a really hard time talking about death and planning for death.”

One of the biggest misunderstandings about palliative care is that people need to be near death to use it. Unlike hospice, Mavity consults with patients who are often still receiving active treatment. Patients can continue to receive active treatment for as long as they wish, though Mavity will try to explain what is and is not likely to help them.

In discussing health care options, Mavity said, “what makes complete natural sense to me makes absolutely no sense to somebody else. It’s really important to bring that focus back to the patient and the family and what they value.”

Meeting patient needs

Mavity is brought into a case by another physician, typically the doctor responsible for the patient’s hospital care. Across the country, the culture of a hospital determines how often a palliative care specialist is used, Storey said. Sometimes there is resistance from doctors who think they already handle palliative care issues well, or who don’t want to talk to patients about the fact that treatment may no longer be helpful.

At OHSU, for example, Dr. R. Hugo Richardson said some specialties are more receptive to using a palliative care physician than others. “When I started in the field, many physicians had a great deal of difficulty understanding it. At OHSU now, we have more and more (departments) who do understand what we can add.”

Mavity said that she does sometimes encounter resistance from physicians who might see ordering palliative care services as giving up on a patient. “Some (physicians) have that in them that having someone die on their watch is a failure, and that’s a really hard thing as a physician because everybody does die at some point.”

Overall, she said, physicians in Bend seem very receptive to using her expertise.

Dr. Stephen Kornfeld, an oncologist at Cancer Care of the Cascades, said that he uses Mavity frequently. “When I look at them, I’m focusing predominantly on their cancer,” he said. “Sometimes the big issue for patients is how the cancer is affecting their life. That’s where you need a palliative care expert.”

Kornfeld said that many doctors, himself included, don’t always have the time to sit down with patients and help them best meet all their needs.

Research has shown that some doctors are not comfortable discussing end-of-life care. A study published last month surveyed physicians caring for cancer patients and found that, even if a patient had less than six months to live, most would not discuss end-of-life issues until the patient was feeling unwell (sometimes patients feel fine despite their prognosis) or had exhausted all treatments. The reasons they gave were often wanting to continue treatment on patients or not wanting to crush a patient’s hopes.

“Some doctors are better at having that talk than others,” Ertle said. “Dr. Mavity is the best.”

That, Ertle said, has been the biggest boon of the palliative care program. “Our job as a hospital and as physicians is to make sure we’re meeting the needs of the patient. We don’t always do the best job of determining what those needs are. The palliative care program is one way we can enhance our ability to meet those needs.”

What does a palliative care doctor do?

Dr. Laura Mavity, a palliative care physician at St. Charles Bend, helps facilitate communication among people involved in medical care.

For patients: Mavity explains the options available and helps them decide what treatments are right for them. She helps control symptoms that may be making them uncomfortable.

For families: Mavity offers support and a nontechnical explanation of what is happening to a patient. She talks with families to resolve disputes about care within families.

For doctors: Mavity consults on cases at the request of a physician. She is often able to take more time to discuss options with patients than other doctors.

For hospitals: Mavity helps determine the needs of patients. Some studies have shown that having a palliative care physician shortens the average length of stay and reduces costs.