Dr. Alexander Nesbitt was an
established family practice physician and very part-time hospice medical
director in Williamsport, PA, when he heard a 2003 presentation by Dr.
Diane Meier, director of the Center to Advance Palliative Care (CAPC). "I had
never heard of palliative care, but I became convinced that it was a really
good idea, and that somebody in Williamsport
should do it. I realized that probably that would have to be me, because nobody
else here was into it like I was."
He attended the Program in
Palliative Care Education & Practice at Harvard Medical
and began working toward board certification in HPM, earning that credential in
2004. He pursued an expanded role in Susquehanna Hospice and started advocating
for a palliative care consultation service at 180-bed Williamsport Hospital &
Both belong to the local Susquehanna Health System.
"The idea of starting a new
program, which included hiring a full-time nurse practitioner to staff it, was
an uphill push. I had to convince the hospital's administration that we should
spend the money, even though the system was undergoing financial difficulties.
Fortunately, CAPC has highly practical tools to use, well adapted to just that
The inpatient palliative care service
launched in January 2005 and grew rapidly, while the hospice census was also
rising to its current level of about 100 patients. "Meanwhile, we realized that
patients were coming toward their dying time in the hospital with the support
of palliative care but without a dedicated place to provide top-level symptom
management. Plus, we had patients in our outpatient hospice in need of
aggressive symptom management, and there was no good place to do that."
So Dr. Nesbitt went back to the
system's administrators and persuaded them to open seven-bed Gatehouse
Inpatient Hospice in July 2006 in a medical office building two miles from the
acute hospital, with him as its medical director. However, this growth in HPM
work was not compatible with full-time family medicine commitments, and
reluctantly he gave up his 20-year practice.
"I delivered a lot of babies, took
care of these families for a long time and felt very engaged with my patients.
So it was a sad day to step away from my practice," he says. "But I realized I
needed to do palliative care. I was pulled toward it. Just like family
medicine, palliative medicine is patient-focused and family-centered, broadly
defined, and I find it very rewarding to get involved with these families."
Assembling the Pieces
Dr. Nesbitt is an employee of the
health system, which employs about half of the physicians in its region. "I had
been working with administrators every step of the way, persuading them of the
importance of this work - for patients and families, as well as for the
system - and sharing outcomes data." When it came time to transfer full-time to hospice
and palliative care, the various responsible parties were ready to sign off on
the change. Dr. Nesbitt's salary is based in part on billing income from
palliative care and inpatient hospice consultations, annualized, as well as an
hourly rate for dedicated administrative responsibilities, which amount to
nearly half of his roughly 50-hour week.
"Although initially I wasn't so
sure, I felt I could set it up piece by piece, and make a job of it," with the
combination of hospice and palliative care a good package for the system, he
says. "There's increasing information out there that this work is beneficial
for the patient and family, for the reputation of the hospital, for customer
satisfaction, for the bottom line, and for readmission rates."
But making the case required
speaking directly to the biggest concerns of each target audience, Dr. Nesbitt
says. "As I prioritized it, first was to do the right thing for the patient and
family. I talked about documented problems in the national health care system,
such as inadequate symptom management, lack of support for patients and
families, lack of understanding of treatment options. And I always included
personal stories, which are very important for engaging people. Another piece of
making the case is data sharing, showing how palliative care benefits the
system. Each audience can hear that message if it's framed specifically for
them. I also think it helps to have a physician leading the effort. I can say,
'Let me tell you about one of my patients and families.'"
In the beginning, Dr. Nesbitt took
the lead on hospital palliative care consults, but as the program established
its credibility, the nurse practitioner now makes over half of the visits.
Another palliative care physician, Karen Brown MD, joined the team in 2007 and
sees patients in affiliated, rural Muncy
10 miles away, and in the region's nine long-term care facilities. In
addition to the hospital-based nurse practitioner, there is a second nurse
practitioner based in the nursing homes, and an advanced practice nurse who sees
patients in nursing homes and coordinates professional education events.
"Within the (HPM) team, each of us
has a primary base, but we also work to float extra team time to wherever it is
needed," he explains. The five members meet monthly to discuss practice issues.
Growing demand for services is a problem, and the team tried to manage
growth in sustainable ways while it extended services into the long-term care
setting. Recently, it was decided to limit weekend palliative care consults to
emergency cases only. "Sometimes we're really busy on the weekends, so we're
working to make that part of this work more manageable," Dr. Nesbitt says.
Dr. Nesbitt starts a typical workday
by rounding on patients in the inpatient hospice unit, and then, depending on
demand for palliative care that day, goes to the hospital. He makes occasional
home visits to hospice patients and sees some patients in his office in the
medical building. So far there is no formalized outpatient clinic setting or
schedule for palliative care, although that may change in the next year,
perhaps in conjunction with the system's Cancer Center. Dr. Nesbitt takes night and weekend call every third week, and he also meets
regularly with various administrators within the health system's organizational
A lot of his time is spent
educating physicians about hospice and palliative care, individually or in
groups, and speaking to community groups. He participates in twice-weekly
hospice interdisciplinary team meetings, inpatient hospice and palliative care
staff meetings, and various clinically focused committees and councils in the
hospital. Other hospice responsibilities include chart reviews, patient
certifications and recertifications, and writing appeal letters for denied
He often has ideas for how to
better manage issues that come up in hospice team meetings, which may lead to
new assessment forms, documentation tools, protocols or drug formulary
adjustments. An example is a recently adopted protocol for administering Ketamine to treat
refractory pain. "I spend time in chat rooms for palliative care around the
world, where issues from difficult cases are discussed, or I may get ideas from
my readings or attending conferences," he says. "I work with a wonderful team
of hospice nurses who ask a lot of good questions and are motivated to learn. I
am also involved in quality improvement activities, clarifying what we want to
learn and how we can best collect and present the data to answer our
Synergy and High
finds wonderful synergies between his hospice and palliative care work, with
enough responsibilities to fill a full-time medical practice. "Developing the
palliative care program has been very helpful for hospice, and having a hospice
that gives great care is a helpful option for referring palliative care patients who have
advanced symptoms," he notes. "These are two separate populations, but they
have significant overlap. Communicating carefully about difficult issues and
managing difficult symptoms for the two populations is essentially the same
skill set, and it makes sense to have both parts working together."
is a city of about 30,000, 180 miles from Philadelphia,
in a county of 117,000. Although Susquehanna Hospice is established as the
community leader in end-of-life care, reflecting its inpatient unit and
palliative care links, in recent years two for-profit hospices opened in the
community, although one subsequently folded.
Based on DAI Palliative Care
Group's analysis of Dartmouth Medical Atlas data, Williamsport and its health system are high
performers on palliative outcomes measures. In fact, overall Susquehanna
outperforms well-known, exemplary health systems like Geisinger Medical Center
and Lancaster General Hospital on such measures as percentage of decedents
seeing 10 or more physicians in the last six months of life, total ICU days
during the last six months of life (and proportion of ICU deaths), and hospital
days during the last six months of life.
Dr. Nesbitt says he'd like to take
some of the credit for these outcomes, although the data mostly precede the
opening of his palliative care service. He thinks the numbers will be even
better in the next Dartmouth Atlas. He also points to recognized medical
practice in the community and the involvement of ICU physicians in
communicating with patients and families. "I think we have a great medical
community that understands hospice and palliative care."
spearheaded a POLST (physician orders for life-sustaining treatment) initiative
in the region, working with the hospitals and nursing homes. The State of Pennsylvania does not give
legal recognition to POLST, but a study group is working toward initiating a
statewide form. He also chairs the hospital's ethics committee
In 2008 Dr. Nesbitt received the
Heart of Hospice clinician award from the National Hospice and Palliative Care
Organization. He and his wife have three adult children and he has taken
several mission trips to Guatemala,
Ecuador and Mexico
to provide medical services for children. One of his hobbies is harmonizing
with other members of Gatehouse Hospice Singers, who sing in groups of eight or
ten to dying patients in their homes, nursing homes or the Gatehouse Hospice
of palliative care in Williamsport
has affirmed for Dr. Nesbitt the difference that one person who feels strongly
about an issue can make. Clearly, much of the local impetus for this development
came from him. "We had a good hospice but it was small. The palliative care
nurse practitioner happened to be here at the right time. But it takes someone
to convene the meetings and start the dialogue. A physician who can find
like-minded people to work with can make a heck of a difference in what happens
to patients in your community."