Who Should Palliative Care See? Diane Meier, Bob Arnold, and Justin Sanders

Palliative care has undergone a profound transformation since its modern inception, evolving from a marginalized discipline associated exclusively with the final moments of life into a dynamic medical specialty. However, this success has precipitated a complex existential crisis regarding patient eligibility and workforce capacity. Recently, prominent figures in the field gathered on the GeriPal Podcast—hosted by Dr. Eric Widera and Dr. Alex Smith—to debate one of the most pressing questions in modern healthcare: Which patients should see a palliative care specialist?

The discussion featured three foundational leaders in the discipline: Dr. Diane Meier, geriatrician, palliative care physician, and Director Emerita of the Center to Advance Palliative Care (CAPC); Dr. Bob Arnold, palliative care physician and co-founder of VitalTalk; and Dr. Justin Sanders, Director of Palliative Care at McGill University. Together, they explored the tension between the boundless need for holistic care and the hard physical limits of a specialized workforce.

The Historical Evolution of Palliative Care

To understand the current debate over patient selection, experts emphasize the necessity of looking back at how the field has developed over the past generation. For decades, specialty palliative care was conflated with end-of-life or hospice care—often lacking only the formal administrative structure of hospice reimbursement. Practitioners frequently encountered institutional resistance, entering hospital wards to whispers of Dr. Death.

Over a generation, however, persistent advocacy and clinical integration altered this perception. Succeeding generations of medical students and residents began to understand that palliative care teams offer invaluable clinical, emotional, and existential support at any stage of a serious illness, rather than merely during the final hours. Outpatient palliative care clinics, in particular, dramatically shifted the timeline of care; institutions that once measured the duration of a palliative consult in mere weeks prior to death began seeing patients years before the end of life.

Yet, this broadening scope has created an unprecedented demand. Palliative care teams are routinely overwhelmed by referrals for individuals who may live for a decade or longer, alongside patients actively navigating the dying process. Consequently, the discipline faces internal pressure to establish clearer eligibility boundaries. While some practitioners propose utilizing prognosis as a filtering mechanism, veterans of the field caution that such a step risks regressing to historical models where specialists are called solely for patients in active physical decline.

Defining Serious Illness and the Problem of Subjectivity

At the heart of the selection debate lies the definition of "serious illness." According to widely cited academic frameworks, such as those established by health services researcher Dr. Amy Kelley, a serious illness is conceptually defined as a health condition that carries a high risk of mortality while negatively impacting a person’s daily function, quality of life, or placing an excessive strain on caregivers.

While this definition is intentionally patient- and family-centered rather than resource-constrained, it introduces substantial operational ambiguity. In practice, clinicians frequently receive consultation requests for patients with chronic conditions who have a high burden of suffering—such as chronic pain syndromes, treatment-resistant depression, or complex social determinants of health—yet possess a long-term prognosis spanning ten to fifteen years.

This creates a philosophical and logistical dilemma for specialty palliative care. Experts argue that while these patients undeniably suffer, specialty palliative care services cannot realistically own every complex patient population without compromising their core mission. The challenge is further complicated by intersecting fields such as addiction medicine and chronic pain management. Palliative care teams often lack dedicated resources—such as embedded physical therapists and pain psychologists—required to comprehensively manage non-malignant chronic pain, leading to difficult decisions regarding consultation acceptance.

Workforce Realities and the One-Year Fellowship Model

A significant driver of the current capacity crisis is the structural design of palliative care training. In North America, the standard fellowship pathway for physicians is a single post-graduate year.

Reflecting on the history of the fellowship model, Dr. Bob Arnold noted that the one-year duration was originally a pragmatic concession designed to secure approval from medical boards and federal agencies, mirroring early developments in geriatrics. However, many experts now view this constraint as a foundational mistake. A single year of specialized training is widely considered insufficient to equip clinicians with the multifaceted skills needed to navigate advanced symptom management, complex psychosocial distress, and overlapping medical subspecialties like physical medicine and rehabilitation or addiction medicine.

Expanding fellowship training to two or three years could theoretically enhance provider competency but risks exacerbating workforce shortages by temporarily reducing the number of entering trainees. Consequently, the healthcare system remains caught between an expanding definition of need and a severely restricted supply of fellowship-trained specialists.

Envisioning the Future: Population Health, Precision Care, and Systemic Change

Addressing the mismatch between supply and demand requires looking beyond traditional inpatient consultation models toward a population health approach. Industry leaders argue that the future of palliative care must rely on structural integration and technological innovation rather than direct, one-on-one specialist intervention for every suffering patient.

Prominent among these proposed solutions is the concept of "precision palliative care," which advocates for routine, comprehensive screening of patient-reported outcomes independent of prognosis. Utilizing digital tools to systematically assess patient distress and functional status within electronic health records could automate the direct referral of individuals to appropriate multidisciplinary resources—such as well-trained oncology nurses, chaplains, and social workers—without requiring direct physician gatekeeping.

Furthermore, experts emphasize that systemic evolution depends heavily on reforming healthcare reimbursement models. As long as payment structures remain dominated by fee-for-service paradigms, health system administrators lack the financial incentive to proactively build robust supportive care systems for populations with chronic, non-fatal serious illnesses. The transition toward global capitated budgets, accountable care organizations (ACOs), and value-based payment models will be essential for institutionalizing community-based palliative care standards.

Implications for Healthcare Administrators and Clinical Practice

The ongoing debate over patient selection carries profound implications for healthcare delivery models, medical education, and health policy over the coming decades:

• Redefining the Role of Specialists: Specialty palliative care must increasingly function as a tertiary resource and catalyst, training and supporting primary care clinicians, oncologists, nephrologists, and cardiologists to manage foundational palliative needs within their own patient panels.
• Investment in Interprofessional Teams: Healthcare organizations must invest in non-physician specialists—including advanced practice registered nurses, social workers, and spiritual care providers—who can shoulder the burden of longitudinal symptom management and advance care planning.
• Standardization of Quality Metrics: The development of consensus-driven quality metrics for community-based palliative care will be critical to securing sustainable reimbursement through public and private payers, ensuring accountability without relying on overly rigid prognostic cutoffs.

Ultimately, the challenge facing palliative care is a byproduct of its own success. By demonstrating the profound value of whole-person, patient-centered care, the discipline has illuminated a vast reservoir of unmet need across global healthcare systems. Navigating the next decade will require the field to resist the urge to retreat behind narrow prognostic walls, choosing instead to champion systemic transformation, empower primary providers, and advocate for rational, value-driven care models that ensure patients and their families receive the support they require.