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Consultation etiquette challenges palliative care to be on its best behavior.

7 THE MOST COMMON MODEL for the growing number of palliative care programs introduced into U.S. hospitals in recent years is the consultation service, typically a multidisciplinary team that may include physicians, nurses, social workers, pharmacists, and/or chaplains. The palliative care service responds to requests from physicians and other colleagues for assistance with pain and symptom management, establishment of goals of care and associated treatment decisions, advance care planning, and other issues related to living with serious illness. Working with consultants is familiar to most physicians, with a range of medical specialists commonly called upon to offer advice on how to deal with a variety of patient care issues. Consultations may be specific to organ (e.g., pulmonology), disease (oncology), or age of the patient (geriatrics). Palliative care, by contrast, is defined by its attention to the whole person and family, with a focus on comfort, symptom management, goal setting and associated decisionmaking, and quality of life for the seriously ill patient. But the consultation role in palliative care in its fundamental structure is exactly the same as for other specialties: the client of the palliative care team is the referring physician. The rules of consultation are known as consultation etiquette: a set of unwritten but important standards that define how the consultant is expected to behave in response to requests from attending physicians, with consequences in terms of loss of future referrals when the rules are breached. Palliative care consultants must recognize that the requesting physician is their primary customer, that the scope of their involvement is determined by the requesting physician, and that they are not in control over what happens to the patient or even whether their recommendations get followed. Palliative care nurses and social workers may not conform to these unwritten rules as readily, because they were not trained or acculturated in consultation etiquette, but they, too, need to learn and follow the rules. Working palliative care consultants contacted for this paper suggest that they face particular challenges and frustrations in the consultant’s role, even as they realize that following the rules of consultation etiquette is essential for gaining the trust of referring physicians and influencing the culture and practice of medicine within their institutions.