Palliative Care 3.0: What We Should Build Now That We Find Ourselves In The Wild West
While this topic is important and topical (and I'm really trying to keep my commentary on current events elsewhere), I couldn't in good conscience not take a moment to acknowledge what's going on around us. These past days have been heavy. The slaying of Alex Pretti & Renee Good has shaken all of us. The ICU nurses who trained me and continue to train me are, to a one, courageous advocates.
In palliative care, we talk a lot about “meeting people where they are.” Most days that refers to symptom burdens, goals of care, or existential questions. But this week, it means meeting colleagues, patients, and ourselves in a place of collective unease—where safety feels increasingly tenuous, and the world outside the hospital walls feels closer and more volatile than it should.
What this moment has brought into sharper focus for me is the simple truth that the only way forward is neighborliness and solidarity. Not the soft, sentimental kind, but the disciplined practice of refusing to look away from one another. The kind that insists we are responsible to each other, even when systems fracture around us. The kind that doesn’t confuse proximity with connection.
Palliative care always requires courage and right intention. It asks us to stay present in rooms where suffering is real and answers are incomplete. This week reinforces to all of us that those same commitments are required outside the patient room, too. To stand alongside our colleagues. To insist on safety and truth. To name violence for what it is. And to keep practicing the kind of presence that makes both care and community possible.
Let's try a reaction post (and let's say I was inspired more by the topic than by the musical theater themes...yes, let's go with that):
Every so often, something happens in our field that shifts the frame. Sometimes it’s benign—another committee meeting about “aligning incentives.” Sometimes it’s absurd—someone launching a “palliative care clinic” that consists of… stress balls.
And sometimes, like in the recent GeriPal conversation with Alan Chiu, Mindy Stewart-Coffee, and Ben Thompson, it’s the moment when you realize the ground is shifting beneath our feet faster than our field’s collective posture is adjusting.
Palliative Care 3.0 isn’t a slogan. It’s the recognition that the world has moved on, and we can no longer pretend we’re still practicing in 2005, or 2015, or even pre-COVID 2019.
We are being redefined—by Medicare Advantage contracts, by risk-bearing entities, by investors, by complex-care companies, and by a healthcare system that sees palliative care as the solution to problems it has no other tools to solve.
The choice isn’t whether to participate. The choice is whether we design the future or let someone else build it for us.
Let’s talk about what came through loud and clear in the GeriPal episode, and how it builds on the monster we’ve already acknowledged we helped create.
1. The Wild West Isn’t Coming — It’s Here
In The Monster We Built, I talked about a health system that increasingly wants the outputs of palliative care without the team, the training, or the time that makes those outputs possible.
Listening to Alan, Mindy, and Ben, it’s obvious that the market is hearing the same thing — and happily obliged.
Suddenly:
- Nurse practitioners are the backbone of community-based palliative care.
- Home-based programs vary wildly in staff, training, and scope.
- Anything involving symptom check-ins or advance care planning is being branded “palliative.”
- And every risk-bearing entity believes their chronically ill population is “palliative” by default.
This isn’t inherently bad. It is inherently unstable.
As Mindy said plainly: even the well-intentioned programs are “solving one piece of the puzzle” while calling it the whole thing. And Alan captured the existential risk: patients now believe they’ve “had palliative care” because someone visited once a month and updated an advance directive.
We already know the result: When they actually need interdisciplinary care, they decline it—because they think they’ve already received it.
This is how fields lose public trust. This is how brands erode. This is how monsters grow.
2. Palliative Care Light Isn’t the Problem — Palliative Care Unmoored Is
On the podcast, everyone flinched at the term “palliative care lite,” and they’re right. It’s pejorative and imprecise. (AND...let's be honest, I'm still planning to use it because it captures a truth pithily.)
The issue isn’t “liteness.” It’s untethered-ness.
We have:
- No national benefit
- No enforceable standards
- No accreditation with teeth
- No quality floor
- And a workforce outpaced by the patient population
In Did Palliative Care Spend a Decade on the Wrong Problem?, I argued that the field chased “everyone with serious illness needs palliative care” while ignoring the real constraint: the payment architecture that makes real teams possible.
The community-based surge makes that even clearer. Organizations aren’t ignoring NQF or NCP standards—they literally can’t meet them inside the constraints of today’s financing.
They can’t afford the chaplain.
They can’t afford the social worker.
They can’t afford the time.
And because investors see palliative care as a cost-saving intervention (accurately), they’re incentivized to deliver the minimum viable product needed to demonstrate “value.”
This is not villainy. It’s economics.
We can rage against it (and I most certainly do), but we must also work on the design of something better.
3. The Only Way Out Is Forward: Tiered Standards for Palliative Care 3.0
If we want to avoid the race to the bottom, we need a structure that:
- Protects patients
- Supports innovation
- Reflects workforce reality
- And aligns with value-based models
The answer is a tiered standard—not a monolith, not a purity test.
Something like:
Tier 1: Foundational | Powered by virtual and tele- tools. Generalist-level skills, early conversations, basic symptom assessment, telephonic outreach. Accessible. Scalable. Safe.
Tier 2: Intermediate | Single palliative-specialist–led teams with interdisciplinary consultation, structured tools, defined clinical protocols.
Tier 3: Advanced | Full IDT, specialty visits, longitudinal continuity, prognostic complexity, home-based crisis response.
This isn’t gatekeeping. It’s signal clarity.
Without tiers, a stress ball and a pamphlet get mistaken for palliative care. With tiers, everyone knows what they’re delivering and what they’re not.
This is what prevents—rather than fuels—the monster.
4. Value-Based Care Is Not the Enemy. Confusion Is.
One of the most helpful insights in the GeriPal discussion was the reminder that palliative care has always sold itself via cost containment. This doesn't automatically become evil as soon as a new flavor of Capitalism enters the chat. Like Eric helped clarify, WE need to be clear on our intentions and use whatever we can to serve our patients.
We’ve always talked about:
- ICU avoidance
- Decreased length of stay
- Reduced rehospitalizations
- Better hospice transitions
In fee-for-service, these were pitch decks. In Medicare Advantage, they’re expectations.
The shift feels existential because the stakes are suddenly real.
But Mindy was correct: if we let fear of “dirty money” push us out of the conversation, someone else will fill the space — and they will not share our values.
Just ask the caregivers whose labor I wrote about in Hospice Caregiver Burden and the Systematic Delegitimization of Care. When a system is allowed to define value without us, unpaid caregivers end up footing the bill in invisible suffering.
The same will happen to palliative care if we don’t stay at the table.
5. Palliative Care 3.0 Requires a Different Relationship With Geriatrics — Not a Merger, but a Partnership
One of the themes that surfaced in the GeriPal conversation was the creeping sense that community‑based palliative care is being asked to inherit a set of responsibilities traditionally associated with geriatrics: falls prevention, polypharmacy management, functional assessment, cognitive evaluation, and the slow‑motion crises of multimorbidity.
First, let’s be clear: Palliative Care is not geriatrics. Geriatrics is not palliative care. And pretending otherwise shortchanges both.
What is true—and what Palliative Care 3.0 must finally acknowledge—is that our patient populations now overlap so substantially that operating in silos no longer serves either discipline well.
The modern palliative care patient isn’t defined by a single life‑limiting diagnosis.
They are defined by, as Alan points out polychronicity, frailty, functional decline, multimorbidity, cognitive vulnerability, and unpredictable trajectories—classic geriatrics territory.
And the modern geriatrics patient isn’t defined solely by “aging physiology.”
They’re defined by serious illness, shifting values, existential distress, caregiver burden, and grief‑tinged decision‑making—classic palliative care territory.
This is not a threat to either field’s identity.
It’s an invitation to finally collaborate on the reality we are already co‑managing.
In practice, that means:
- Geriatrics brings the tools: frailty indices, deprescribing frameworks, functional assessments, fall risk mitigation, delirium prevention.
- Palliative Care brings the frame: values‑based decision‑making, serious illness communication, goal‑concordant care, support for caregivers, symptom management, and existential coherence.
Each discipline holds a piece of the puzzle. Neither replaces the other.
And if Palliative Care 1.0 was built on oncology and Palliative Care 2.0 was built on hospital consults, Palliative Care 3.0 will be built at the intersection—where frailty meets uncertainty, where multimorbidity meets shifting goals, where caregivers are drowning, and where the system finally notices.
This isn’t “scope creep.” It’s acknowledging that modern serious illness is geriatric by default and palliative by consequence—and that the only ethical, scalable way forward is to build models that integrate both without collapsing either.
The future isn’t a merger. It’s a partnership. A partnership we’ve needed for years (and that some have been innovating on for ages...pun intended).
A partnership Palliative Care 3.0 finally forces us to build...the greatest team there's ever been.
6. So Where Do We Go From Here?
Palliative Care 3.0 requires an uncomfortable but necessary evolution:
- Less focus on purity
- More focus on coherence
- Less fear of for-profit participation (why are we still talking about this?!)
- More insistence on standards
- Less nostalgia for Palliative Care 1.0
- More design for the populations actually being served
- Less fighting over labels
- More clarity about roles, tiers, and expectations
We cannot “defend the brand” by keeping palliative care small.
We defend it by making it legible, structured, and scalable—and by tying it back to what Alan, Mindy, and Ben kept repeating:
The mission hasn’t changed: reduce avoidable suffering and maximize quality of life.
Everything else is negotiable AND to do those things we have to be in the room where it happens.
The Conclusion: Palliative Care 3.0 Is the Work We Can No Longer Pretend Someone Else Will Do
If there’s one through‑line from Alan, Mindy, and Ben’s conversation, it’s this:
the future isn’t waiting for us to catch up.
Community-based models have already outpaced our definitions. Risk-bearing entities have already begun designing care pathways. Patients and caregivers are already encountering “palliative care” programs that may or may not resemble the discipline we trained for.
We can respond with purity tests. We can wring our hands about for-profit involvement. We can lament the dilution of our brand and the confusion of our patients.
Or we can build something better.
Palliative Care 3.0 isn’t nostalgia for a golden age. It’s a recognition that serious illness care is bigger, messier, older, more complex, and more culturally heterogeneous than the models we inherited.
It asks us to evolve—not by absorbing geriatrics or being absorbed by it, but by collaborating where our patients already live: in the overlap.
It asks us to design tiered standards—not to exclude, but to clarify.
It asks us to take a seat at the value‑based table—not to validate the cost-first mindset, but to insist that quality, integrity, and personhood drive the architecture.
It asks us to lead—not react.
Because if palliative care does not shape what comes next, the system will.
And as we’ve learned—from Compassion on Clearance, from The Monster We Built, from Caregiver Delegitimization—systems built without us tend to externalize suffering onto the people least able to bear it.
Palliative Care 3.0 is our opportunity to stop that cycle. Not by retreating. Not by romanticizing the past. Not by hiding in old arguments. But by designing a future in which:
- Access expands without eroding quality
- Innovation flourishes without abandoning standards
- Geriatrics and palliative care work in partnership, not in competition
- Risk-bearing entities invest in care models that reflect human values, not just actuarial math
- And patients and caregivers finally receive care that matches the complexity of the lives they are actually living
This isn’t really about defying gravity. Maybe it’s about accepting that the wind has changed—and building ways for us to fly on purpose instead of drifting by accident.
Palliative Care 3.0 is no one’s to build but ours.
And the work starts now.
(Insert Battle Cry here.)
