Definition of palliative care

What is palliative care?

Palliative care is specialized medical care for people with serious illness that is focused on improving quality of life for patients and their families and caregivers. It is available to patients of any age and any stage of disease, starting at diagnosis, and can be offered alongside disease targeted treatments. Palliative care services are provided by an interdisciplinary team, including physicians, nurses, social workers, pharmacists, chaplains, psychologists, and other disciplines. Clinicians use expert communication skills to elicit patient and family goals and values and recommend a care plan aligned with preferences. Care includes assessment and management of physical, psychological and spiritual distress, and support of patients and families. Unlike hospice, which is available only to persons with an expected prognosis of 6 months or less and who have chosen to forego life sustaining treatments, palliative care can be provided at any point in a serious illness based on need rather than prognosis, and alongside any appropriate treatments. Essential domains of palliative care are detailed in Table 1.1 , adapted from the National Consensus Project for Quality Palliative Care.

Palliative care is available to patients living with serious illness, defined as “a condition that carries a high risk of mortality, negatively impacts quality of life and daily function, and/or is burdensome in symptoms, treatments, or caregiver stress.” Palliative care, including first line symptom management, advance care planning, and shared decision making, is often provided by primary care providers and oncologists, with referral to specialist palliative care services for complex or challenging symptom and communication issues. The American Society of Clinical Oncology (ASCO) provides a strong evidence-based recommendation for early integration of palliative care services alongside oncologic treatment for patients with advanced cancer or those who have a high burden of physical or psychosocial needs.

Access to palliative care has grown rapidly in recent years. Although palliative care has traditionally been available in hospitals as an inpatient consultative model, access to outpatient and community-based care is expanding. In 2000, only one quarter of hospitals with 50 or more beds had a specialist palliative care team. By 2019, that number grew to 72%. In contrast to small hospitals where access is less common, 94% of hospitals with 300 or more beds reported having a palliative care team ( America’s Care of Serious Illness: A State-by-State Report Card on Access to Palliative Care in Our Nation’s Hospitals , 2019 ). A survey of National Cancer Institute cancer centers showed that 98% had a palliative care program but only 59% had ambulatory palliative care services. Access to ambulatory palliative care is expanding but remains less common than inpatient services. A study of California hospitals showed that only 18% of sites that had an inpatient consult service also offered outpatient services. In some areas, palliative care teams practice in additional settings, including nursing homes and providing home visits.

What is the difference between palliative care and hospice?

Although hospice and palliative care share a focus on interdisciplinary care intended to improve quality of life, they differ in important ways, including the patient population, services provided, location of care, and payment structure. Palliative care is available for patients with any stage of illness, from diagnosis to cure or end of life, and can be provided alongside disease-directed treatments that may be curative in intent. In contrast, hospice care is a form of palliative care for patients who are at the end of life, and to be eligible, a patient must have an estimated survival of less than 6 months and choose to forgo any further disease-directed or curative treatments. Key differences between palliative care and hospice are detailed in Table 1.2 .

To receive hospice care, two physicians must certify that a patient is terminally ill with an expected prognosis of 6 months or less, and a patient must elect the Medicare hospice benefit, which covers medications, equipment, and services related to their terminal diagnosis. When a patient elects this benefit, they waive further disease-directed or curative treatments for their terminal diagnosis. Although most palliative care services are currently provided in the inpatient hospital setting, the majority of hospice care takes place in the home, and nurses typically provide regular visits to manage symptoms under the supervision of a hospice physician. Patients enrolled in hospice spend more time out of the hospital near the end of life and receive less-aggressive medical care than those who do not use hospice. A cohort study of more than 80,000 patients with advanced cancer showed that patients who enrolled in hospice had fewer hospitalizations, intensive care unit (ICU) admissions, and invasive procedures at the end of life and significantly lower costs of medical care during the last 12 months of life. Bereaved family members also benefit from hospice care, reporting higher quality of care and lower rates of posttraumatic stress disorder than families of patients who died without hospice. ^,