Integrating Rehabilitative and Palliative Care Principles Within Acute Care Practice

Palliative Care in Acute Care Settings

The demand for palliative care is greater than ever before, largely driven by the increase in the aging global population and the accompanying increased burden of chronic disease, including stroke, ischemic heart disease, lung cancer, and other chronic progressive diseases—the leading causes of death globally. ^,

According to the WHO Global Health Estimates, more than 20 million people worldwide require palliative care at the end of their life every year, with the majority from the older population over 60 years of age. The major noncommunicable diseases that account for palliative care requirement are cardiovascular diseases, cancer, chronic obstructive pulmonary diseases, HIV/AIDS, and diabetes. The increased burden of chronic disease that accompanies the aging population shows an alarming trend for increased palliative care requirements. This raises the question of where will all the people requiring palliative care be accommodated? Would it be at home, hospice, hospital, or communal establishment for the care of the sick? Are we future-ready to deliver these services?

Acute care hospital settings include more than one-third of inpatients who need palliative care services. The requirement of such care in cancer patients is well recognized, but despite this, many cancer patients are missed by physicians and die in hospitals without being identified as needing palliative care. Failure to recognize palliative needs could result in unnecessary interventions for the patient, and prolonged and inappropriate hospitalization, thereby increasing the financial stress on the patient and associated family members, thus impacting their quality of life. There is a need to train health care professionals to identify patients who are facing their last stage of life and require palliative care. Patients with chronic diseases often present to the hospital with acute exacerbations. At times, it becomes challenging for health care professionals to distinguish whether these deteriorations are treatable or require a palliative approach. Therefore it is very important to introduce the concepts of palliative care to all health care professionals to sensitize them to effectively deliver quality of care that embraces timely onset of palliative care when indicated.

Delivery of Palliative Care

Several models exist for the delivery of palliative care, including hospice care, care homes, community care, hospice programs in partnership with hospitals, or within acute care hospitals. Palliative care can be provided at three different levels: (a) primary palliative care, which refers to basic skills and knowledge acquired by all the physicians; (b) secondary palliative care, which refers to specialist clinicians providing consultation and specialty care; and (c) tertiary palliative care, which refers to an academic medical center where specialist care is provided along with academic research and the training of students and professionals. The provision of secondary or tertiary levels of palliative care embraces a more comprehensive management for patients and their family members that incorporates control for physical symptoms, psychologic distress, and spiritual and financial issues during patient management.

Palliative care is conducted within the framework of interdisciplinary teamwork, which comprises physician, specialist clinician, nursing staff, social worker, physical and occupational therapist, dietitian, pharmacist, and spiritual counsellor. They can provide their services on a consultative basis or be integrated within the hospital services. ^,

Goals of Palliative Care in the Acute Care Setting

As in other fields of medicine, palliative care clinicians aim to provide comfort to their patients, and patients and caregivers are at the center of their management plans. It is important to discuss the goals of care with patients, their family members, and caregivers. A clear communication of goals will improve patient satisfaction, avoid aggressive interventions, reduce hospitalization, and help patients deal with pending family issues or events, if any. These factors contribute to better care through the end of life.

Transition or shift to palliative care also needs be addressed and studied carefully. Usually the patients are identified as palliative only a few months before death or at the final admission before death. The timing and frequency of providing palliative care needs to be reviewed so that it is not seen as the last option of management. There is an urgent need to understand that if introduced early in the disease trajectory, palliative care will be more beneficial to patients. ^,

What Is Delivered Within a Palliative Care Pathway?

In an acute hospital environment, the intent of treatment is curative, and the majority of health care professionals are attuned to this approach of management. It is critical to integrate the knowledge of recognizing the palliative needs early in the trajectory of life-threatening diseases. Palliative care aims to manage physical symptoms, and the psychologic and spiritual needs of patients to provide maximum comfort to patients, their caregivers, and family members. Some of the most commonly experienced symptoms include pain, dyspnea, cough, nausea, vomiting, constipation, fever, anxiety, insomnia, and delirium, and studies have shown better control of pain and other symptoms if the palliative approach begins along with the curative intent in the early course of disease. The timing of providing palliative care is important; at the end stage of life, the focus of care should be linked with the physical symptoms and not with a specific diagnosis. While managing patients with life-threatening conditions in an acute hospital setting, an early recognition of the palliative care needs of the patient is very critical. An early palliative care can help in maximizing the comfort of the patient and their caregivers.

Barriers to Palliative Care in the Acute Setting

Providing palliative care in an acute care setting, where needs of the patients are complex and varied, is challenging and many barriers may be encountered. These barriers may include the following.