Role of Palliative Care

Defining Palliative Care

Palliative care is defined by the World Health Organization as “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.” The field of palliative medicine was developed over the course of the late 20th century in response to increased awareness of the impact of suffering on quality of life in a context of care previously divided into disease-directed therapy or comfort care. Dame Cicely Saunders, one of the founders of the field, described four broad domains of palliative care: physical, i.e., symptoms; psychological; social; and spiritual. Palliative care can be delivered across a multitude of care contexts and by a variety of providers and should be viewed as distinct from hospice, defined later. Palliative care is also referred to in some contexts as supportive care.

According to some estimates, approximately 75% of patients approaching end of life would benefit from palliative care. Estimates of future needs suggest a 40% increase in these needs by 2040, driven predominantly by dementia and cancer. Illnesses treated by palliative care teams include heart disease, cancer, stroke, diabetes, renal disease, Parkinson’s disease, and Alzheimer’s disease.

The Multidisciplinary Team

One of the focal components of palliative care delivery is the multidisciplinary team model, which is designed to provide comprehensive symptom management and to address psychological, social, and spiritual needs. Although the specific members may vary by institution, a palliative care team often involves the patient and their supporters, a palliative physician, other providers on the patient’s care team, a nurse, social worker, pharmacist, and chaplain as well as volunteers. Physical and occupational therapists and dietitians are also frequently incorporated onto palliative care teams.

Palliative Care and Hospice

Whereas palliative care can be implemented at any stage in care, the term “hospice” specifically describes noncurative, comfort-targeted care delivered to patients nearing the end of life. Patients referred to hospice have a life expectancy of 6 months or less as assessed by two physicians. Many features of hospice care, including a multidisciplinary care team and a focus on comprehensive symptom management, are shared with palliative care; however, patients enrolled on hospice care no longer receive disease-directed therapies targeting their life-limiting illness. Hospice care is traditionally delivered in the home but can also be provided across a variety of other settings, including inpatient units and nursing homes. In the United States, hospice care is funded through a provision in Medicare. A comparison of palliative care and hospice is seen in Table 43.1 .

Primary versus Specialist Palliative Care

Although palliative medicine is a dedicated medical subspecialty, many of the basic domains of palliative care can be delivered by all providers. Primary palliative care has been defined as “the basic [palliative] skills and competencies required of all physicians and other health-care professionals.” In a seminal 2013 paper, Quill and Abernethy describe a series of skill sets that all clinicians should be capable of delivering, including basic management of pain, depression, anxiety, and other symptoms as well as basic discussions about prognosis, goals of treatment, suffering, and code status. Specialist consultation is recommended for guidance regarding management of refractory physical or complex psychological symptoms as well as for assistance with management of conflict among stakeholders and in cases of near-futility ( Table 43.2 ). These recommendations are congruent with consensus statements from the Center to Advance Palliative Care (CAPC), which further recommend that hospitals should develop screening assessments to identify unmet palliative needs in patients.

According to a recent study, some 8% of American adults aged 65 years or older would benefit from primary palliative care for management of advanced chronic illnesses, predominantly chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). Palliative-focused organizations such as CAPC, Vitaltalk, and Ariadne Labs have developed tools designed to inform and improve primary palliative care delivery by providing a paradigm for introducing difficult topics and decisions. Two examples of such tools are depicted in Table 43.3 .

Advance Care Planning

Advance care planning describes the engagement of patients and their family members around decisions that may need to be made regarding their current and future medical care. This process frequently includes discussion of current and anticipated medical needs with elicitation of the patient’s preferences for utilization of life-sustaining treatments; for example, cardiopulmonary resuscitation, prolonged mechanical ventilation, artificial nutrition and hydration, or comfort care. These preferences may be codified in the form of an advance directive. Palliative care providers may initiate or assist in advance care planning, particularly in complex or conflicted situations.

Symptom Management

Patients with life-limiting illnesses frequently experience a combination of symptoms, the nature of which may vary over the course of their illness. Disease-specific symptomatology is addressed later by disease. Table 43.4 describes symptoms and management strategies in detail. Table 43.5 specifically addresses management of cancer pain.