Why Palliative Care is More Than Just Care for the Dying

04/24/18
Timothy W Holder, MD

WBy working in a regional cancer hospital, I am continually reminded of the need for and the benefits of early palliative care for patients living with advanced, life-limiting illnesses. Palliative care improves patients’ quality of life while undergoing cancer therapy and helps them complete recommended treatments. Too often clinicians believe patients do not need palliative care since the “patient is not dying.” 

Hospice and Palliative Medicine is one of medicine’s newest specialties, having been recognized by the American Board of Medical Specialties in September 2006. Many physicians still mistakenly believe that hospice and palliative medicine are one and the same. Palliative care can be given concurrently with disease modifying and curative therapies. Hospice care is given within the last six months of a patient’s life when a patient foregoes further curative therapy.

The World Health Organization defines palliative care 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.” This definition suggests that palliative care is (1) appropriate for any patient who has a life-threatening illness (such as cancer; heart, lung, renal and liver diseases; and movement disorders), (2) is a way to prevent and alleviate suffering, and (3) should be started early within a patient’s disease course in order to maximize the identification and treatment of problems as they arise. Palliative care is an essential part of the co-management of life-threatening illness.

As early as 2010, Temel and colleagues (NEJM 2010;363:733-742) demonstrated that early palliative care improved symptoms and survival for patients living with stage IV lung cancer.  Since this groundbreaking study, other accumulated evidence promotes the integration of early palliative care for cancer and other chronic illnesses.

Currently, many professional associations recognize that all physicians who care for patients with life-limiting illnesses should have a basic or generalist palliative care skill set, including basic management of pain and non-pain symptoms, depression and anxiety, and basic discussions regarding prognosis, goals of care, suffering and code status. 

Specialist-level palliative care has a different skill set, including management of refractory pain and non-pain symptoms; managing more complex depression, anxiety, grief or existential distress; assisting with conflict resolution within families or between medical staff and families; and assistance in addressing cases of perceived futility.  

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The National Coalition for Hospice and Palliative Care published the Clinical Practice Guidelines for Quality Palliative Care in three prior editions (2004, 2009, and 2013). A national summit convened in June 2017 to discuss and define the essential elements for quality primary and specialty palliative care. The fourth edition of the National Consensus Project’s Clinical Guidelines will be published in the fall of 2018 with these latest recommendations.  

By concentrating on a generalist education for all physicians who provide medical care to patients with life-threatening illnesses with the consultation that specialty trained palliative care physicians can provide, patients with life-threatening illness will be able to receive appropriate palliative care early in their disease course and specialist-level of care when needed.