Palliative care

Palliative care (from Latin root palliare "to cloak") is an interdisciplinary medical care-giving approach aimed at optimizing quality of life and mitigating or reducing suffering among people with serious, complex, and often terminal illnesses.^[1] Many definitions of palliative care exist. The World Health Organization (WHO) describes palliative care as:

[A]n 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.^[2]

Palliative medicine physician

Occupation
Occupation type	Specialty
Activity sectors	Medicine
Description
Education required	Doctor of Medicine (M.D.) Bachelor of Medicine, Bachelor of Surgery (e.g. MBBS or MBChB) UK: Certificate of Completion of Specialist Training (4 years full-time) (US only) Doctor of Osteopathic medicine (D.O.)
Fields of employment	Hospitals, clinics

Since the 1990s, many palliative care programs involved a disease-specific approach. However, as the field developed throughout the 2000s, the WHO began to take a broader patient-centered approach that suggests that the principles of palliative care should be applied as early as possible to any chronic and ultimately fatal illness.Sepúlveda C, Marlin A, Yoshida T, Ullrich A (August 2002). "Palliative Care: the World Health Organization's global perspective". Journal of Pain and Symptom Management. 24 (2): 91–96. doi:10.1016/S0885-3924(02)00440-2. PMID 12231124.</ref> This shift was important because if a disease-oriented approach is followed, the needs and preferences of the patient are not fully met and aspects of care, such as pain, quality of life, and social support, as well as spiritual and emotional needs, fail to be addressed.^[3] Rather, a patient-centered model prioritizes relief of suffering and tailors care to increase the quality of life for terminally ill patients.^[4]

Palliative care is appropriate for individuals with serious/chronic illnesses across the age spectrum and can be provided as the main goal of care or in tandem with curative treatment. It is ideally provided by interdisciplinary teams which can include physicians, nurses, occupational and physical therapists, psychologists, social workers, chaplains, and dietitians. Palliative care can be provided in a variety of contexts, including but not limited to: hospitals, outpatient clinics, and home settings. Although an important part of end-of-life care, palliative care is not limited to individuals nearing end of life and can be helpful at any stage of a complex or chronic illness.^[1][5]

Scope

Palliative care is able to improve healthcare quality in three sectors: Physical and emotional relief, strengthening of patient-physician communication and decision-making, and coordinated continuity of care across various healthcare settings, including hospital, home, and hospice.^[4] The overall goal of palliative care is to improve quality of life of individuals with serious illness, any life-threatening condition which either reduces an individual's daily function or quality of life or increases caregiver burden, through pain and symptom management, identification and support of caregiver needs, and care coordination. Palliative care can be delivered at any stage of illness alongside other treatments with curative or life-prolonging intent and is not restricted to people receiving end-of-life care.^[6][7] Historically, palliative care services were focused on individuals with incurable cancer, but this framework is now applied to other diseases, including severe heart failure,^[8] chronic obstructive pulmonary disease, multiple sclerosis and other neurodegenerative conditions.^[9] Forty million people each year are expected to need palliative care, with approximately 78% of this population living in low and middle income countries. However, only 14% of this population is able to receive this kind of care, with a majority in high-income countries, making this an important sector to pay attention to.^[10]

Palliative care can be initiated in a variety of care settings, including emergency rooms, hospitals, hospice facilities, or at home.^[11] For some severe disease processes, medical specialty professional organizations recommend initiating palliative care at the time of diagnosis or when disease-directed options would not improve a patient's prognosis. For example, the American Society of Clinical Oncology recommends that patients with advanced cancer should be "referred to interdisciplinary palliative care teams that provide inpatient and outpatient care early in the course of disease, alongside active treatment of their cancer" within eight weeks of diagnosis.^[6]

Appropriately engaging palliative care providers as a part of patient care improves overall symptom control, quality of life, and family satisfaction of care while reducing overall healthcare costs.^[12][13]

Palliative care vis-à-vis hospice care

See also: Hospice and palliative medicine and Hospice care in the United States

The distinction between palliative care and hospice differs depending on global context. In the United States, the term hospice refers specifically to a benefit provided by the federal government since 1982. Hospice care services and palliative care programs share similar goals of mitigating unpleasant symptoms, controlling pain, optimizing comfort, and addressing psychological distress. Hospice care focuses on comfort and psychological support and curative therapies are not pursued.^[14] Under the Medicare Hospice Benefit, individuals certified by two physicians to have less than six months to live (assuming a typical course) have access to specialized hospice services through various insurance programs (Medicare, Medicaid, and most health maintenance organizations and private insurers). An individual's hospice benefits are not revoked if that individual lives beyond a six-month period. In the United States, in order to be eligible for hospice, patients usually forego treatments aimed at cure, unless they are minors. This is to avoid what is called concurrent care, where two different clinicians are billing for the same service. In 2016 a movement began to extend the reach of concurrent care to adults who were eligible for hospice but not yet emotionally prepared to forego curative treatments.^[15]

Outside the United States, the term hospice usually refers to a building or institution that specializes in palliative care. These institutions provide care to patients with end of life and palliative care needs. In the common vernacular outside the United States, hospice care and palliative care are synonymous and are not contingent on different avenues of funding.^[16] Over 40% of all dying patients in the United States currently undergo hospice care.^[17] Most of the hospice care occurs at a home environment during the last weeks/months of their lives. Of those patients, 86.6% believe their care is "excellent".^[17] Hospice's philosophy is that death is a part of life, so it is personal and unique. Caregivers are encouraged to discuss death with the patients and encourage spiritual exploration (if they so wish).^[18]

History

The field of palliative care grew out of the hospice movement, which is commonly associated with Dame Cicely Saunders, who founded St. Christopher's Hospice for the terminally ill in 1967,^[19] and Elisabeth Kübler-Ross who published her seminal work "On Death and Dying" in 1969.^{[citation needed]} In 1974, Balfour Mount coined the term "palliative care".^[19] and Paul Henteleff became the director of a new "terminal care" unit at Saint Boniface Hospital in Winnipeg.^[20] In 1987, Declan Walsh established a palliative medicine service at the Cleveland Clinic Cancer Center in Ohio which later expanded to become the training site of the first palliative care clinical and research fellowship as well as the first acute pain and palliative care inpatient unit in the United States.^[21] The program evolved into The Harry R. Horvitz Center for Palliative Medicine which was designated as an international demonstration project by the World Health Organization and accredited by the European Society for Medical Oncology as an Integrated Center of Oncology and Palliative Care.^[22]

Women have played a central role in the historical development of palliative care, particularly through their work in hospice settings, which helped expand services beyond oncology to encompass frail elderly patients.^[23] These contributions established the foundation for geriatric palliative care as a distinct and expanding domain of global health.

Advances in palliative care have since inspired a dramatic increase in hospital-based palliative care programs. Notable research outcomes forwarding the implementation of palliative care programs include:

• Evidence that hospital palliative care consult teams are associated with significant hospital and overall health system cost savings.^[24][25]
• Evidence that palliative care services increase the likelihood of dying at home and reduce symptom burden without impacting on caregiver grief among the vast majority of Americans who prefer to die at home.^[26]
• Evidence that providing palliative care in tandem with standard oncologic care among patients with advanced cancer is associated with lower rates of depression, increased quality of life, and increased length of survival compared to those receiving standard oncologic care^[27][28] and may even prolong survival.^[27]

Over 90% of US hospitals with more than 300 beds have palliative care teams, yet only 17% of rural hospitals with 50 or more beds have palliative care teams.^[29] Hospice and palliative medicine has been a board certified sub-specialty of medicine in the United States since 2006. Additionally, in 2011, The Joint Commission began an Advanced Certification Program for Palliative Care that recognizes hospital inpatient programs demonstrating outstanding care and enhancement of the quality of life for people with serious illness.^[30]