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Top 10 Things Palliative Care Clinicians Wished Everyone Knew About Palliative Care

      Abstract

      With a focus on improving quality of life for patients, palliative care is a rapidly growing medical subspecialty focusing on the care of patients with serious illness. Basic symptom management, discussions of prognostic understanding, and eliciting treatment goals are essential pieces in the practice of nearly all physicians. Nonetheless, many complex patients with a serious, life-threatening illness benefit from consultation with palliative care specialists, who are trained and experienced in complex symptom management and challenging communication interactions, including medical decision making and aligning goals of care. This article discusses the changing role of modern palliative care, addresses common misconceptions, and presents an argument for early integration of palliative care in the treatment of patients dealing with serious illness.

      Abbreviations and Acronyms:

      CHF (congestive heart failure), COPD (chronic obstructive pulmonary disease)
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      Learning Objectives: On completion of this article, you should be able to (1) employ expanded definitions of palliative care in conversations with your patients, (2) describe the benefits of early integration of palliative care in severe illness, and (3) identify common symptoms experienced by patients with severe and life-threatening illness and understand their prevalence.
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      In their editorial and administrative roles, William L. Lanier, Jr, MD, Terry L. Jopke, Kimberly D. Sankey, and Nicki M. Smith, MPA, have control of the content of this program but have no relevant financial relationship(s) with industry.
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      1. Palliative Care Can Help Address the Multifaceted Aspects of Care for Patients Facing a Serious Illness

      Palliative care is specialized medical care focused on identifying and relieving the pain and other symptoms of a serious illness. Its goal is to improve quality of life for such patients at any stage of illness regardless of current treatment plans, and it is tailored to the needs of the patient and the family. Given that patients and their illnesses do not exist in a vacuum, palliative care is meant to be an active and comprehensive form of medical care that targets the physical, emotional, and social aspects of a patient's disease experience.
      • Quill T.E.
      • Abernethy A.P.
      Generalist plus specialist palliative care–creating a more sustainable model.
      Understanding how illness affects patients' lives, both mentally and physically, is a critical aspect of a palliative care evaluation.
      Adhering to this philosophy of patient- and family-centered care requires an interdisciplinary team of health care professionals, including physicians, nurses, advanced-practice clinicians (eg, nurse practitioners and physician assistants), social workers, chaplains, and pharmacists. Access to palliative care is rapidly growing and is available for many patients with a serious illness. More than 85% of US hospitals with 300 or more beds have palliative care consultative services,
      • Morrison R.S.
      • Augustin R.
      • Souvanna P.
      • Meier D.E.
      America's care of serious illness: a state-by-state report card on access to palliative care in our nation's hospitals.
      and such services are federally mandated in all Department of Veterans Affairs medical centers.
      • Goldsmith B.
      • Dietrich J.
      • Du Q.
      • Morrison R.S.
      Variability in access to hospital palliative care in the United States.
      As this subspecialty grows, it is important for referring clinicians to understand the scope, timing, and misconceptions about palliative care referrals.

      2. Palliative Care is Appropriate at Any Stage of Serious Illness

      Early models of palliative care's role conveyed both an ideologic and a chronologic separation between life-prolonging care (eg, chemotherapy and hemodialysis) and palliative care. Palliative care was often errantly equated with only providing end-of-life care. In practice, this led (and unfortunately still leads) to palliative care involvement occurring late in an illness when such disease-modifying interventions are either no longer an option or no longer desired by the patient.
      In fact, the goals of palliative care, such as improving quality of life through comprehensive symptom management and patient and family support, are ideally applied throughout the trajectory of a serious illness. An intensive focus on symptom management, psychosocial support, and attention to advance care planning provided by early palliative care integration has benefits for patients, families, and fellow caregivers. Conversely, there is a growing recognition that increased intensity of invasive interventions in late stages of illness does not necessarily prolong survival or reliably improve quality of life.
      • Wright A.A.
      • Zhang B.
      • Ray A.
      • et al.
      Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment.
      In addition, there is now convincing evidence that early integration of palliative care, including active symptom management, provided concurrently with disease-modifying care can improve quality of life, minimize such invasive interventions, and potentially have a measureable mortality benefit.
      • Temel J.S.
      • Greer J.A.
      • Muzikansky A.
      • et al.
      Early palliative care for patients with metastatic non-small-cell lung cancer.
      • Greer J.A.
      • Pirl W.F.
      • Jackson V.A.
      • et al.
      Effect of early palliative care on chemotherapy use and end-of-life care in patients with metastatic non-small-cell lung cancer.
      • Zhang B.
      • Wright A.A.
      • Huskamp H.A.
      • et al.
      Health care costs in the last week of life: associations with end-of-life conversations.

      3. Early Integration of Palliative Care is Becoming the New Standard of Care for Patients With Advanced Cancer

      Support for an expanded and upstream role for palliative care is well supported by recent data from the oncologic literature, in which well-designed studies have found that early integration can lead to more optimal clinical outcomes than prior archetypes of late-stage involvement.
      • Temel J.S.
      • Greer J.A.
      • Muzikansky A.
      • et al.
      Early palliative care for patients with metastatic non-small-cell lung cancer.
      • Bakitas M.
      • Lyons K.D.
      • Hegel M.T.
      • et al.
      Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer.
      A recent landmark phase 3 randomized controlled trial reported that early involvement of palliative care at the time of initial diagnosis in patients with advanced non–small cell lung cancer undergoing disease-targeted therapy led to improved outcomes in terms of quality of life, mood, and less aggressive interventions at the end of life.
      • Temel J.S.
      • Greer J.A.
      • Muzikansky A.
      • et al.
      Early palliative care for patients with metastatic non-small-cell lung cancer.
      Notably, patients in the palliative care arm lived 2.7 months longer than patients in the standard care arm, a statistically significant and unanticipated outcome. When involved early in the disease course, initial palliative care visits focused on symptom management and prognostic awareness, with goals of care discussions gaining added importance later in the disease course.
      • Yoong J.
      • Park E.R.
      • Greer J.A.
      • et al.
      Early palliative care in advanced lung cancer: a qualitative study.
      On the basis of these and other findings, in 2012, the American Society of Clinical Oncology recommended that palliative care be integrated early in the illness for patients with metastatic cancer and/or high symptom burden.
      • Smith T.J.
      • Temin S.
      • Alesi E.R.
      • et al.
      American Society of Clinical Oncology provisional clinical opinion: the integration of palliative care into standard oncology care.
      Similarly, the National Comprehensive Cancer Network has recommended that institutions develop processes to integrate and offer palliative care in conjunction with disease-modifying therapies and that patients be screened at regular intervals to assess for benefit of palliative care involvement.
      • Levy M.H.
      • Adolph M.D.
      • Back A.
      • et al.
      NCCN (National Comprehensive Cancer Network)
      Palliative care.
      International bodies, such as the World Health Organization, advocate early involvement of palliative care in tandem with therapies intended to prolong life, describing palliative care as an essential part of cancer control.

      World Health Organization. Palliative Care. 2013. http://www.who.int/cancer/palliative/en/. Accessed July 8, 2013.

      The new standard of comprehensive oncologic care includes the integration of early palliative care provided alongside cancer-targeted therapy.

      4. Moving Beyond Cancer: Palliative Care can be Beneficial for Many Chronic Diseases

      Although palliative care is increasingly integrated into contemporary cancer care, barriers to involving palliative care into the care of nononcologic patients with a serious illness remain. Patients with severe chronic obstructive pulmonary disease (COPD), advanced congestive heart failure (CHF), pulmonary hypertension, end-stage renal disease, and neurodegenerative diseases (eg, amyotrophic lateral sclerosis and Huntington disease) have a heavy symptom burden.
      • Blinderman C.D.
      • Homel P.
      • Billings J.A.
      • Portenoy R.K.
      • Tennstedt S.L.
      Symptom distress and quality of life in patients with advanced congestive heart failure.
      • Blinderman C.D.
      • Homel P.
      • Billings J.A.
      • Tennstedt S.
      • Portenoy R.K.
      Symptom distress and quality of life in patients with advanced chronic obstructive pulmonary disease.
      • Davison S.N.
      Pain in hemodialysis patients: prevalence, cause, severity, and management.
      • Chiò A.
      • Canosa A.
      • Gallo S.
      • et al.
      Pain in amyotrophic lateral sclerosis: a population-based controlled study.
      These patients, along with those with critical illness in intensive care units, may benefit from palliative care involvement in aggressive symptom management, psychosocial and spiritual support, shared decision making, continuity of care, and staff support.
      • Nelson J.E.
      • Azoulay E.
      • Curtis J.R.
      • et al.
      Palliative care in the ICU.
      This benefit is increasingly recognized by a variety of specialty societies calling for early palliative care integration.
      • Smith T.J.
      • Temin S.
      • Alesi E.R.
      • et al.
      American Society of Clinical Oncology provisional clinical opinion: the integration of palliative care into standard oncology care.
      • Lanken P.N.
      • Terry P.B.
      • DeLisser H.M.
      • et al.
      An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses.
      • Selecky P.A.
      Palliative and end-of-life care for patients with cardiopulmonary diseases: American College of Chest Physicians position statement.

      5. Palliative Care Teams Manage Total Pain

      Pain among cancer patients is well described, affecting 30% to 60% of patients receiving active, cancer-directed treatment and 70% to 90% of those with advanced-stage disease.
      • van den Beuken-van Everdingen M.H.J.
      • de Rijke J.M.
      • Kessels A.G.
      • Schouten H.C.
      • van Kleef M.
      • Patijn J.
      Prevalence of pain in patients with cancer: a systematic review of the past 40 years.
      • Portenoy R.K.
      • Lesage P.
      Management of cancer pain.
      Functional status and quality of life are significantly affected by inadequate treatment of pain. Despite the known prevalence and effect of cancer pain, it is often undertreated, with one review suggesting that 43% of cancer patients receive suboptimal analgesia.
      • Deandrea S.
      • Montanari M.
      • Moja L.
      • Apolone G.
      Prevalence of undertreatment in cancer pain: a review of published literature.
      Although cancer-related pain is a well-known entity among clinicians, incidence of pain in patients with other serious illnesses is often underappreciated. More than 50% of patients with advanced COPD and up to 85% of patients with severe CHF have pain symptoms, and approximately one-third of these patients have severe pain.
      • Blinderman C.D.
      • Homel P.
      • Billings J.A.
      • Tennstedt S.
      • Portenoy R.K.
      Symptom distress and quality of life in patients with advanced chronic obstructive pulmonary disease.
      • Goodlin S.J.
      • Wingate S.
      • Albert N.M.
      • et al.
      Investigating pain in heart failure patients: the Pain Assessment, Incidence, and Nature in Heart Failure (PAIN-HF) study.
      Half of all patients with diseases as different as amyotrophic lateral sclerosis and end-stage renal disease undergoing hemodialysis have undertreated pain.
      • Davison S.N.
      Pain in hemodialysis patients: prevalence, cause, severity, and management.
      • Chiò A.
      • Canosa A.
      • Gallo S.
      • et al.
      Pain in amyotrophic lateral sclerosis: a population-based controlled study.
      • Claxton R.N.
      • Blackhall L.
      • Weisbord S.D.
      • Holley J.L.
      Undertreatment of symptoms in patients on maintenance hemodialysis.
      Palliative care clinicians have training and expertise in the management of pain syndromes associated with chronic and severe illness. Experienced with the use of opioids and nonopioid adjuvants, palliative care clinicians are well versed in management of pain using a broad array of pharmacologic and nonpharmacologic therapies. With active surveillance and treatment, most patients with a serious illness can obtain effective analgesia.
      • Meuser T.
      • Pietruck C.
      • Radbruch L.
      • Stute P.
      • Lehmann K.A.
      • Grond S.
      Symptoms during cancer pain treatment following WHO-guidelines: a longitudinal follow-up study of symptom prevalence, severity and etiology.
      Many institutions have access to the expertise of interventional pain clinicians, and there can be uncertainty as to which service to involve for a given patient with pain. Palliative care clinicians may be most helpful when dealing with pain in the setting of a serious or life-threatening illness or when there are concomitant nonpain symptoms that affect that patient's experience of pain (eg, nausea, anxiety, and depression). In addition, given that many patients face complex psychosocial and spiritual issues related to their serious illness and its fluctuations, palliative care teams are well placed to address what Dame Cicely Saunders described as “total pain,” defined as physical, social, psychological, and spiritual suffering.
      • Richmond C.
      Dame Cicely Saunders.
      At our respective institutions, palliative care and pain management teams often collaborate on challenging cases. Palliative care clinicians can also help identify and refer patients for interventional pain therapies, such as intrathecal drug delivery or neurolytic blocks for refractory cancer pain, and assist in weighing goals of care of such interventions.

      6. Patients With a Serious Illness Have Many Symptoms That Palliative Care Teams Can Help Address

      Many patients with chronic and severe illness endure many nonpain symptoms.
      • Meuser T.
      • Pietruck C.
      • Radbruch L.
      • Stute P.
      • Lehmann K.A.
      • Grond S.
      Symptoms during cancer pain treatment following WHO-guidelines: a longitudinal follow-up study of symptom prevalence, severity and etiology.
      Nausea is a distressing symptom that affects as many as 70% of patients with advanced cancer and up to 50% of patients with noncancer diagnoses, such as CHF, COPD, and renal failure.
      • Harris D.G.
      Nausea and vomiting in advanced cancer.
      Delirium occurs in up to 85% of terminally ill cancer patients.
      • Breitbart W.
      • Bruera E.
      • Chochinov H.
      • Lynch M.
      Neuropsychiatric syndromes and psychological symptoms in patients with advanced cancer.
      Delirium can not only affect the quality of life of patients but can also have a lingering emotional effect on family and caregivers.
      • Breitbart W.
      • Gibson C.
      • Tremblay A.
      The delirium experience: delirium recall and delirium-related distress in hospitalized patients with cancer, their spouses/caregivers, and their nurses.
      • Buss M.K.
      • Vanderwerker L.C.
      • Inouye S.K.
      • Zhang B.
      • Block S.D.
      • Prigerson H.G.
      Associations between caregiver-perceived delirium in patients with cancer and generalized anxiety in their caregivers.
      Fatigue affects two-thirds of patients with advanced CHF,
      • Blinderman C.D.
      • Homel P.
      • Billings J.A.
      • Portenoy R.K.
      • Tennstedt S.L.
      Symptom distress and quality of life in patients with advanced congestive heart failure.
      more than 70% of patients with advanced COPD,
      • Blinderman C.D.
      • Homel P.
      • Billings J.A.
      • Tennstedt S.
      • Portenoy R.K.
      Symptom distress and quality of life in patients with advanced chronic obstructive pulmonary disease.
      and 80% of cancer patients receiving chemotherapy and/or radiotherapy.
      • Henry D.H.
      • Viswanathan H.N.
      • Elkin E.P.
      • Traina S.
      • Wade S.
      • Cella D.
      Symptoms and treatment burden associated with cancer treatment: results from a cross-sectional national survey in the U.S.
      Dyspnea affects up to 90% of patients with end-stage lung disease,
      • Blinderman C.D.
      • Homel P.
      • Billings J.A.
      • Tennstedt S.
      • Portenoy R.K.
      Symptom distress and quality of life in patients with advanced chronic obstructive pulmonary disease.
      70% of patients with cancer,
      • Cachia E.
      • Ahmedzai S.H.
      Breathlessness in cancer patients.
      nearly half of patients with end-stage renal disease,
      • Janssen D.
      • Spruit M.
      • Wouters E.
      • Schols J.
      Daily symptom burden in end-stage chronic organ failure: a systematic review.
      and more than 60% of patients with end-stage CHF.
      • Levenson J.W.
      • McCarthy E.P.
      • Lynn J.
      • Davis R.B.
      • Phillips R.S.
      The last six months of life for patients with congestive heart failure.
      Experienced with management of such nonpain symptoms, palliative care clinicians can not only help identify and address the many symptoms that affect a patient's quality of life during an illness but can also ameliorate the effect those symptoms have on caregivers.

      7. Palliative Care Can Help Address the Emotional Impact of Serious Illness on Patients and Their Families

      Psychological distress is common among patients with a serious illness and is strongly correlated with impaired quality of life.
      • Block S.D.
      American College of Physicians - American Society of Internal Medicine
      Assessing and managing depression in the terminally ill patient. ACP-ASIM End-of-Life Care Consensus Panel.
      Importantly, although clinical depression is not a normal part of the dying process, preparatory grief is experienced by most dying patients. Preparatory grief occurs when people prepare for their death by mourning impending losses, including loss of function, anticipated missed events (such as a child's wedding), and separation from loved ones.
      • Block S.D.
      American College of Physicians - American Society of Internal Medicine
      Assessing and managing depression in the terminally ill patient. ACP-ASIM End-of-Life Care Consensus Panel.
      • Periyakoil V.S.
      • Hallenbeck J.
      Identifying and managing preparatory grief and depression at the end of life.
      Distinguishing between normal preparatory grieving and clinical depression is a substantial clinical challenge, given the similarity of many of the signs and symptoms. Moreover, many of the neurovegetative symptoms we commonly associate with depression are a normal part of severe illness.
      • Block S.D.
      American College of Physicians - American Society of Internal Medicine
      Assessing and managing depression in the terminally ill patient. ACP-ASIM End-of-Life Care Consensus Panel.
      • Periyakoil V.S.
      • Hallenbeck J.
      Identifying and managing preparatory grief and depression at the end of life.
      Palliative care teams can help providers with these essential distinctions, allowing for earlier interventions given that depression is associated with substantial suffering and even decreased longevity, requiring prompt treatment, even in the very late stages of an illness.
      • Block S.D.
      American College of Physicians - American Society of Internal Medicine
      Assessing and managing depression in the terminally ill patient. ACP-ASIM End-of-Life Care Consensus Panel.
      Beyond identification and treatment for depression, palliative care teams work to improve mood through aggressive symptom management, as well as psychosocial and spiritual support. Improving the management of other symptoms, such as severe pain or intractable nausea, can markedly improve a patient's mood, sense of hope, and quality of life.
      • Block S.D.
      American College of Physicians - American Society of Internal Medicine
      Assessing and managing depression in the terminally ill patient. ACP-ASIM End-of-Life Care Consensus Panel.
      • Block S.D.
      Psychological issues in end-of-life care.
      Many patients facing the end of their lives are able to achieve a high degree of equanimity and acceptance of their illness and impending death. Factors that contribute to effective coping and achieving peace include good communication and trust among the patient, family, and clinical team; opportunities for the patient to share fears and concerns; and meticulous attention to physical symptoms and psychological and spiritual concerns.
      • Block S.D.
      Psychological issues in end-of-life care.
      The opportunity for patients to share hopes, worries, and what their illness means to them is therapeutic for many patients.
      • Block S.D.
      Psychological issues in end-of-life care.
      It is this combination of meticulous attention to both psychosocial distress and physical symptoms that is at the heart of palliative care.

      8. Palliative Care Teams Assist in Complex Communication Interactions

      Although emotionally intense conversations with patients with serious illness are part of the everyday work of the palliative medicine practitioner, the importance of excellent communication skills extends to the work of all health care practitioners. This type of patient-centered, empathic communication between patients and physicians has been found to improve patient satisfaction, adherence to therapy, and health outcomes.
      • Weng H.-C.
      • Steed J.F.
      • Yu S.-W.
      • et al.
      The effect of surgeon empathy and emotional intelligence on patient satisfaction.
      • Mercer S.W.
      • Jani B.D.
      • Maxwell M.
      • Wong S.Y.S.
      • Watt G.C.M.
      Patient enablement requires physician empathy: a cross-sectional study of general practice consultations in areas of high and low socioeconomic deprivation in Scotland.
      • Riess H.
      • Kelley J.M.
      • Bailey R.W.
      • Dunn E.J.
      • Phillips M.
      Empathy training for resident physicians: a randomized controlled trial of a neuroscience-informed curriculum.
      Strong emotions are a normal response to discussing stressful, life-changing events, such as being sick.
      • Jackson V.A.
      • Back A.L.
      Teaching communication skills using role-play: an experience-based guide for educators.
      • Back A.
      • Arnold R.
      • Tulsky J.
      Mastering Communication with Seriously Ill Patients: Balancing Honesty With Empathy and Hope.
      Patients' emotions are important pieces of clinical data that can teach us what patients understand about their medical circumstances and what kind of additional support or information they might need. The challenge for all clinicians is to be present with patients and respond to their emotions without trying to “fix” it.
      • Jackson V.A.
      • Back A.L.
      Teaching communication skills using role-play: an experience-based guide for educators.
      • Back A.
      • Arnold R.
      • Tulsky J.
      Mastering Communication with Seriously Ill Patients: Balancing Honesty With Empathy and Hope.
      Responding to emotion and demonstrating empathy align us with our patients and make them feel heard.
      • Back A.
      • Arnold R.
      • Tulsky J.
      Mastering Communication with Seriously Ill Patients: Balancing Honesty With Empathy and Hope.
      Nonverbal responses to emotion include such actions as leaning forward, moving the chair closer, making eye contact, and handing the family tissues. Verbal responses of empathy include expressions of support, understanding, and respect.
      • Back A.
      • Arnold R.
      • Tulsky J.
      Mastering Communication with Seriously Ill Patients: Balancing Honesty With Empathy and Hope.
      • Evans W.G.
      • Tulsky J.A.
      • Back A.L.
      • Arnold R.M.
      Communication at times of transitions: how to help patients cope with loss and re-define hope.
      How clinicians respond to these emotions and the words used can have powerful and unintended consequences. Our words are most effective when they are clear and align us with the patient. Phrases such as “there is nothing more we can do” or “withdrawing care” not only damage the patient-provider relationship,
      • Pantilat S.Z.
      Communicating with seriously ill patients: better words to say.
      but they also fail to reflect clinical reality. We are always providing care and working to optimize quality of life, regardless of whether or not further life-prolongation is possible. Palliative care clinicians can help reinforce this notion of ongoing care, working with collaborating providers to manage distressing symptoms and support the patient and family, even when life-prolonging therapies are no longer available or desired.

      9. Addressing the Barriers to Palliative Care Involvement: Patients' Hopes and Values Equate to More than a Cure

      Concerns that a patient “is not ready for palliative care” often center around a worry that palliative care involvement signals a “beginning of the end” and will take away a patient's hope. Patients and their families may echo these concerns and resist meeting with the palliative care team. Yet, data suggest that engaging in discussions about one's illness, wishes, and the benefits and burdens of disease-modifying therapies helps patients make better decisions about the types of health care they wish to receive. In addition, improved understanding of one's illness and associated prognosis leads patients to make different decisions about the types of care they wish to receive.
      • Wright A.A.
      • Zhang B.
      • Ray A.
      • et al.
      Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment.
      • Fried T.R.
      • Bradley E.H.
      • Towle V.R.
      • Allore H.
      Understanding the treatment preferences of seriously ill patients.
      Furthermore, such discussions do not seem to cause psychological harm and may be associated with improved patient quality of life and family member bereavement.
      • Wright A.A.
      • Zhang B.
      • Ray A.
      • et al.
      Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment.
      Although resistance to upstream palliative care involvement can stem from both patients and clinicians, the root of this resistance is often a misunderstanding of the role of palliative care. Public opinion data commissioned in 2011 reveal that almost 80% of respondents lacked knowledge about the role of palliative care. However, many physicians continue to equate palliative care with end-of-life and/or hospice care. After hearing that palliative care is specialized medical care focused on alleviating pain and other symptoms associated with serious illness and that it ideally occurs concurrently with life-prolonging care, more than 90% of respondents believed that patients with a serious illness should be educated about palliative care. Respondents also believed that palliative care should be available alongside curative-intent therapies and is appropriate at any age and any stage of illness.

      Center to Advance Palliative Care and American Cancer Society. 2011 Public Opinion Research on Palliative Care: A Report Based on Research Public Opinion Strategies. www.capc.org. Accessed July 8, 2013.

      In considering the growth of palliative care teams, clinicians may rightfully question which palliative care skills should simply be part of “good medical care.” Many of the skills used by palliative care clinicians are indeed aspects of high-quality care that should be provided by a patient's primary care clinician or primary specialty caregiver (eg, pulmonologist or cardiologist). While training in these areas has traditionally been neglected in medical education, the increasing numbers of patients facing a serious illness require that all providers develop basic competency in symptom assessment and initial management along with basic discussions about goals of treatment and prognosis.
      • Quill T.E.
      • Abernethy A.P.
      Generalist plus specialist palliative care–creating a more sustainable model.
      Subspecialty level palliative care is needed when treating complex pain and nonpain symptoms, managing complex and/or highly conflict-rich communication interactions with patients and families, and responding to complicated, multifaceted psychosocial and/or spiritual distress. Such challenging clinical tasks require specialty training along with dedicated time and space to focus on such concerns. The Table provides examples of reasons to refer patients for palliative care consultation and collaboration.
      TablePutting It All Together: Practical Reasons to Call Palliative Care Specialists
      Assistance with complex symptom management
      • Managing escalating or refractory symptoms (eg, pain, dyspnea, and nausea)
      • Complex pharmacologic management in patients facing a life-limiting illness (eg, opioid infusions, opioid rotations, patient-controlled analgesia, methadone initiation, and ketamine initiation)
      • Addressing complex depression, anxiety, grief, and existential, spiritual, or psychosocial distress
      • Respite and/or palliative sedation for intractable symptoms
      Care of complex, severely ill patients over time
      • New diagnosis with metastatic cancer and/or malignancy with high symptom burden
      • Frequent hospital admissions for the same diagnosis of a serious illness
      • Intensive care unit admission with metastatic cancer
      • Intensive care unit admission with poor prognosis
      • Prolonged intensive care unit stay
      Assistance with medical decision making and determining goals of care
      • Discussing transitions in care
      • Complex and/or evolving goals of care discussions
      • Assistance with conflict resolution regarding goals or methods of treatment, whether that conflict is within the family, between the family and the medical teams, or between treatment teams
      • Redefining hope, in the setting of complex illness
      • Complex code status discussions
      • Assistance with managing patient and/or family conflict or complex social issues
      • Ethical dilemmas
      Questions regarding future planning needs
      • Determining and discussing prognosis, where desired
      • Care and planning in the setting of advanced illness
        • Consider referral when one would answer “yes” to the question, “Would I be surprised if my patient died within 12 months?”
      • Discussing issues pertaining to artificial feeding or hydration
      • Determining present and future care needs
      • Help with determining hospice eligibility and providing hospice education

      10. Palliative Care Enhances Health Care Value

      How does palliative care fit into a health care system in which attention has shifted to improving quality of a care without also increasing cost? Interestingly, increasing health care expenditures have not been associated with better care at the end of life, when patients and families may continue to experience untreated symptoms, caregiver distress, and poor quality of life.
      • Zhang B.
      • Wright A.A.
      • Huskamp H.A.
      • et al.
      Health care costs in the last week of life: associations with end-of-life conversations.
      • Teno J.M.
      • Clarridge B.R.
      • Casey V.
      • et al.
      Family perspectives on end-of-life care at the last place of care.
      Conversely, analysis of more than 5000 patients suggests that palliative care involvement has been associated with a cost savings of $1696 per admission for patients who survived hospitalization and $4908 per admission for patients who did not survive hospitalization. Palliative care involvement was associated with significant reductions in pharmacy, laboratory, and intensive care costs.
      • Morrison R.S.
      • Penrod J.D.
      • Cassel J.B.
      • et al.
      Cost savings associated with US hospital palliative care consultation programs.
      Other studies have found a cost benefit with palliative care involvement associated with reductions in intensive care unit length of stay and a variety of other cost-avoidance mechanisms.
      • Norton S.A.
      • Hogan L.A.
      • Holloway R.G.
      • Temkin-Greener H.
      • Buckley M.J.
      • Quill T.E.
      Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients.
      • Campbell M.L.
      • Guzman J.A.
      A proactive approach to improve end-of-life care in a medical intensive care unit for patients with terminal dementia.
      • Albanese T.H.
      • Radwany S.M.
      • Mason H.
      • Gayomali C.
      • Dieter K.
      Assessing the financial impact of an inpatient acute palliative care unit in a tertiary care teaching hospital.
      Notably, cost improvement associated with palliative care involvement has not come at the expense of quality of care. In fact, the opposite seems to be true. Palliative care is associated with improvement in quality of life,
      • Temel J.S.
      • Greer J.A.
      • Muzikansky A.
      • et al.
      Early palliative care for patients with metastatic non-small-cell lung cancer.
      mood,
      • Temel J.S.
      • Greer J.A.
      • Muzikansky A.
      • et al.
      Early palliative care for patients with metastatic non-small-cell lung cancer.
      and patient and family satisfaction.
      • Casarett D.
      • Johnson M.
      • Smith D.
      • Richardson D.
      The optimal delivery of palliative care: a national comparison of the outcomes of consultation teams vs inpatient units.
      Hence, given that 90 million Americans currently live with a serious and life-threatening illness, a number that is only likely to increase, palliative care will play an integral role in a changing health care landscape that is increasingly focused on providing higher-quality care at a lower cost.
      The Table provides some examples of common reasons to seek palliative care consultation. In addition, the Center to Advance Palliative Care website (www.getpalliativecare.org) provides information for clinicians, patients, and caregivers to learn more about palliative care and its role in helping patients with a serious or life-threatening illness.

      Conclusion

      Palliative care is a multidisciplinary specialty focused on improving the quality of life of patients with serious illness and their families. Its model of care is centered on reducing symptom burden, attending to psychosocial needs, and working with patients, families, and clinicians to align care with a patient's goals. Rather than merely end-of-life care, palliative care teams are available to help clinicians care for patients and their families at any age and any stage of a serious illness, including those who are actively undergoing disease-targeted therapies. Notably, palliative care seems to yield greater benefit for patients and their families when involved early in a disease course. This involvement leads to more effective and efficient care associated with cost savings, not less care.

      Supplemental Online Material

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