Palliative care: a guide for clinicians

By initiating a conversation, primary care providers can identify specific end-of-life needs and goals, manage symptoms, and coordinate care.
By initiating a conversation, primary care providers can identify specific end-of-life needs and goals, manage symptoms, and coordinate care.

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When primary care providers are working with very ill patients, initiation of the palliative care dialogue can be difficult for the patients and caregivers as well as for the clinicians. Starting the conversation on palliative and end-of-life (EOL) care is essential, particularly as the number of older US adults with complex chronic comorbidities increases. 

Consider the effect of the baby boomers alone (individuals born between 1946 and 1964). At present, there are 47.6 million people in the United States aged older than 65 years, a number that is predicted to increase to 72.8 million by the year 2030.1 As the incidence of chronic illnesses, such as chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), diabetes, dementia, and cancer, increases, individuals are living longer but with substantially more chronic illnesses than in the past.1

 

Little has changed since the publication of the Institute of Medicine (IOM) report on the state of EOL care in 2014,2 which warned of increasing medicalization, the depersonalization of death, and exorbitant costs. Singer et al recently reported that after more than a dozen years, patient and family suffering and quality of life are worse than formerly, with more pain, depression, and confusion occurring in patients currently than in the 1990s.3

According to the IOM report, many US adults have not addressed how to manage their own personal EOL care.2 The report calls for a national effort to implement quality EOL care, ecommending that not only physicians but also other providers, including the healthcare community and healthcare organizations, reach out to patients about evidence-based advanced care planning for personalized and quality EOL care. The US health system requires major reform to address quality care that is affordable and sustainable.2 Nurse practitioners, physician assistants, and nurses, along with primary care physicians, are in a unique position to implement quality standardized care and coordinate the EOL processes best suited for their primary care patients. 

Better access to palliative care is associated with a decreased symptom burden and better quality of life for patients at the EOL.4 Such access is also associated with a lower likelihood of dying in intensive care, an increase in care consistent with preferences, an increase in hospice use, and significant reductions in healthcare costs.5 According to the IOM report, Americans prefer to die at home with control over their healthcare decisions.2 Nonetheless, at present, there is little or no advanced care planning in place.2 

Palliative care vs hospice care

It is essential that primary care providers be able to educate their patients about palliative care as a standard component of overall health care. Furthermore, both providers and patients and their families benefit if they understand that palliative care and hospice are not synonymous. 

Hospice is a type of care and a philosophy designed to provide comprehensive, interdisciplinary, team-based palliative care for patients with “life-limiting illness with a prognosis of six months or less if the disease follows its natural course.”6 The palliative approach to care shares the holistic philosophy of hospice care but is broader in that care is provided to patients who may not be dying or who are unable to obtain or not interested in hospice services. Therefore, hospices overall deliver palliative services, but not all palliative care is delivered in hospices.6 The differences between palliative care and hospice care are summarized in Table 1.

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