Palliative Care


Article Author:
Dac Teoli


Article Editor:
Virginia Kalish


Editors In Chief:
Casey Ciresi


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
6/28/2019 12:07:51 PM

Introduction

The World Health Organization characterizes the field of palliative care as a form of specialized medical care which aims to optimize the quality of life and alleviate the suffering of patients. One of the primary ways to achieve this is through early identification and treatment of new symptoms along with management of those that prove refractory. Palliative care addresses the physical, psychosocial, and spiritual aspects of patients with a life-threatening disease by employing an interprofessional team approach. A palliative, or supportive, team is comprised of a wide array of professionals, including the palliative physician, nurse, social worker, chaplain, and pharmacist.  Of note, palliation consists of comprehensive care provided to patients with life-limiting illness and should not be considered an alternative to failed life-prolonging care.

The physicians who specialize in palliative care have often completed a fellowship in hospice and palliative medicine (HPM). As an official subspecialty recognized by the American Board of Medical Specialties (ABMS), completion of a fellowship is needed to sit for the ABMS or American Osteopathic Association (AOA) board certification examinations.

Currently, the following specialties are pathways to completing an HPM fellowship: internal medicine, family medicine, emergency medicine, psychiatry, neurology, surgery, pediatrics, radiology, OBGYN, anesthesiology, and physical medicine and rehabilitation. Therefore, palliative care physicians most often have underlying formal training in at least one of these specialties. Of note, almost always pediatric palliative care physicians have completed a residency in pediatrics before subspecializing.[1][2]

Function

The primary goal of the palliative care interprofessional team, consisting of nursing, spiritual care, social work, and pharmacy, is to improve the quality of life of patients and their families. As alluded to above, it is a common misconception that palliative care only concentrates on physical needs. In reality, there is a wide net of consideration cast out to assess psychological, cultural, ethical, legal, psychiatric, religious, and social needs as well.

Nevertheless, management of symptoms, whether commonly encountered or rare, is a central focus of the field. Some of these symptoms include pain, dyspnea, nausea, anxiety, depression, and fatigue. For the treatment of acute pain, identifying the etiology and intervening therapeutically when possible is the objective. Depending on the situation, pain medication such as opiates is usually a valuable mainstay. Additionally, opioids may be necessary for the management of dyspnea and air hunger; again, providers should determine the etiology.  Preventative measures should be considered such as prescribing stimulant laxatives to patients at high risk of developing constipation (whether from utilizing opiates, being dehydrated, or decreased oral intake). Additional examples of symptomatic management include the use of steroids to relieve bone pain and performance of a therapeutic thoracentesis for symptomatic pleural effusions. Anticholinergic agents, such as atropine, can be administered to assist in secretion reduction. Furthermore, dopaminergic medications which target the chemoreceptor trigger zone, such as haloperidol or metoclopramide, are considered first-line agents for nausea and vomiting at the end of life.[2][3]

Issues of Concern

Hospice was introduced to the United States in 1971 and variably embraced and evolved geographically throughout North America.  The hospice movement was controversial, creating myths and misconceptions about palliative care. Erroneous believes that palliative care was only intended for patients that are dying, that entering hospice was akin to "giving up," and that palliative care hastened death developed from the medicalization of the dying process, having moved out of the family home to hospitals and nursing homes. These misconceptions can be properly dispelled. Palliative care does indeed look to provide comfort to patients that are dying; however, palliative care encompasses all individuals and their families suffering from chronic or life-limiting ailments regardless of age, gender, nationality, race, creed, sexual orientation, disability, diagnosis, or ability to pay. Palliative services are not for when a patient's primary physician has “given up”; instead services are requested when the primary physician feels that integrating the palliative team into the patient’s care would improve the quality of that patient’s life. Palliative care focuses on easing a person’s suffering before, during, and, for the family, after the patient dies. Further, these services are not limited to a hospital; there are many community clinic and in-home opportunities from which to benefit when services are needed.[3][4]

Clinical Significance

Palliative care correlates with improvement in symptom control, patient satisfaction, and understanding of diagnosis and prognosis.  A goal of palliation is to align the patients’ values and preferences for treatment while attending to family members’ concerns and desires. Family support through respite care can be an immense help to caregivers providing round-the-clock care for their loved one.  Furthermore, palliative care consultation can be of support for clinicians managing the complexities of patients’ comorbidities.[4]

Other Issues

As a practitioner of palliative care, the physician must know about serious and complex illnesses and be adept at managing palliative emergencies. The physician becomes skillful in prognostication and advanced care planning. She or he collaborates deftly with the interdisciplinary team to care for the whole patient, focusing on body, mind, spiritual, and social needs. Using mastered techniques in communication, palliative physicians facilitate complex decision-making, consultation, and transitions of care. Often palliative care physicians are seasoned in the logistical aspects of care delivery, including services, payment models, and coordination for care off-site, in the hospital, home health, and hospice.

Hospice and palliative care are not synonymous services, but instead, hospice is an offering which falls under the umbrella of palliative care.  Hospice provides palliative service to patients in the last months of life. To qualify, a patient must have a terminal diagnosis with a six month or less prognosis of survival, progressive signs, and have declined pursuit of further curative treatments.[5]

Enhancing Healthcare Team Outcomes

Patients approaching imminent death can benefit from palliative care services by receiving aggressive management of symptoms such as pain, air hunger, and secretions. However, it is worth reiterating that palliative care services are not solely for patients at the end of life.  Palliative treatments might indeed be administered alongside curative care. Overall palliative care provides a team-based approach to patient care with both seasoned and new efficacious means of improving quality of life whether treating a potentially curable or incurable disease.[6][7][8]


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Palliative Care - Questions

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Which of the following best defines "palliative care"?



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Which is false regarding palliative care?



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Which is true of the goals of palliative care?



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Which is incorrect concerning the delivery of palliative care?



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Select the choice which is the LEAST desired outcome of the palliative care model:



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Which of the following symptoms is not managed by palliative care services?



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A 74-year-old man presents to the clinic for a new consultation regarding palliative care services. He was sent by his internist who believes the patient has lung cancer given a recent episode of hemoptysis associated with a distant history of extensive tobacco usage. The internist notes in his letter to the palliative team that in his prior experience, all patients with this presentation were later confirmed to have lung cancer on imaging and that this patient would, therefore, benefit from palliative care assessment. Today, the patient's vital signs are all within the normal range, and he has not undergone any radiologic imaging since suffering an ankle sprain one decade ago. The patient's internist recently attended a palliative care seminar where speakers emphasized the main recognized way in which primary care providers can best improve care outcomes from palliative specialist consultations. Which of the following best captures a potential risk, as demonstrated by the internist, with adopting this emphasized approach?



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An 82-year-old man is a patient on an inpatient palliative care unit. He is progressing toward death, and his family is at the bedside. The patient's family exclaim that the patient seems to have a lot of saliva or fluid in his mouth, causing him to cough and "rattle." Since this distresses the family, the patient is given a sublingual medication frequently used to reduce secretions in dying patients. Which of the following is the most likely side effect of this medication?



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A 59-year-old male presents to palliative medicine clinic. This is his initial visit after being referred by his family practitioner. He has a history of metastatic prostate cancer with diffuse bone pain. He is not pursuing curative therapy, and the only medication he currently takes is a high dosage of scheduled opioids for his pain. Which of the following is most appropriate in order to prevent the most common side effect of his symptomatic regimen?



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A 72-year-old man with gastric cancer is admitted to the hospital for severe dehydration. Over the past several days, he has had severe nausea. He refuses to receive oncology services. During his stay, he is given haloperidol for nausea. The patient has satisfactory improvement to his nausea. Unfortunately, upon discharge, his primary care provider is unfamiliar with this off-label use of haloperidol and refuses to prescribe it to the patient. Which of the following is the next step in the management of the patient?



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Palliative Care - References

References

Sepúlveda C,Marlin A,Yoshida T,Ullrich A, Palliative Care: the World Health Organization's global perspective. Journal of pain and symptom management. 2002 Aug;     [PubMed]
Kelley AS,Morrison RS, Palliative Care for the Seriously Ill. The New England journal of medicine. 2015 Aug 20;     [PubMed]
Rodriguez KL,Barnato AE,Arnold RM, Perceptions and utilization of palliative care services in acute care hospitals. Journal of palliative medicine. 2007 Feb;     [PubMed]
Shin SH,Hui D,Chisholm GB,Kwon JH,San-Miguel MT,Allo JA,Yennurajalingam S,Frisbee-Hume SE,Bruera E, Characteristics and outcomes of patients admitted to the acute palliative care unit from the emergency center. Journal of pain and symptom management. 2014 Jun;     [PubMed]
Albert RH, End-of-Life Care: Managing Common Symptoms. American family physician. 2017 Mar 15;     [PubMed]
Aslakson RA,Curtis JR,Nelson JE, The changing role of palliative care in the ICU. Critical care medicine. 2014 Nov;     [PubMed]
Sarradon-Eck A,Besle S,Troian J,Capodano G,Mancini J, Understanding the Barriers to Introducing Early Palliative Care for Patients with Advanced Cancer: A Qualitative Study. Journal of palliative medicine. 2019 Jan 11;     [PubMed]
Mizuno A,Shibata T,Oishi S, The Essence of Palliative Care Is Best Viewed as the     [PubMed]

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