Continuing Education Activity

The World Health Organization characterizes the field of palliative care as a form of specialized medical care that aims to optimize the quality of life and alleviate the suffering of patients with serious illnesses. One of the primary ways to achieve this is through early identification and treatment of new symptoms, along with managing those that prove refractory. Palliative care can be administered in multiple settings and by various healthcare providers. Primary care providers, hospitalists, and emergency medicine physicians often provide the first interventions for palliative concerns. This activity reviews palliative care and highlights the role of the interprofessional team in evaluating and treating patients near the end of life or suffering from a severe chronic illness using an appropriately trained team of professionals.

Objectives:

• Describe how the World Health Organization defines palliative care.
• Explain the signs and symptoms addressed by palliative care.
• Describe the healthcare team members that should be in place to offer palliative care.
• Review palliative care and the role of the interprofessional team in evaluating and treating patients near the end of life using an appropriately trained team of professionals.

Introduction

The World Health Organization characterizes the field of palliative care as a form of specialized medical care that aims to optimize the quality of life and alleviate the suffering of patients.[1] One of the primary ways to achieve this is through early identification and treatment of new symptoms, along with managing those that prove refractory. Palliative care addresses the physical, psychosocial, and spiritual needs of patients with a serious illness, including but not limited to those with a life-limiting diagnosis, by employing an interprofessional team approach.[2] A palliative team is comprised of a wide array of professionals, including the palliative physician, nurse, social worker, chaplain, and pharmacist. Notably, palliation consists of comprehensive care provided to patients with life-limiting illnesses and should not be considered an alternative to failed life-prolonging care. Early utilization of palliative care has been correlated with improved survival in patients with metastatic cancer, reduced cost of care, and improved quality of life.[3][4]

Palliative care can be administered in multiple settings and by various healthcare providers. Primary care providers, hospitalists, and emergency medicine physicians often provide the first interventions for palliative concerns.[5] However, some specialists have 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. A specialist in palliative care is often sought out for complex cases, refractory or difficult-to-manage symptoms, complex family dynamics, and patients who may need additional guidance and care.[3] Specialists in palliative care may also have more time to dedicate solely to palliative care during their visits. Some hospitals employ a team of palliative care providers. Patient's can be referred to palliative care in both outpatient and hospital settings.[6] 

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 have formal training in at least one of these specialties.

Palliative care is often delivered by an interdisciplinary team, with each member working within their specific specialty and area of focus. For example, palliative care teams often include chaplains and social workers who help address patients' spiritual and emotional needs. It is common for palliative care teams to employ physicians, physician assistants, nurse practitioners, nurses, social workers, and chaplains. 

Function

The primary goal of the interprofessional palliative care team is to improve the quality of life of patients and their families. It is a common misconception that palliative care only concentrates on physical needs. In reality, psychological, cultural, ethical, legal, psychiatric, spiritual, and social needs are also assessed. Palliative care aims to alleviate all forms of suffering; in addition to physical suffering, it acknowledges spiritual or existential, and psychological suffering. It also recognizes that the patient lives within a community and is affected by interpersonal relationships, financial resources, and cultural dynamics. Palliative care specialists can also assist with prognostication, assessment of goals of care, communicating difficult news, conducting family conferences, and determination of decision-making capacity.[7] 

Nevertheless, the management of symptoms, whether commonly encountered or rare, is a central focus of the field. These symptoms include pain, dyspnea, nausea, anxiety, depression, and fatigue.[2] Palliative care providers are adept at using a variety of pharmaceutical and nonpharmaceutical therapies to alleviate symptoms.

Identifying the etiology and intervening therapeutically when possible is the objective for the treatment of pain. Pain can be treated with modalities such as acupuncture, massage, heat or ice therapy, injections, or meditation. Pharmaceutical treatments include NSAIDs, opiates, antidepressants, antiepileptics, and steroids. 

Opiates may also be utilized for the management of dyspnea or air hunger. Often anticipating and preventing symptoms before they occur is more effective than treating them after they occur. For example, prescribing the appropriate bowel regimen for patients at risk of developing constipation. Patients taking opiates will need stimulant laxatives to increase bowel motility, while other patients who struggle with dehydration may need osmotic laxatives and improved hydration to hold water in the stool. Additional examples of symptomatic management include the use of radiotherapy to relieve bone pain and the performance of a therapeutic thoracentesis for symptomatic pleural effusions. Anticholinergic agents, such as atropine, can be administered to assist in secretion reduction. Furthermore, dopamine receptor antagonists that target the chemoreceptor trigger zone, such as haloperidol or metoclopramide, help treat nausea and vomiting.[8] 

Palliative care providers are also communication specialists. Sharing information regarding a terminal diagnosis or poor prognosis can be very challenging. Palliative care providers receive additional training and experience navigating emotional and challenging conversations. Increased sensitivity to cultural nuances and patient preferences regarding health-related information is imperative.[9] The SPIKES Mneumonic is commonly used to assist providers in delivering difficult news. 

S: Set up an interview. Prepare the pertinent information, arrange a meeting with important parties, set up the environment with a private space, and minimize interruptions. 

P: Perception. Use open-ended questions to assess the patient's current understanding of their illness and prognosis. Learn what they are thinking and feeling about the information. "What have you heard from your providers about your condition thus far?" "What specific concerns do you have?"

I: Invitation. Obtain permission to share information as desired by the patient. Some patients will want all the details; others may prefer a summarized version or even that you speak to a trusted family member instead. They may also prefer to wait for a different time to have the conversation. 

K: Knowledge. Impart the information that needs to be shared in accordance with the patient's wishes. Briefly summarize the current information and events up to this point. Using warning statements is helpful. "I am afraid that what I have to share is not the news we were hoping for." Give the information in short, easy-to-understand pieces of information. Avoid medical jargon and pause frequently to allow time for emotional response and processing and confirm understanding. Address uncertainty as able, using ranges of time or describing most likely, worst, and best case scenarios can be helpful. It is important to provide meaning along with information. A patient may not clearly understand the implications of a diagnosis, so clearly imparting the meaning, even if difficult, in a compassionate way is important. 

E: Emotions. Pause and address emotions as they arise. Ask for clarifying statements to understand emotions better if not clear. Validate a patient's emotions with empathetic statements. "I can imagine anyone in your position would feel that way." "Can you tell me more about what concerns you?"

S: Summarise and Strategize. Summarize what has been shared to assist in understanding. Assess current understanding and remedy knowledge gaps or misunderstandings. Answer any questions they have. Share the timeline of interventions or decisions that need to occur by. Set up a clear plan for communication and follow-up. "I know this was frightening news, and you may have more questions as you process this information. Please write them down, and we will review them at our next meeting." Avoid statements that imply abandonment or "there is nothing else we can do for you." This may include focusing on symptom management and social support. "We will continue working with you every step of the way."[10][11]

Issues of Concern

Palliative care is often confused with hospice care. Palliative care is a larger umbrella that encompasses hospice care but is not limited to it. Palliative care works to enhance the quality of life and limit suffering in patients regardless of their goals of treatment, including working with patients seeking curative treatment. Dame Cicely Saunders first developed hospice in 1967 to care for patients dying from advanced cancer. Hospice programs and payment models vary across the country. A patient must meet the criteria to qualify for hospice set forth by insurance and federal programs. The exact criteria are diagnosis-specific; however, in general, a patient is eligible for hospice if they have decided to forgo curative treatment and instead focus on treatment aimed at improving quality of life (controlling pain and other unpleasant symptoms) and having a life expectancy or prognosis of 6 months or less. If a patient lives longer than six months after enrolling in hospice, they can renew or prolong services as long as they meet admission criteria. Hospice services are most often delivered in the patient's home or living facility; however, they can also be utilized in hospital settings.[2]

The hospice movement was initially controversial, creating myths and misconceptions about palliative care. Erroneous beliefs circulate, for example, that palliative care is only intended for dying patients and that entering hospice was akin to "giving up" or that palliative care hastened death by the medicalization of the dying process. These misconceptions can be dispelled appropriately. Studies have shown early use of palliative care improves the quality of life and, in many cases, prolongs survival in patients with advanced cancer.[12] 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, serious, or life-limiting conditions 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, the clinician requests services when the primary physician feels that integrating the palliative team into the patient's care would improve the quality of that patient's life.[13] Palliative care focuses on easing a person's suffering before, during, and for the family after the patient dies.  

Clinical Significance

Palliative care correlates with improvement in symptom control, patient satisfaction, understanding of diagnosis and prognosis, and in many cases, prolonged survival. A goal of palliation is to align with the patient's values and preferences for treatment and attend 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 assist clinicians in managing the complexities of patients' comorbidities and helping with complex family dynamics concerning patients' goals of care. Studies have also shown that using palliative care teams can decrease overall healthcare costs, including improved ICU utilization, decreased emergency department utilization, and reduced inpatient readmission rates.[4]

Other Issues

As a palliative care practitioner, the physician must know about serious and complex conditions and be adept at managing palliative emergencies such as acute pain crises.[14] The physician becomes skillful in prognostication and advanced care planning. They collaborate deftly with the interprofessional 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.[7] 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, with home health, and hospice. 

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 take place alongside curative care and have been shown to improve survival in some cases.[4] 

Overall, palliative care provides an interprofessional team-based approach to patient care with both seasoned and new efficacious means of improving quality of life, whether treating potentially curable or incurable diseases.[15] The team consists of clinicians, specialists, hospice/palliative specialty nursing staff, social workers, medical assistants, and pharmacists. Each specialty has its function but must work collaboratively; pharmacists must assist with medication selection for palliation, and nursing will administer these drugs. Psychological professionals will attend to the needs of the patient and the family. Nurses must be alert for changes in conditions that may warrant modification of care and alert the clinicians. If all these disciplines coordinate and communicate, then patient care will benefit. [Level 5]