The field of palliative care hasgrown rapidly in recent yearsin response to patient need andclinician interest in effective approachesto managing chronic andlife-threatening illness. The article byKhatcheressian et al reviews the datathat make the case for palliative careas a core component of modern oncologypractice. They point out thatthe issue is not whether we have aquality problem here-it is clear thatwe do. Rather, the focus of this articleis on how best to address that problemin the context of the very real time andfinancial constraints in which we nowpractice oncology in the United States.
The field of palliative care has grown rapidly in recent years in response to patient need and clinician interest in effective approaches to managing chronic and life-threatening illness. The article by Khatcheressian et al reviews the data that make the case for palliative care as a core component of modern oncology practice. They point out that the issue is not whether we have a quality problem here-it is clear that we do. Rather, the focus of this article is on how best to address that problem in the context of the very real time and financial constraints in which we now practice oncology in the United States. Scope of Palliative Care
The palliative care referred to by the authors is not limited to individuals in the terminal stages of illness and is applicable from the time of diagnosis of any serious or advanced illness, based on complexity and patient and family need, not simply prognosis. Palliative care clinicians work side by side with oncologists to help identify and address the physical, psy- chological, and practical burdens of illness. Palliative care consultants are trained to deliver expert assessment and treatment of pain and other symptoms; employ evidence-based communication methods with patients, families, and colleagues; contribute to the process of complex medical decision-making and goal-setting; and help to insure medically informed care planning, coordination, and continuity of care, across health-care settings and throughout the course of illness. Palliative care is both a general approach to health care and a growing practice specialty for professionals committing most or all of their time to the delivery of palliative care services. As of 2005, over 1,800 physicians had received specialty certification through a palliative care credentialing exam. As of January 2005, there were more than 50 postgraduate palliative care specialty fellowship programs available in the United States. Between 2000 and 2003, the American Hospital Association (AHA) annual survey recorded a 67% growth in the number of hospital- based palliative care programs reported, from 632 up to 1027, for a total of 25% of responding AHA member hospitals, and over 33% of hospitals with at least 100 beds. There is every reason to believe that this rate of growth will continue until the majority of leading hospitals in the country have an established and well-integrated palliative care program, developed to support clinicians in the care of their sickest and most complex patients. Impact on Quality of Care
Palliative care services utilizing a range of models and approaches have been shown to significantly reduce pain[6-8] and other symptom distress,[ 6,9,10] as well as improve patient and family satisfaction[10-13] with both care and physician communication.[ 14,15] Observational studies have yielded no differences in mortality between patients receiving palliative care and case controls receiving usual care.[9,16,17] Clinical Components
The three primary domains of palliative care clinical practice are
(1) expert assessment and treatment of pain and other symptom distress, including psychiatric symptoms;
(2) skilled communication about goals of care and support for complex medical decision-making; and
(3) provision of practical and psychosocial support, care coordination and continuity, as well as bereavement services if death occurs.[1,19] Palliative care specialists work to support primary physicians in the care of complex and seriously ill persons by providing intensive bedside treatment and reassessment of multiple-symptom distress, by helping with time-consuming and difficult interactions with distressed family members, and by assuring a seamless, safe, and well communicated discharge and followup process after the patient leaves the hospital. Resources for physicians seeking more knowledge or training in the treatment of symptom distress and other aspects of palliative care are given in Table 1.
The core components of symptom management for physicians[21-23] include routine and repeated formal as- sessment (without which most symptoms will neither be identified nor addressed); expertise in prescribing, including the safe use of opioid analgesics, adjuvant approaches to pain management, and management of a wide range of other common and distressing symptoms (for example, delirium, dyspnea, fatigue, nausea, bowel obstruction, and depression); and the skillful management of treatment side effects. Communication skills and effective support for decision-making about clinical care goals include fundamental physician responsibilities such as communicating bad news and elucidating patient wishes for future care. In addition, the palliative care clinician must be able to promote communication and consensus about care goals among multiple specialist consultants, to address and resolve disagreements and conflicts about goals of care between patients, families, and providers, and to assist in the evolving process of balancing the benefits and burdens of various medical interventions.[24-28] The great majority of care for an illness is provided at home by family members who are neither trained nor emotionally prepared for these responsibilities.[13,29] Burden on family caregivers is one of the top concerns of seriously ill patients. Because of the fragmented nature of the US health-care system, these patients and families often struggle with anxieties about doing the wrong thing, difficulty traveling to physician's offices, social isolation, and a high prevalence of preventable suffering of all types. Palliative care clinicians provide medically informed, and therefore, more sophisticated care management, discharge planning, and mobilization of a range of community resources, increasing the likelihood that the family will be able to manage the care at home with the necessary supports and back-up in place.[32,33] Controlled trials of palliative care have demonstrated a reduction in the number of emergency department visits, hospitalizations, and hospital length of stay, due to the efficacy and comprehensiveness of the care coordination in averting crises.[16,34,35] Access to Palliative Care
Despite evidence of the need for palliative care in cancer populations as well as the multiple studies documenting its effectiveness, inadequate symptom management, poor quality of communication, and absence of needed support through the trajectory of an illness and across settings remain the primary concerns of our patients and their families. The reasons for failure to improve this situation are many and complex but include the time pressures facing practicing clinicians; the increasing financial constraints mandating higher and higher patient volumes to sustain a practice; and the poor reimbursement for cognitive (or so-called evaluation and management) services under major insurers in the United States. As a result of these very real influences on oncology practice, the practicing physician may choose to seek a combination of resources to help better address the palliative care needs of oncology patients. These include, but are not limited to, ensuring access to palliative medicine consultants in your hospital, office, or clinic, so that patient and family needs for time and attention to symptoms and long-term planning can be met without interrupting the work flow of a busy office practice; training of office staff in the basics of formal symptom assessment using validated tools, and utilizing symptom management algorithms that can be delivered by nursing staff with oversight of physicians; and identifying appropriate case management and social work consultants for your patients who can provide counseling, ensure practical support at home, and offer advice on available insurance and community resources. Finally, a range of educational resources have become available to physicians in recent years (Table 1). Combining the above resources (increasingly available in many communities) with increased physician knowledge and skill will go a long way toward addressing the needs of patients. Education in Palliative Care
Both the Liaison Committee for Medical Education (LCME) and the Accreditation Council for Graduate Medical Education (ACGME)[36,37] now require or strongly encourage under- and postgraduate training in palliative care in order to accredit programs.[ 38,39] More than 25% of teaching hospitals have established palliative care clinical services, the necessary platform for clinical training. Physicians already in practice may gain knowledge and skills through a range of national courses, Web-based resources, and preparation for the certifying exam given annually by the American Board of Hospice and Palliative Medicine (Table 1). Conclusion
Increased attention to palliative care as a core component of modern oncology practice reflects a grass roots public and professional response to the needs of a rapidly growing patient population with long-term chronic disease and family care burdens within a health-care system designed for sporadic acute care. A number of resources are available to health-care professionals seeking more training as well as for hospitals or nursing homes wishing to establish their own clinical or educational programs. Such programs have provided a platform for both newly graduated and seasoned professionals to continue to serve the needs of their patients through the assessment and relief of suffering, provided simultaneously with their efforts to cure or mitigate disease.
Dr. Meier is a Faculty Scholar of the Project on Death in America. This work was supported by a National Institute on Aging (NIA) Leadership Career Development Award and by the Center to Advance Palliative Care, a National Program Office of the Robert Wood Johnson Foundation.
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