Palliative Care – So Much More Than We Think!

Issues of the wellbeing of our present traditional medical system are not mysterious to those of us working in health care. As providers we have been “raised” to accept that health care is in a constant state of transformation; it is expected. For example, the theory of the four humors of black bile, yellow bile, phlegm, and blood once were believed to be the etiology for afflictions4. We can marvel at developments since the four humors; interventional therapies, robotics, significant advancements in cancer treatment, innovative capability to personalize medications through the human genome, and the use of technology in the arenas of artificial intelligence and telemedicine. Somewhere within the transformation of our historical medical model, another model developed in the last 30 years. An emergence of hospice and palliative care to meet the growing needs of our society. 

Each of these specialties provides a unique approach to caring for patients, families, and communities. Patients with a prognosis of less than 6 month of life with a focus on comfort for the end of their lives are provided with quality care under a hospice team. This multidisciplinary approach addresses patient goals, support to family and management of symptoms affecting quality of life. Hospice team members embrace the interrelationship with each other and include nurses, chaplains, home health aides, nurse practitioners, social workers, volunteers, and physicians. 

The palliative care (PC) model provides care for patients with serious, chronic illnesses. Notably palliation is to “ease” and has long been integral to all health care practice5. To offer more clarity on the differences in the range of palliative care delivery we, need to consider primary, secondary, and tertiary levels of palliative care. Primary palliative care is and has long been part of health care. An example is through primary care practices (PCP) and specialties in medicine as they deal with people living with serious, chronic illness5. Treatment for these patients has been and continues to be consistent in the goal to extend life while enhancing day to day living. 

Secondary palliative care is the specialty of consultative services which partners with attending providers in acute care facilities, PCP/specialty practices in the community and in clinics3. These partnerships allow a supportive consultative service to the provider, patient, and family1. Palliative care provides this through the goals of pain and symptom management, clarifying a patient’s goals of care and possible code status discussions1. 

Tertiary PC concentrates on educating and preparing future PC specialists to meet the growing demands being made on a stressed health care system3. Fellowship programs are designed to nurture providers in the art and science of palliative care for physician, nurse practitioner or physician assistants2. All three tiers, primary palliative care, secondary palliative care and tertiary palliative care ultimately demonstrate an innovative health care model. It also provides another layer of support to those patients, their families, referring providers and other team members. 

Ultimately the health and well being of an ever-changing medical world requires innovative approaches to care. This article explores the models of hospice and palliative care delivery as forward-thinking change that needs to be nurtured further. Hospice approach to care contrasts significantly from end-of-life care in an intensive care unit tethered to all life extending machines. Palliative care emphasizes specialty care using the four pillars of care: goals of care clarification, pain and symptom management, code status discussion/clarification and a layer of support to patients, families, and the health care team; ultimately extending a commitment to excellence in practice.

References
1. Ahia, C; Blais C. Primary Palliative Care for the general internist: integrating goals of care discussions into the outpatient setting. Ochsner J. 2014 Winter; 14(4): 704–711.
2. Beasley, A; Bakitas, M; et al. Models of non-hospice palliative care: a review. Annals of Palliative Medicine. February 26, 2019. Volume 8, Supplement 1
3. Gunten, C; Secondary and tertiary palliative care in US hospitals. JAMA. 2002;287(7):875-881
4. Lagay, F. The Legacy of Humoral Medicine. American Journal of Ethics: illuminating the art of
Medicine 2002;4(7):206-208.
5. Schenker, Y. Primary Palliative Care. https://www.uptodate.com/contents/primary-palliative-care
6. Quill, T; Abernethy, A. Generalist plus specialist palliative are-creating a more sustainable model. New England Journal of Medicine. 2013;368:1173-1175