DEFINITION OF PALLIATIVE CARE AND HOSPICE
Palliative Care is a specialty in medicine for people with serious illness. The focus is on improving quality of life and providing an extra layer of support to the patient and family. Palliative Care is provided by doctors, nurses, social workers, spiritual care, and other specialists. Palliative Care is appropriate at any stage of illness, regardless of the treatment goals.
Hospice care is a subset of palliative care for patients with a prognosis of 6 months or less who have decided to focus on comfort and quality of life rather than cure.
TRADITIONAL EMPHASIS ON CURE OVER PALLIATION
Palliative Care can be provided when the focus of medical care is on comfort or along with potentially curative or life-prolonging treatment. Previously, the transition to palliative care usually depended on recognizing when a patient is at the end of life and cure is no longer possible or desired. Several studies document that for the most illnesses our ability to predict death within six months is poor no matter what models are used. For this and other reasons, physicians often delay introducing palliative care. Providing Palliative Care sooner in the trajectory of illness and more often can benefit patients and families with serious illness. Here is a key article on the topic:
Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010 Aug 19;363(8):733-42. doi: 10.1056/NEJMoa1000678. http://www.ncbi.nlm.nih.gov/pubmed/20818875
Despite many efforts to improve palliative care in the U.S., a number of barriers and challenges remain. Those most relevant to the palliative care track are described as follows by the 2014 Institute of Medicine Report: Dying in America:
- “barriers in access to care that disadvantage certain groups; a mismatch between the services patients and families need and the services they can obtain;
- inadequate numbers of palliative care specialists and too little palliative care knowledge among other clinicians who care for individuals with serious advanced illness; and
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a fragmented care delivery system, spurred by perverse financial incentives, that contributes to the lack of service coordination across programs and unsustainable growth in costs.”
- “For the millions of Americans who work in or with the health care sector- including clinicians, clergy, caregivers, and support staff- providing high-quality care for people who are nearing the end of life is a matter of professional commitment and responsibility.”
According the the National Hospice and Palliative Care Organization (NHPCO), in 2013 the median hospice length of stay was 18.5 days and the average hospice length of stay was 72.8. This indicates that transition to hospice continues to occur late in the disease trajectory. Cure and technical interventions are heavily emphasized in the training of future physicians. The dominant message is that the point of “no benefit” to a patient is the time for transition to palliative care. This model implicitly and explicitly values cure over palliation throughout the trajectory of illness and leads to late introduction of palliative care and hospice, denying many patients the most appropriate care at the end of their lives.
http://www.nhpco.org/sites/default/files/public/Statistics_Research/2014_Facts_Figures.pdf
EDUCATIONAL GOALS
The goal of this clerkship is for you recognize and critically evaluate those behaviors that allow clinicians to provide excellent palliative/hospice care to patients and families living with life limiting illness. Conversely you should be able to recognize and critically evaluate those behaviors that hinder the provision of palliative/hospice care.
To meet these goals you will explore a Best Practice Model based upon well-documented research as well as clinical experience. It is a simplified way of describing what experts in the field usually do when caring for patients and families with chronic, life limiting illness. In order to meet these goals, this model will provide you with the following:
- A framework to critically observe the complex processes of discussing and providing palliative care in clinical settings.
- A common model and language for you and your preceptors to discuss the complex processes observed while providing palliative care in the clinical setting.
- Discrete, concrete behaviors to practice that approximate expert behavior both in the clinical and educational setting.
- A model to help guide your future education and development in palliative care during residency, fellowship and clinical practice.