Palliative Care Through Illness Trajectory
Am Fam Physician. 2017 Mar 15;95(6):386-388.
I am caring for Y.S., a 50-year-old man with multiple health problems, including type 2 diabetes mellitus, depression, hypertension, and advanced scleroderma complicated by severe pulmonary hypertension. He has pain and progressive shortness of breath with declining function, which cause him to be homebound nearly all the time. I am aware of research demonstrating improved quality of life and less health care utilization among patients with advanced illness who receive specialty outpatient palliative care alongside usual, life-prolonging treatment. Some studies have even shown increased lifespan in patients with lung cancer.1,2 However, there are no ambulatory palliative care services available in my area. Is it possible to deliver basic palliative care through my practice, and does it make a difference for patients?
Persons with multimorbidity often have unmet multidimensional needs related to their health.3,4 For example, Y.S. may also be experiencing poorly controlled symptoms, financial distress, and increasing anxiety. His family is likely distressed by his decline in health and unsure about what to expect next. Palliative care specialists employ a systematic approach to evaluating unmet needs across a range of physical, mental, social, and existential and spiritual dimensions, and then develop care plans that explicitly reflect patients' goals for their health. Palliative care delivered by subspecialists is known to have many benefits: enhancing quality of life1,5; improving communication6,7; reducing deaths away from home5,8; reducing depression and other symptoms1,2,5,8; and reducing health care utilization.5,6 Palliative care can begin at any time during illness, or even before illness occurs. Patient and family needs are evident throughout the course of progressive illness, not only near the end stage.
Persons with multimorbidity and advancing illness are treated in primary care practices more commonly than in any other setting.9 The Institute of Medicine and the World Health Organization encourage primary care physicians to deliver basic palliative care.10,11 Although many primary care physicians respond to identified patient needs as best they can, most physicians do not realize that they can readily incorporate proactive or systematic assessments for multidimensional needs into their practice, thereby facilitating the delivery of basic palliative care. We refer to basic palliative
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2. Higginson IJ, Bausewein C, Reilly CC, et al. An integrated palliative and respiratory care service for patients with advanced disease and refractory breathlessness: a randomized controlled trial. Lancet Respir Med. 2014;2(12):979–987.
3. Noël PH, Frueh BC, Larme AC, Pugh JA. Collaborative care needs and preferences of primary care patients with multimorbidity. Health Expect. 2005;8(1):54–63.
4. Fortin M, Soubhi H, Hudon C, Bayliss EA, van den Akker M. Multimorbidity's many challenges. BMJ. 2007;334(7602):1016–1017.
5. Bakitas M, Lyons KD, Hegel MT, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. JAMA. 2009;302(7):741–749.
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7. Casarett D, Pickard A, Bailey FA, et al. Do palliative consultations improve patient outcomes? J Am Geriat Soc. 2008;56(4):593–599.
8. Gomes B, Calanzani N, Curiale V, McCrone P, Higginson IJ. Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers. Cochrane Database Syst Rev. 2013;(6):CD007760.
9. Sharma MA, Cheng N, Moore M, Coffman M, Bazemore AW. Patients with high-cost chronic conditions rely heavily on primary care physicians. J Am Board Fam Med. 2014;27(1):11–12.
10. Institute of Medicine. Committee on Approaching Death. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington, DC: The National Academies Press; 2014.
11. World Health Organizarion. Strengthening of palliative care as a component of comprehensive care throughout the life course. Sixty-seventh World Health Assembly. 2014. http://apps.who.int/gb/ebwha/pdf_files/WHA67/A67_R19-en.pdf. Accessed August 12, 2016.
12. Thoonsen B, Gerritzen SH, Vissers KC, et al. Training general practitioners contributes to the identification of palliative patients and to multidimensional care provision: secondary outcomes of an RCT [published online ahead of print April 18, 2016]. BMJ Support Palliat Care. http://spcare.bmj.com/content/early/2016/04/18/bmjspcare-2015-001031.abstract. Accessed August 12, 2016.
13. Gómez-Batiste X, Martínez-Muñoz M, Blay C, Espinosa J, Contel JC, Ledesma A. Identifying needs and improving palliative care of chronically ill patients: a community-oriented, population-based, public-health approach. Curr Opin Support Palliat Care. 2012;6(3):371–378.
14. Shaw KL, Clifford C, Thomas K, Meehan H. Improving end-of-life care: a critical review of the gold standards framework in primary care. Palliat Med. 2010;24(3):317–329.
15. Mason B, Buckingham S, Finucane A, et al. Improving primary palliative care in Scotland: lessons from a mixed methods study. BMC Fam Pract. 2015;16:176.
16. Detering KM, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ. 2010;340:c1345.
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