Burton J. Tabaac, MD
As physicians and healthcare providers, we often focus on restorative care and efficacious treatments. It is paramount, and of high import, that we are competent and trained to provide high-quality end-of-life care as well. Essential in our role is the ability to offer comfort measures when consistent with a patient’s wishes, and to serve as a source of information and support for family members when loved ones are transitioning to comfort-guided care.
This article’s authors provide a contemporary review of the literature and offer recommendations on how providers may integrate palliative medicine into the care of their patients. Palliative care is an approach to medical care for patients with serious illness. It includes end-of-life and hospice care, but is much broader. Palliative care is not limited to those with a terminal prognosis, but rather is appropriate at any age and at any stage of a serious illness.(1) The article articulates, “Palliative care focuses on improving communication about goals of care and maximizing comfort and quality of life of patients and families through the identification, prevention, and relief of pain and suffering in body, mind, and spirit.”
Early involvement of palliative care specialists in the cancer setting has been associated with improved quality of life, symptom control, increased patient and caregiver satisfaction, more appropriate health resource use, and healthcare savings and has even improved survival.(2) A National Quality Forum on Palliative Care and End-of Life Care directs and details the primary palliative care skills that should be expected from providers and taught to medical residents and fellows. These skills include: psychosocial and spiritual support; helping the family establish goals of care based on patient and family values, goals, and treatment preferences; providing anticipatory guidance regarding the dying process for patients and their families; and facilitating bereavement support for family members.
Decision-makers appreciate prognostic information early in the course of serious or critical illness, even if this prognostic information is framed with a statement of a high degree of uncertainty.(3) Anticipatory guidance helps patients and families prepare for anticipated developments, expect complications and plan for potential decisions that may ensue. By effectively assessing the decision-maker’s understanding and exploring the patient’s values, the good communicator shares information in a way that encourages participation. The Ask-Tell-Ask approach involves asking what the patient or family member understands (Ask) before giving the news and information (Tell) and then assessing what the patient or family member understood (Ask) from the information given.(4)
The palliative care needs of patients consist of psychosocial support for patient and family members, shared decision-making for preference-sensitive treatment decisions, determination of patient-centered goals of care, and pain and symptom management. Medical education needs to include palliative care competencies to ensure all providers are proficient in primary palliative care skills, as well as effective in triaging identified needs to consulting specialties. The authors make a strong case that rigorous, multi-site evidence-based research is needed to determine best methods for prognosis communication, identifying patient treatment preferences and patient- and family-preferred roles in decision-making and individualizing treatment decisions.
It was English novelist, poet, and journalist George Eliot who eloquently stated, “Our dead are never dead to us, until we have forgotten them.”
This post is dedicated in memoriam of Beatrice H. Shorr, mother of two, grandmother of four, and great-grandmother of four. Her passion and interest in health care served influential for her children’s children to seek careers in the medical field.
1. About Palliative Care. Center to Advance Palliative Care Web. Site: https://www.capc.org/about/palliative-care.
2. Morrison RS, Dietrich J, Ladwig S, Quill T, Sacco J, Tangeman J, et al. Palliative care consultation teams cut hospital costs for Medicaid beneficiaries. Health Aff (Millwood). 2011;30:454–463. doi: 10.1377/hlthaff.2010.0929.
3. LeClaire MM, Oakes JM, Weinert CR. Communication of prognostic information for critically ill patients. Chest. 2005;128:1728–1735. doi: 10.1378/chest.128.3.1728.
4. Back AL, Arnold RM, Baile WF, Tulsky JA, Fryer-Edwards K. Approaching difficult communication tasks in oncology. CA Cancer J Clin. 2005; 55:164–177.