Palliative/supportive care

Happy Palliative and Advanced Care week!

Benjamin Franklin famously noted that death is one of the only two certainties human beings are allowed.  Yet, despite the ubiquity and antiquity of mortality, the dying process and end-of-life care are issues that today remain emotionally fraught and ethically challenging.  Inevitably, it is healthcare professionals who are often with patients and families as they struggle to make difficult decisions in the face of serious injury and/or illness.  Technologies and therapies that allow life to be extended for longer spans have further complicated the topic by offering more options for treatment, without accompanying criteria to establish when and if care becomes futile. Together, patients, caregivers, and health care staff must grapple with questions about quality of life, personal dignity, and what it means to have a “good death.”  Supportive or palliative (the terms are often used interchangeably; the latter seems more common) care teams have become an important part of helping clients navigate the transition process.  Currently, demand for palliative services continues to increase, particularly since their utility extends beyond individuals for whom death is imminent; patients with complex, debilitating, and chronic illnesses can also benefit from the patient-centered approach supportive care employs to optimize quality of life.

Palliative care originated in the 1960’s and gained traction in American hospitals in the 1990’s. It is often associated or conflated with hospice care by the public, with a key difference being that palliative care more readily coexists with curative efforts.  That there is confusion is perhaps not surprising, since definitions of what exactly this type of care entails vary, and some sources consider hospice care to be a specialized subtype of palliative care. In fact, it is the inverse: hospice care falls under the palliative "umbrella." The primary goal of palliative care are to improve quality of life through amelioration of physical and psychological symptoms for patients and their loved ones.  As such, palliative care can be initiated at any point in the course of treatment (whereas hospice care is usually limited to the last six months of life).  Because palliative care encompasses so many aspects, it is often provided through the coordinated efforts of an interdisciplinary team of professionals (see Table 1 below for an example of team members and their functions).

While supportive care teams usually cannot offer hope for more life, they can offer patients some choice about how they want to spend what time they do have.  Supportive care interventions revolve around symptom management, and are not intended to treat or cure any underlying disease. That said, palliative care may actually help increase lifespan, especially if adopted earlier in the treatment process.

Symptoms patients experience may be directly or indirectly caused by disease processes, or side-effects of certain therapies, and typically include pain, dyspnea, nausea, and insomnia. Pressure injuries and other wounds are also frequently experienced by patients with chronic and life-limiting illnesses. Wound care can be palliative, and the wound care specialist works with the patient and their team to create a treatment plan tailored to the patient's goals. For example, if wound maintenance and comfort are prioritized, this can be facilitated by choosing antimicrobial dressings that require fewer changes.

Palliative care teams are frequently called upon to iterate unwelcome news and have difficult conversations about goals of care (GOC) with patients and their families. Communication through stressful situations and overwhelming emotions is not always easy. A popular healthcare professional communication model goes by the acronym COMFORT: Communication; Orientation and Opportunity; Mindful presence; Family; Openings; Relating, and Team. I was also taught the AMEN (affirm, meet, educate, no matter what) approach. These models are not strict protocols, but rather guiding principles; providing flexibility of use is necessary, as every patient is unique in their circumstance and family dynamic. 

Palliative care continues to evolve and grow as a specialty, providing valuable services to patients in all stages of life/illness. I am so grateful to all the Palliative Care clinicians I have worked with, and always impressed with their kindness, compassion, and commitment to patient comfort and autonomy.

Interested in a deeper dive? Some media I have personally enjoyed:

That Good Night: Life and Medicine in the Eleventh Hour by Sunita Puri, MD

This author also did an interview with Dr. Zubin Damiana (aka ZDoggMD):

When Breath Becomes Air by Paul Kalanithi, MD

Being Mortal by Atul Gawande, MD, MPH

Curbsiders #38 Hospice and palliative care: How to manage end of life symptoms

Disclaimer: This content is for informational purposes only and should not be taken as medical advice or construed as the basis of a patient-provider relationship. Always seek the advice of a physician or other qualified clinician with any questions you have regarding a medical condition or treatment plan. Opinions/recommendations are my own and do not necessarily represent the views of Excelled Healing, LLC.