Basic Palliative Care: Not for Experts Only

Roxanne Nelson

March 06, 2013

Palliative care was recently granted formal specialty status by the American Board of Medical Specialties. Despite the growing number of clinicians specializing in this field, "basic palliative skills" need to be part of the model for all providers, according to an essay published online in the New England Journal of Medicine.

The demand for palliative care is growing, and the specialty itself has experienced rapid growth, write Timothy E. Quill, MD, from the University of Rochester Medical Center in New York, and Amy P. Abernethy, MD, from the Duke University School of Medicine in Durham, North Carolina. However, they assert that some of the "core elements of palliative care, such as aligning treatment with a patient's goals and basic symptom management, should be routine aspects of care delivered by any practitioner."

To some degree, that is happening now; more physicians are taking an interest in palliative care, Dr. Quill told Medscape Medical News.

"But the knowledge base in primary palliative care among nonpalliative specialists and primary care physicians is uneven at best," said Dr. Quill, who is president of the American Academy of Hospice and Palliative Medicine. "There needs to be additional training to bring the basic level up to standard. That is part of what we are proposing."

The importance of palliative care interventions in the provision of high-quality oncology care has been recognized. Last year, the American Society of Clinical Oncology (ASCO) issued recommendations on the optimal provision of palliative care to patients with cancer. A provisional clinical opinion from ASCO noted that "combined standard oncology care and palliative care should be considered early in the course of illness for any patient with metastatic cancer and/or high symptom burden," and that "substantial evidence demonstrates that palliative care — when combined with standard cancer care or as the main focus of care — leads to better patient and caregiver outcomes."

Palliative care grew out of the hospice tradition, Drs. Quill and Abernethy explain, when this type of care was being delivered primarily at the end of life. Now palliative care is being given at earlier stages of the disease, alongside standard medical treatment, which improves the quality of care.

Although it seems theoretically optimal for specialists to perform all aspects of palliative care, Drs. Quill and Abernethy caution that this might not be the best approach.

First, they point out that the number of palliative care providers will be unable to keep pace with the increasing demand for such care. There is nowhere near enough palliative care specialists to provide for every patient in need of this type of care.

Second, many aspects of palliative care can be administered by clinicians caring for the patient. The addition of another specialist to address "all suffering may unintentionally undermine existing therapeutic relationships," they write.

Finally, they explain that if palliative care specialists take over all aspects of palliative care, primary care physicians and other specialists might begin to believe that the management of basic symptoms and psychosocial support are not their responsibility. This could cause further fragmentation of care.

Instead, Drs. Quill and Abernethy believe a model is needed that distinguishes primary palliative care (skills that all clinicians should have) from the care of specialists who are equipped to manage complex and difficult cases. Ideally, they will coexist and support each other.

Every medical specialty, including oncology, critical care, and surgery, and every health system "need to delineate basic expectations regarding primary palliative care skills to be learned and practiced by its members," Drs. Quill and Abernethy write. In addition, a triage system to help decide when palliative care specialists are needed should be implemented.

Representative Skill Sets for Primary and Specialty Palliative Care
Primary palliative care
— Basic management of pain and symptoms
— Basic management of depression and anxiety
— Basic discussions regarding prognosis, treatment goals, suffering, and code status
Specialty palliative care
— Management of refractory pain and other symptoms
— Management of more complex depression, anxiety, grief, and existential distress
— Assistance with conflict resolution regarding goals or methods of treatment within family units, between staff and families, and among the healthcare teams

Educating   providers is a starting point, Drs. Quill and Abernethy note, and existing training workshops are a model to begin with. Oncotalk, for example, is a program designed for oncology fellows to learn and practice basic palliative care skills under supervision. In addition, the Agency for Healthcare Research and Quality, in collaboration with the American Academy of Hospice and Palliative Medicine, recently funded a grant to ASCO to develop a primary palliative care curriculum for oncology that is based on current best evidence. The goal is to enhance understanding of the basic principles of palliative care among oncologists, while acknowledging that complex scenarios and refractory suffering should be addressed by palliative medicine specialists.

Dr. Quill believes that clinicians are interested in learning about and practicing basic palliative care. "Clinicians who work with very ill patients are not blind to their suffering," he explained, "but their skill set to address different dimensions may be limited or very uneven."

He believes that, increasingly, oncologists will incorporate basic palliative care into practice and draw on specialists for the more complex cases. Therefore, "we will need to develop Oncotalk-like programs geared toward other specialists and primary care clinicians," Dr. Quill said.

The coordinated palliative care model could simplify the healthcare system and reinforce existing relationships, Drs. Quill and Abernethy note. It would enhance the skills of all clinicians and improve their ability to provide basic palliative care. Satisfaction might also increase, because it will "enable deeper, more meaningful relationships with patients across the continuum of care."

As an added benefit, the model might help control healthcare costs by decreasing the number of specialists needed to routinely comanage patient care.

"There has been increasing emphasis on including palliative care as a fundamental part of the care of people with serious illness because it leads to better quality of life, less depression, less healthcare waste, and maybe even longer survival," said Dr. Abernethy in a statement. "Better symptom control, defining and aligning goals of care, and attention to the needs of the family are just some of the fundamental principles of palliative care to be included in the generalist and specialist palliative care toolbox," she added.

N Engl J Med. Published online March 6, 2013. Abstract