In inpatient settings, family physicians frequently care for patients with progressive, incurable conditions that cause severe pain. Interventions aimed at slowing the progress of a disease often add to patients' physical distress; therefore, pharmacologic management of pain is a key component of end-of-life care, as outlined in an article in the July 1st issue of American Family Physician. However, as Drs. Timothy Daaleman and Margaret Helton discuss in an accompanying editorial, providing analgesia is only the starting point for effective palliative care:
Palliative care generally begins with diagnosis of a life-limiting disease and initiation of an ongoing conversation on the goals of care and treatment. This often begins in patient-centered medical homes, continues through acute hospitalizations, and may conclude in long-term care facilities. At each point, family physicians may be called on to provide primary palliative care and can expect to encounter nonpharmacologic challenges in managing pain.
Misconceptions about palliative care are common. For example, many believe that palliative care, like hospice care, cannot be offered to patients who are still pursuing "aggressive" treatments such as chemotherapy for cancer. On the contrary, one of the American Academy of Hospice and Palliative Medicine's Choosing Wisely recommendations states, "Don’t delay palliative care for a patient with serious illness who has physical, psychological, social or spiritual distress because they are pursuing disease-directed treatment." Palliative care does not necessarily increase patient comfort at the cost of shortening life; in a randomized trial of patients with metastatic non-small-cell lung cancer, patients assigned to early palliative care not only experienced better quality of life and fewer symptoms of depression than patients receiving standard care, they actually lived more than two months longer.
The recent announcement by a large health insurance company in the Pacific Northwest that it will prioritize palliative care by training physicians and caregivers about having appropriate end-of-life conversations; and pay for previously unreimbursed home health services and counseling about advanced directive planning suggests that policymakers are finally recognizing the value of improving the availability of palliative care to appropriate patients. What have been your experiences with connecting patients or loved ones to palliative care services?