November 2019
Palliative Medicine and Hospice Care: Practical, Comforting Options to Help Empower Patients and their Families
By: Dr. Derek J. Robinson, M.D., MBA, FACEP, CHCQM, Vice President and Chief Medical Officer, Blue Cross and Blue Shield of Illinois (BCBSIL)
We are committed to helping to promote the health and wellness of our members. To that end, we emphasize the importance of promoting quality of life for those with serious, chronic conditions such as multiple sclerosis or lupus, as well as illnesses that can be life-limiting, such as cancer or advanced cardiopulmonary diseases. Individuals with serious illnesses may have physical and emotional symptoms related to the illness itself, or the treatment of the illness, and they may need help clarifying their options and priorities as their illnesses progress. When faced with physically and emotionally challenging health conditions, your patients and their families may not be aware of health care options that may be available to provide support.
Palliative medicine can help ease physical, psychosocial and spiritual distress while also helping patients clarify their health care goals at various stages of illness. The basic goal of palliative medicine is to help people continue to lead their lives as fully as possible according to what is important to them in terms of comfort level and quality of life. Palliative medicine can be initiated anytime when someone is diagnosed with a serious illness, regardless of whether the illness is life-limiting. Palliative medicine is often associated with hospice care, but palliative medicine is broader. Hospice care focuses on maximizing comfort for a patient suffering from a life-limiting illness if comfort has emerged as the patient’s primary goal of care. Palliative care is about emphasizing treatments and interventions focused on comfort and quality of life while still pursuing strategies focused on maximizing life.1
Both palliative medicine and hospice care involve specialized medical services offered by interdisciplinary teams of physicians, nurses, social workers and chaplains. The purpose of this health care team is to focus on the person as a whole – and not just their illness – to provide additional support to patients, caregivers and family members. Palliative medicine is often coordinated through the primary provider or specialist and can occur in the hospital, clinic or home setting. Hospice aims to provide services to where one chooses to live and therefore usually and preferably occurs in one’s home, but depending on acute patient needs, also occurs in dedicated inpatient hospice facilities. Both palliative medicine and hospice involve aggressive management of symptoms, including but certainly not limited to controlling pain. Managing other troubling symptoms, such as nausea, constipation, shortness of breath, cough, fatigue, anxiety and depression is often involved, too. Addressing the goals of care and the associated psychological and spiritual implications for patients with life-threatening illnesses and their loved ones is often a large component of both hospice care and palliative medicine.
Recognizing the value of offering early palliative care to patients with life-threatening illnesses is important. For example, for patients with cancer, palliative medicine may be offered to help improve symptom management and quality of life while still pursuing chemotherapy. In fact, studies have shown that patients with lung cancer who received palliative care had a higher quality of life in terms of physical, functional, emotional and social well-being, with less depressive symptoms compared to patients who did not receive focused symptom management.2 Patients receiving early palliative care were also more likely to receive less aggressive end-of-life care when the benefits of continued life-sustaining treatments were more limited, since, despite receiving less aggressive care, median survival was longer among patients receiving early palliative care.3 Clearly, early palliative care can be beneficial by empowering individuals with a practical approach to accepting and managing their conditions with a focus on living.
Access to palliative medicine continues to grow. For U.S. hospitals with 50 or more beds – hospitals that currently service 87% of all U.S. hospitalized patients – 72% have an inpatient palliative care team.4 The growth of these programs has been dramatic: up from 67% in 2015, 53% in 2008, and just 7% in 2001.5 This rapid development is even more impressive when considering that the American Board of Medical Specialties only recognized the field as an independent specialty in 2006 with the first certifications issued in 2008.6
It is not surprising that the growth of the field has centered around hospitals. These programs historically arose out of the need to assist primary care doctors, hospitalists and a range of specialists to manage complicated, end-of-life situations, particularly assisting medical teams with challenging shared decision-making involving the goals of care. However, these hospital-based palliative care programs are continuing to expand their range of services and increasingly offering outpatient availability in the clinic setting. Likewise, facilities that historically offered hospice services are also expanding their palliative care services beyond the hospice population to provide patients and their families with palliative care home nursing services using clinicians who are well-trained and comfortable managing symptoms in patients with serious illnesses.
We anticipate and hope that palliative care services will continue to grow in the outpatient setting. We look forward to working with palliative medicine clinicians throughout Illinois, including in rural areas, to continue to expand access to these vital services beyond the hospital to the outpatient setting, and, as much as possible, into patient homes where this care may have the greatest effect for our members and their families. |
Do you have ideas or comments you’d like to share on this important topic? Please email our Blue Review editor with any thoughts or feedback. We value your input!
Learn more about Dr. Derek J. Robinson
1 Kelley AS, Morrison RS. Palliative Care for the Seriously Ill. N Engl J Med. 2015 Aug 20;373(8):747-55. Available at https://www.nejm.org/doi/full/10.1056/NEJMra1404684.
2,3 Temel JS, et al. "Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer." N Engl J Med 2010. 363(8):733-742. Available at https://www.nejm.org/doi/full/10.1056/NEJMoa1000678
4,5 Best and Worst States Providing Access To Palliative Care 2019: State-By-State Report Card Shows Rapid Growth, But Gaps In Care Remain. Center to Advance Palliative Care. Sept. 26, 2019. Available at https://www.capc.org/about/press-media/press-releases/2019-9-26/best-and-worst-states-providing-access-palliative-care-2019-state-state-report-card-shows-rapid-growth-gaps-care-remain/.
6 American Board of Medical Specialties Board Certification Report, 2017-2018. Available at https://www.abms.org/media/194885/abms-board-certification-report-2017-2018.pdf.
The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. References to third party sources or organizations are not a representation, warranty or endorsement of such organizations. Any questions regarding those organizations should be addressed to them directly. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.