Time for Change: Integrating Palliative Medicine to Mainstream Medicine

Palliative medicine worldwide suffers from an identity crisis, as most health care professionals perceive it synonymous with end-of-life care. This misdirected opinion is partially due to present set of clinicians who practice palliative medicine and deliver their services through hospice care or inpatient consultation only after life-prolonging treatment has failed. This limitation of specialty palliative medicine to those chosen population excludes a majority of patients who are facing a serious life-limiting illness and has physical and psychological symptoms throughout their disease trajectory.

The emerging trends in modern palliative medicine are (1) acute palliative care unit (APCU) model, (2) simultaneous and shared care model and (3) integrated model. These emerging trends are reinventing and redefining the palliative medicine and aim to swing back the pendulum to normalcy such that the specialty of palliative medicine is perceived as “Treatment” rather than just “Care”.

An APCU model is different from the traditional PCU model. In the PCU model palliative interventions are provided only after acute interventions have failed and patients have been transferred to the PCU for comfort care only. In the APCU model in addition to counseling and symptom management measures, all clinically indicated interventions (e.g. hydration, opioid analgesia, anti-infective, bisphosphonates, blood products, interventional procedures, radiation therapy, oral chemotherapy, and bi-level positive airway pressure machines etc.) are provided.

Various studies demonstrate that the APCU decreased mortality, decreased ICU admission, showed better delirium control and had higher degrees of family acceptance and satisfaction. The APCU was successful at managing symptoms and facilitating the discharge of both ward inpatients and emergency department admission patients alive with symptoms better controlled back to the community. The APCU model facilitates successful development of an in-hospital mortality algorithm and would enable quality improvement efforts at the institutional level. It would also assist patients and health professionals in end-of-life decision making and apt resource allocation. Sepsis, metabolic disturbances and need for supplemental oxygen are leading causes of death in the APCU which may not be recognized and treated at all in a PCU setting.

Patients admitted to the APCU are now receiving low-intensity palliative chemotherapy and radiotherapy. Newer oral agents/targeted therapy has fewer adverse effects providing a chance for both improved length and quality of life. These patients have access to both palliative care and oncology teams; the care is simultaneous and shared which highlights the key advantage of an integrated palliative care program. Integrating palliative medicine into mainstream medical management would benefit patients, in terms of quality as well as quantity of life. Continuity of care, support, early assessment and management of symptoms and augmented physical well-being makes the therapeutic experience more acceptable to the patient and hence there are higher possibilities of completion of the disease modifying therapies. It would also determine and allow appropriate person-centered goals of care at various stages of the disease including a dignified, peaceful end of life experience.

The main purpose of the APCU is to provide sophisticated interdisciplinary transition from active care to end-of-life. For patients who are dying, the APCU enables optimal symptom control, with a focus on maximizing comfort measures for the terminally ill. For patients who are likely to go home, the APCU actively treats acute complications and symptoms related to the cancer and its treatments. For patients who are going to hospice, the APCU plays a critical role in facilitating a smooth and rapid transition, attending to patients' physical and psychosocial needs through inter-professional teamwork. Thus, the APCU facilitates complex decision-making and bridges the gap between acute care and the community.

To ensure that our patients receive the best care throughout their disease trajectory, it is important that the palliative care should be initiated alongside standard medical care. Integration of modern medical science and practices to current model of palliative medicine provision is quintessential for better patient outcomes such that palliative medicine is accepted as a broad specialty by other health care professionals as the one that provides a form of essential treatment in situations with life-limiting illness and not just the care.