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Thread: Basic Palliative Care: Not for Experts Only

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    Default Basic Palliative Care: Not for Experts Only

    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.

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  2. #2
    PharmD Candidate Xavier's Avatar
    Join Date
    Sep 2013


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

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