Principles of Palliative Care Medicine
Palliative care is a patient and family-centered approach that focuses on improving quality of life through early identification, assessment, and treatment of pain and other physical, psychological, emotional, and spiritual distress for patients with serious illnesses, regardless of disease stage or need for other therapies. 1
Core Principles of Palliative Care
Holistic Approach to Care
- Palliative care addresses the whole person, including physical, psychological, social, and spiritual dimensions of suffering 1
- Care should be delivered concurrently with curative or life-prolonging treatments rather than only at end-of-life 1
- The goal is to prevent and relieve suffering while supporting the best possible quality of life for patients and families 1
Patient and Family-Centered Care
- Care should be tailored to patient/family needs, values, beliefs, and cultural preferences 1
- Family is considered the unit of care, with support extending beyond the patient's death through bereavement services 1, 2
- Caregiver support and screening for caregiver fatigue should be integrated into routine care 1
Integrated and Individualized Model
- Palliative care should begin at diagnosis of serious illness and continue throughout the disease trajectory 1
- The intensity of palliative care should vary based on patient and family needs, not just prognosis 1
- Care should be delivered through an interdisciplinary team approach 1
Communication Excellence
- Excellence in communication is essential for advance care planning, goals of care discussions, and prognostication 1
- Regular reassessment of goals of care should occur, especially at sentinel events (hospital admission, new complications) 1
- Facilitating patient autonomy and access to information is a key component 1
Palliative Care Screening and Assessment
Screening Criteria
- All patients should be screened at every visit for: 1
- Uncontrolled symptoms
- Moderate to severe distress related to diagnosis and therapy
- Serious comorbid conditions
- Limited life expectancy
- Patient/family concerns about disease course and decision-making
- Specific requests for palliative care
Comprehensive Assessment
- Assessment should evaluate: 1
- Benefits and risks of disease-directed therapy
- Physical symptoms requiring management
- Psychological, social, or spiritual distress
- Personal goals and expectations
- Educational and informational needs
- Cultural factors affecting care
Delivery Models of Palliative Care
Primary vs. Specialist Palliative Care
- Primary palliative care: Delivered by clinicians who are not palliative care specialists 1
- Specialist palliative care: Provided by clinicians with dedicated training/certification in palliative medicine 1
- Clear triggers and pathways for specialist referral should be established 1
Distinction from Hospice Care
- Palliative care can be provided at any stage of illness, concurrently with curative treatments 2
- Hospice care is specifically for patients with prognosis of 6 months or less if disease follows expected course 2
- Hospice typically involves discontinuing curative treatments while palliative care does not require this 2
Common Pitfalls to Avoid
- Delaying palliative care until end-of-life, as early integration improves both quality and duration of life 2
- Failing to complete advance care planning early in the course of serious illness 2
- Focusing only on physical symptoms while neglecting psychological, social, and spiritual needs 1
- Inadequate assessment and management of caregiver needs 1
- Lack of clear communication about prognosis and goals of care 1
Symptom Management Principles
- Use the lowest effective dosage of medications for the shortest duration consistent with treatment goals 3
- Monitor patients closely for adverse effects, especially respiratory depression with opioids 3
- Titrate medications individually to achieve adequate symptom control while minimizing side effects 3
- Consider both pharmacological and non-pharmacological approaches to symptom management 4
By implementing these principles, healthcare providers can deliver comprehensive palliative care that improves quality of life, reduces suffering, and supports patients and families throughout the illness trajectory.