By Wayne S Saltsman, MD, PhD, CMD, CPE, Senior Medical Director at CCA and
Meghan Malone-Moses, MPH, Clinical Research Manager at CCA

While all hospice care is palliative, not all palliative care includes hospice. This critical distinction is often misunderstood—sometimes to the detriment of patient care.

Palliative care aims to improve the quality of life for people with serious illness by relieving symptoms and stress with a holistic approach focused on mind, body, and spirit. A serious illness is defined as “a condition that carries a high risk of mortality, negatively impacts quality of life and daily function, and is burdensome in symptoms, treatments, or caregiver stress.”¹ However, a diagnosis of a serious illness does not always equate with end-of-life. In fact, unlike hospice, palliative care can be offered to anyone with a serious illness, at any stage of the condition. Palliative care can still align with treatment-focused and curative care; it integrates into the care already being provided and is not meant to replace it.

When or if that serious illness becomes terminal, and the person’s mortality prognosis is six months or less, the person may choose to shift away from curative treatments and into hospice care. At this stage, the goals change to carrying out a patient’s wishes and ensuring comfort as they transition toward end of life.

The Benefits of Palliative Care

When a patient is diagnosed with a serious illness, there is no reason to wait for palliative care. In fact, incorrect inferences about palliative care by patients and their clinicians can lead to a delay in receiving stabilizing services. With its focus on a patient’s symptom management, quality of life, and goals of care, palliative care is designed to help patients and their caregivers navigate the physical and emotional consequences that a serious illness diagnosis can elicit. Palliative care is a proactive approach to overcoming illness issues that can lead to further decline; it helps anticipate changing needs and wishes and promote a fuller life.

For example, a 40-year-old woman who is diagnosed with breast cancer may benefit greatly from receiving palliative care services. To cure this serious illness, she may require chemotherapy and/or surgery. However, during her treatment she may also experience pain, nausea, and other symptoms that need to be addressed to increase comfort and improve her quality of life. She may also benefit from identifying and documenting her specific goals of care, which could provide her and her family with a sense of control during this uncertain time. She would also likely benefit from care that addresses the psychosocial impacts of a cancer diagnosis to ensure she and her caregivers are prepared and supported emotionally. Palliative care focuses on all these aspects of serious illness.  

Instead of reacting to her treatment sequelae, the palliative care team can provide services proactively to avoid unnecessary physical and psychosocial discomfort, which, in turn, can improve the tolerability of the process and offer her and her family a sense of security. Once she has recovered and is stable, she could be discharged from the service.

Palliative Care Increases a Patient’s Choices

Palliative care, a specialty consultative service, offers additional time, planning, and benefits that supplement and support primary or specialty care services already being provided. When someone with a serious illness begins palliative care, they work closely with their palliative care team to understand their illness and its course so that they are intellectually and emotionally prepared to make informed choices about the care and support they may desire moving forward. The palliative care team focuses on understanding and honoring the patient’s and caregiver’s physical and emotional needs, values, preferences, and goals for care. With this trust and connection established, they can work closely with the primary and specialty care teams to ensure that the right type and level of care is delivered at the right time. This collaborative approach enhances the patient’s satisfaction and expectations for care.

Benefits of Early Palliative Care

Because the role and offerings of palliative care are often misunderstood, many clinicians fail to consider palliative care in a timely manner. It is not uncommon for a clinical colleague to comment that “it is not time for palliative care yet”. This can lead to unnecessary pain and suffering or lost opportunities to better understand and support a patient’s goals and preferences. However, evidence shows that early palliative care—offered further upstream in the disease trajectory or closer to the diagnosis of a serious illness—is associated with improved quality of life^2,3 and symptoms² and is recommended by clinical practice guidelines.⁴ The sooner a palliative care team can connect with a patient after diagnosis of a serious illness, the greater the impact and benefits that can be realized through coordination and integration with standard treatment that aligns with the patients’ values, beliefs, and goals.

In addition, palliative care has proven to be cost-effective due to a basic tenant: shared decision making. When patients are engaged in their care decisions and presented with reasonable options, they are more likely to feel empowered and informed, choose less-invasive treatments, report improved satisfaction, and incur lower costs and patient safety concerns.⁵ Cost-avoidance and lower cost settings for care are aligned with greater satisfaction and higher quality care: a win-win for both patients and the healthcare system. 

At its essence, palliative care is about helping people through a serious illness by lowering their symptom burden, advocating for quality of life holistically, and empowering them through advance care planning. 

Palliative Care for People with Complex Needs

Commonwealth Care Alliance® (CCA) has developed a community-based palliative care program to support its members and their caregivers with a specialized team that provides consultative, holistic care with attention to resource stewardship. The program is designed to reach individuals with serious illness early in their trajectory through predictive analytics and clinician referral.

CCA’s palliative care program is designed to allow curative and symptomatic treatment to naturally merge.

The CCA program was specially designed to address the unique needs of CCA’s dual-eligible patient population. Therefore, it is well-positioned to provide palliative services to all patients, regardless of the level or type of palliative support needed. The palliative care team partners with the rest of the patient’s interdisciplinary care team at CCA and their network providers to deliver community-based palliative care services wherever patients live, whether at home, in a nursing home, group home, shelter, or assisted living facility.

Key aims of CCA’s palliative care program:

• Deliver specialized, culturally intelligent palliative care that is flexible and designed to meet the medically and/or behaviorally complex care needs of patients in a community-based setting.
• Provide education and consultation for all providers caring for members with complex healthcare needs. This is offered to both CCA care teams and to our network providers.
• Create a culture change regarding palliative care by concentrating on “quality of life focused care” that is directed by patient goals. This allows curative and symptomatic treatment to naturally merge. Conversations about goals of care occur throughout the continuum rather than only at end of life. The conversation evolves as a process, not an event. 
• Improve quality of life for patients and their caregivers through a person-centered approach that focuses on the patient’s unique needs and specific goals of care at all stages of the serious illness.
• Reduce avoidable spending and utilization in all settings through 1) the use of shared decision making, 2) provision of more consistent palliative consults, and 3) alignment of care to member goals.

CCA’s palliative care program was designed as a high-touch, specialty program to meet the unique needs related to members’ serious illnesses. Close integration with a member’s other care providers and the ability to reach those members earlier in their disease trajectory allows CCA to proactively address and positively impact their physical and emotional health. With a goal of improving quality of life, palliative care should be considered for all patients with serious illness—the earlier, the better.

References:

¹ Kelley AS. Defining “serious illness”. J Palliat Med. 2014;17(9):985. doi:10.1089/jpm.2014.0164

² Haun MW, Estel S, Rücker G, et al. Early palliative care for adults with advanced cancer. Cochrane Database Syst Rev. 2017;6(6):CD011129.

³ Gaertner J, Siemens W, Meerpohl JJ, et al. Effect of specialist palliative care services on quality of life in adults with advanced incurable illness in hospital, hospice, or community settings: systematic review and meta-analysis. BMJ. 2017;357:j2925

⁴ Ferrell BR, Temel JS, Temin S, et al. Integration of Palliative Care Into Standard Oncology Care: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol. 2017;35(1):96-112

⁵ Castro EM, Van Regenmortel T, Vanhaecht K, Sermeus W, Van Hecke A. Patient empowerment, patient participation and patient-centeredness in hospital care: A concept analysis based on a literature review. Patient Educ Couns. 2016;99(12):1923-1939