For a Modern Concept of Palliative Care

Pain relief and palliative care Unit, La Maddalena Cancer Center, Palermo, and University of Palermo, Italy

*Corresponding Author:

Dr. Sebastiano Mercadante
Pain Relief and Palliative Care Unit
La Maddalena Cancer Center
Via San Lorenzo Colli 312, 90146, Palermo, Italy
E-mail: terapiadeldolore@lamaddalenanet.it, 03sebelle@gmail.com

Received date: December 14, 2011; Accepted date: December 16, 2011; Published date: December 18, 2011

Citation: Mercadante S (2012) For a Modern Concept of Palliative Care. J Palliative Care Med 2:e105. doi:10.4172/2165-7386.1000e105

Copyright: © 2012 Mercadante S. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Palliative care culture has grown from the sixties. During the 1970’ various organizations, usually charities or no-profit organizations, developed hospice care for patients with advanced stage disease. In the last decade there have been investments in the field of community care and health districts under the input of new legislations, and new resources from the Health Care System have been allocated for palliative care. In Italy, for example, active centres involved in palliative care progressively increased with a large distribution in Northern Italy, and more than 200 hospices are now available for cancer and non cancer palliative care population [1].

Unfortunately, in most countries hospice care addresses end-of life care. In Italy, for example, despite a new law has generated much interest in palliative care and pain control in Italy, also facilitating opioid prescription, institutional indications have suggested that the palliative care network should be formed by home care and hospice care only, excluding the vast majority of patients living some years or months during the course of disease. This limited network may result in more expenses due to inappropriate admissions in hospitals without expertise in palliative care while excluding most patients for a large period of time for prolonged periods of time, when they should need a specific help in pain and symptom management. Patients are referred to palliative care only in the last weeks of life, as reported in many studies in home care setting [1,2]. This aspect was even underlined in very specialized centers in other countries [3].

In fact the most relevant findings of palliative care population are the short survival either at home or in hospice and the high number of patients dying in hospice. In the last three months before hospice admission, most patients are admitted to hospital and spent about 1/3 of this period in hospital, and half of them received chemotherapy in the last month of life. Thus, home care and hospice patients receive specialized palliative care only for 2-3 weeks before death, implying an inacceptable timing for patients with several problems presumed to be present early during the course of disease. This is confirmed by the large number of hospital admissions in different acute settings expected to not providing specialized palliative care resulting in a low level of cost-effectiveness [4] .

This approach is misleading and contradicted by many experiences the duration of survival of patients enrolled in hospice programs is an important measure to assess the appropriateness of timing of referral of terminally ill patients to palliative care. In a national follow-back survey representative of Italian population, 51% of patients died at home, meaning that many patients were admitted to acute wards unfit to provide end-of-life care [5]. Finally, about 25% of patients followed at home presented severe symptom intensity for which home care was practically impossible, suggesting that the best option would probably be the admission to hospices or specialized inpatients hospital units. More recently, 10% of patients followed at home were admitted to acute wards unfit to provide end-of-life care hospital [3]. This late referral to palliative care is also in contrast with the classical definition of palliative care provided by WHO: “Palliative care is ….. applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications” [6]. Finally, recent scientific evidence in a population subgroup confirms this WHO statement either for quality of life as well as survival. As compared with patients receiving standard care, patients receiving early palliative care had less aggressive care at the end of life but longer survival [7]. Futile treatments should be limited [8,9].

Recent evidence strongly suggests to spread palliative care in other settings, other than traditional home care and hospice, to intercept oncologic patients in their disease trajectory early, for example in high volume oncologic departments, rather than restricting the action area only in the last weeks of life [10-16]. While oncologist should be comfortable with the competencies related to symptom management, psychological interventions, communication, and transition of care, for patients with severe distress, early referral to an interdisciplinary supportive/palliative care team should be recommended [17].

References

1. Mercadante S, Vitrano V (2010) Palliative care in Italy: problems areas emerging from the literature. Minerva Anestesiol 76: 1060-1071.
2. Mercadante S, Valle A, Porzio G, Costanzo BV, Fusco F, et al. (2011) How do cancer patients receiving palliative care at home die? A descriptive study. J Pain Symptom Manage 42: 702-709.
3. Cheng WW, Willey J, Palmer JL, Zhang T, Bruera E (2005) Interval between palliative care referral and death among patients treated at a comprehensive cancer center. J Palliat Med 8: 1025-1032.
4. Mercadante S, Valle A, Sabba S, Orlando A, Guolo F, et al. Pattern and characteristics of advanced cancer patients admitted to hospice in Italy, submitted.
5. Costantini M, Beccaro M, Merlo F (2005) The last three months of life of Italian cancer patients. Methods, sample characteristics and response rate of he Italian Survey of the Dying of cancer (ISDOC). Palliat Med 19:628-638.
6. http://www.who.int/cancer/palliative/definition/en/
7. Temel J, Greer J, Muzikansky A, Gallagher ER, Admane S et al. (2010) Early palliative care for patients with metastatic non-small-cell lung cancer. N Eng J Med 363: 733-742.
8. Earle C, Landrum MB, Souza J, Neville B, Weeks J, et al. (2008) Aggressiveness of cancer care near the end of life: is it a quality-of- care issue? J Clin Oncol 26: 3860-3866.
9. Saito AM, Landrum MB, Neville BA, Ayanian JZ, Earle CC (2011) The effect on survival of continuing chemotherapy to near death. BMC Palliat Care 10:14.
10. Mercadante S, Villari P, Ferrera P (2003) A model of acute symptom control unit: Pain Relief and Palliative Care Unit of La Maddalena Cancer Center. Support Care Cancer 11: 114-119.
11. Mercadante S, Intravaia G, Villari P, Ferrera P, David F, et al. (2008) Clinical and financial analysis of an acute palliative care unit in an oncological department. Palliat Med 22: 760-767.
12. Smith T, Coyne P, Cassel B, Penberthy L, Hopson A, et al. (2003) A highvolume specialist palliative care unit and team may reduce in-hospital end-oflife care costs. J Palliat Med 6: 699-705.
13. Braiteh F, El Osta B, Palmer L, Reddy S, Bruera E (2007) Characteristics, findings, and outomes of palliative care inpatient consultations at a comprehensive cancer center. J Palliat Med 10: 948-955.
14. Hui D, Elsayem A, Palla S, De La Cruz M, Li Z, et al. (2010) Discharge outcomes and survival of patients with advanced cancer admitted to an acute palliative care unit at a comprehensive cancer center. J Palliat Med 12: 49-57.
15. Lagman R, Rivera N, Walsh D, LeGrand S, Davis MP (2007) Acute inpatient palliative medicine in a cancer center: clinical problems and medical interventions. A prospective study. J Palliat Med 24: 20-28.
16. Rigby A, Krzyzanowska M, Swami N, Coe G, Rodin G, et al. (2008) Impact of opening an acute palliative care unit on administrative outcomes for a general oncology ward. Cancer 113: 3267-3274.
17. Bruera E, Hui D (2010) Integrating supportive and palliative care in the trajectory of cancer: establishing goals and models of care. J Clin Oncol 28: 4013-4017.