This is the first in a four-part series about palliative care.
For many patients, the words “palliative care" strike a chord of fear, as they closely associate that term with "hospice care" and end-of-life treatment.
But palliative and hospice care are actually two separate ways that doctors, nurses, mental health professionals and social workers help patients feel comfortable as they deal with an illness.
"People can receive palliative care at any stage of an illness. They don't have to be within the last six months of life, or in the end-of-life stage, which is what differentiates it from hospice care," explained Chandana Banerjee, M.D., M.P.A., assistant clinical professor in the Department of Supportive Care Medicine.
Palliative care is included within hospice care to keep hospice patients comfortable, because what palliative care does is focus on symptom management," she explained.Hospice care is a service available to patients with a prognosis of six or fewer months to live who are no longer receiving curative treatments.
At City of Hope, palliative care falls under the larger umbrella of the Department of Supportive Care Medicine, which is dedicated to helping both patients and their families cope with the physical and emotional issues that surround the treatment of a complex disease. “The department is comprised of other professionals from departments such as psychology, psychiatry, spiritual care and social work. All of us work together with hematology and oncology to help the patient achieve the best possible outcomes,” Banerjee said. “If the disease still progresses and the patient has a poor prognosis, the palliative medicine physicians work with the other teams to discuss the goals of care and options for the patient, which sometimes may mean referring them to hospice.”
Palliative Care: A Deeper Look
Banerjee clarifies exactly what palliative care means to patients going through what she calls "chronic complex diseases," particularly cancer and other life-threatening illnesses: "Palliative care's goal is to help manage physical, emotional, spiritual and psychosocial issues for patients to enable them to live longer, happier lives." This supportive care encompasses a wide range of treatments, beginning with symptom management. "We assess patients often for symptoms that they're having secondary to the effects of treatment plans or the disease itself," Banerjee said.
If the patient is in pain, that means putting them on opioids or other pain medications, as necessary. “If they have issues with nausea and vomiting, we can put them on antiemetics. We know that opioids are famous for causing constipation, so we always counsel our patients and put them on a bowel regimen. We also manage symptoms like fatigue and shortness of breath," Banerjee said.
There is an entire team to support the patient and his or her and loved ones emotionally as well. "We work very closely with psychologists and psychiatrists, as well as spiritual care and social workers, to provide the full scope of care that a patient might need. They have a lot of issues that they're dealing with, not only on a personal level, but also in terms of family dynamics and caregiver burnout," Banerjee added.
Hospice Care: Easing the End-of-Life Experience
Hospice-care service, be it in a specially designated facility or managed at home, is begun when, according to Banerjee, "the curative treatment is no longer an option."
At this point, palliative care meshes with hospice care, all with a single goal: to keep the dying person comfortable. This goal is met with both physical and spiritual guidance, offered by a team of caregivers. Alleviating the physical symptoms (which include pain, nausea, constipation, shortness of breath, agitation and delirium) as well as the emotional distress — the "existential suffering" caused by the knowledge of death's proximity — are the elements that hospice care doctors and the rest of the hospice team focus on, as the patient spends months, weeks or only days in their care. Providing comfort and quality of life as someone approaches the end of their time on earth is the main purpose of hospice care.
At City of Hope, palliative care services are available to all patients in the 217-bed hospital and ambulatory clinics devoted to patients with cancer. According to Banerjee, there may be as many as 50 patients in the inpatient setting at any one time who are on the palliative care consult service, whether for symptom management or other needs identified by the oncology and hematology teams. Hospice care on the City of Hope campus is currently limited to four beds, but plans are underway to add more. Others are referred to hospice agencies in their home regions. Studies show that most patients prefer to die at home to be in the presence of their families and loved ones, and that becomes one of the goals when deciding on the location for hospice service.
Regardless of whether a patient needs palliative care or end-of-life hospice care, one thing is consistent in the experience for both, as the key to both treatments is reducing pain and other physical suffering while addressing emotional, psychosocial and spiritual issues. "The focus is on quality of life, and on a comfortable end of life when the time is near,” Banerjee said.