INTRODUCTION TO PALLIATIVE CARE MEDICINE

Dr Maimoona Ali
Specialist Trainee in
Palliative Care
Medicine
Weston Park Cancer
Centre, Sheffield.
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 Objectives
What is Palliative care?
Describe the history and philosophy of Palliative Care
Identify the difference between palliative care and traditional medicine
Identify Barriers to effective palliative care
Palliative care settings ?
Who is palliative care for?
When to consider palliative care?
List the benefits of palliative care in patients with advanced illness.

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 Definition
Palliative care means patient and family‐centered care
that optimizes quality of life

by anticipating,

preventing, and

treating suffering .

Palliative care throughout the continuum of illness

involves addressing physical, intellectual, emotional,
social, and spiritual needs and to facilitate patient
autonomy, access to information, and choice.

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 PALLIATIVE CARE - WHO
An approach which improves QUALITY OF LIFE of PATIENTS and their
FAMILIES facing LIFE-THREATENING ILLNESS through prevention and
RELIEF OF SUFFERING by means of early identification and
impeccable assessment and treatment of pain and other problems,
physical, psychosocial and spiritual.
Cancer pain relief and palliative care. Geneva; World Health Organization: 2002
Palliative Care and the sub-speciality Palliative medicine, is specialised medical care of people living with
serious illness. It focuses on providing relief from the symptoms and stress of serious illness whatever the
diagnosis. The GOAL is to improve quality of Life for both patient and family.

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HOSPICE
HOS : Host PIS : Guest
Linguistic root words:
Hospital, Hospitality,
Shelter, Respite, Caring,
A place of refuge and solace

A place where pilgrims and travellers could find food and refuge
The religious orders also cared for the sick, dying and destitute

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PALLIATIVE CARE
Pallium : Cloak Cover

Palliative : To relieve without suffering

Hospitium : Place for host and guest

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Syrian hospices ?when Early 4th century
Fabiola (Roman Matron) ‘Christian works of mercy’
11th Century Jerusalem
1842 Mme. Jeanne Garnier (Lyons – France)
1879 Our Lady’s Hospice (Dublin)

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1905 St Joseph’s Hospice, Hackney
1963 Dame Saunders introduces the idea of specialized care for
dying to the United States in a lecture at Yale University.
1967 St Christopher’s Hospice (Dame Cecily
Saunders)
1950+ Organised Development

Independent Hospices, Marie Curie services, Sue Ryder Homes,

Clinical Specialist Nurses, IPU, Day Hospice, Hospice at Home

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 HISTORY
1979 Hospice is promoted through the film “Hospice: An Alternative
Way of Care for the Dying.”
1988 Royal College of Physicians London became first
authority to recognise it as a specialty
1989 WHO pain ladder
1990 WHO issues first definition
1996 First specialty training programme in the world in UK

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 Palliative Care in Pakistan
Shaukat Khanum Cancer Memorial Hospital and Research centre
Agha Khan Hospital, Karachi
Shifa International Hospital, Islamabad
Cancer Care Hospital and Research Centre, Lahore
Relatively minimal public awareness
CPSP- does not recognise Palliative care as speciality for training (UK 1996)
Palliative care as subject not part of curriculum for medical or nursing education
 Shaheen Palliative Care Project of Pakistan- Post Graduate Certificate in Palliative Care

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PALLIATIVE MEDICINE
Specialist: Hospices, Palliative care teams, In-patient Units,
Domiciliary Advice

Generalist: Community and Hospital

Every healthcare professional

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Quality Care?
Safe
Effective and reliable
Patient-centered
Quality Timely
Institute of Medicine, 2001
Efficient
Equitable

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 “Patient Centered Care”

What Are the Patient

wishes and
does family
of
the patient
goals
patient guide the
possible palliative
want? ? approach

Is the current system of medical care “patient and family centered”?

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BARRIERS TO EFFECTIVE PALLIATIVE CARE
Patient related:
Anxieties about death and dying
Fear
Lack of cultural acceptance of death and dying
Stigma that palliative care may cause patients to be depressed

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BARRIERS TO EFFECTIVE PALLIATIVE CARE
Professional related:
Anxieties about death and dying
Fear
Difficulty empathising with patients
Lack of education
Lack of resources

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BARRIERS TO EFFECTIVE PALLIATIVE CARE
Institution related:
Lack of resources
Lack of culture to prompt good deaths
Not economically beneficial

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BARRIERS TO EFFECTIVE PALLIATIVE CARE
Culture – related:
Lack of acceptance of death
Myths about death and dying
Lack of education
Lack of financial, emotional and leadership resources

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PALLIATIVE CARE SETTINGS
Hospital
Hospice
(Specialist Palliative care unit)
Community

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 Palliative Care VS Hospice Care
Question
Who can receive care?
Can I continue to receive treatments to cure my
illness?
Does private insurance pay?
How long can I receive care?
What organization provides these services?
Where are services provided?
Who provides Hospice and Palliative services?
Palliative Care Hospice Care
Anyone with a serious illness, regardless of life Someone with a life-threatening illness and a life
expectancy, can receive palliative care expectancy of six months or less. Talk with your
physician.
You may receive palliative care and treatment with Treatments and medicines aimed at relieving
curative intent at the same time symptoms are provided by hospice. The goal is
comfort not cure.
Certain treatments and medications may be Most private insurers have a hospice benefit
covered
This will depend upon your care needs As long as you meet the criteria of an illness with a
life expectancy of months not years
•Hospitals / Hospices •Hospice organizations
•Nursing Facilities •Hospice programs based out of a hospital
•Healthcare Clinics •Other healthcare organizations
•Home •Usually, wherever the patient resides. In their
•Assisted living facility home, assisted living facility, nursing facility, or
•Nursing facility hospital.
•Hospital •Some hospices have facilities where people can
live, like a hospice residence, or receive care for
short-term reasons, such as acute pain or symptom
management.
Doctors, nurses, social workers, therapists and A hospice team that consists of a medical doctor,
spiritual counselors.
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nurse, social worker, chaplain, volunteer, home
health aide and others.
Where you practice Palliative?
Anywhere
 Hospital Inpatient
Unit based
Consultation Team
 Outpatient
 Home
 Nursing Home
 Inpatient hospice

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Integrated Model Palliative Care
Therapies to modify disease Hospice

Palliative Care

Presentation Therapies to relieve Death

with serious suffering or improve Bereavement Care
illness quality of life

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When to initiate Palliative Care?
Any time in the course of serious illness

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Traditional Medicine

No cure for old age or death

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 Curative Palliative

Disease driven Symptoms driven

Cure specific issue Relief from serious illness / Suffering

Traditional
Disease process is primary Disease process is secondary to person, family
Object of analysis is the disease and illness
process

Care Evidenced based treatments Distressing symptoms are treated as entities,

vs
Symptoms are treated as clues to Treatments focussed at quality and comfort
diagnosis rather than evidence alone

Palliative Curative treatment has potential to Palliative care for serious illness not aimed at
extend overall length of life extension of life but relief

Care Primary value is on measureable Primary value is on subjective data

data, e.g. labs
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 Curative Model vs. Palliative Model
Devalues subjective information
Therapy indicated for eradication/ slowing
disease progression
Patients are viewed as collection of body parts
instead of as person.
Death is ultimate failure
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Values patient’s experience of illness
Therapy to control symptoms & to
relieve sufferings
Treatment is congruent with the values,
beliefs & concerns of patients & family,
evolves based on patient prognosis.
Success is enabling a patient to live
comfortably until he / she dies.
Examples of Palliative Care
& Traditional Care Overlap of Interventions
Variable Generally
Palliative Not Palliative
Support
Transfusions CPR
• Emotional
• Spiritual Infection Rx Ventilation
• Psychosocial Thromboembolism
Electrolytes- Highly
Control of Hypercalcemia burdensome
Interventions
• Pain Tracheostomy
• Dyspnea
Tube Feeding
• Nausea
• Vomiting Dialysis

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Palliative Care is for whom?

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 Palliative care for…..
Any chronic complex illness
◦Incurable cancer
◦Progressive, advanced organ failure (heart, lung, kidney, liver)
◦Advanced neurodegenerative illness (ALS, Alzheimer’s
Disease)
Any age
Complements disease-modifying therapy or it may become the total
focus of care

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 Palliative Philosophy on Death

Patient and family hopes for peace

and dignity are supported
throughout the course of illness,
during the dying process, and after
death

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 Role of Palliative care Practice
Assessment Ensure Quality of Living & Dying
Symptom Management Establishing a plan of care
Rehabilitation  Terminal care
Respite Bereavement
Psychological, Social and Spiritual Support Above needs a holistic assessment
Counselling
Cultural consideration
Financial
Preservation of personhood and dignity

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 Palliative Care
• Care of mind, body and • Patient centred care incorporating respect for
spirit, focussing on patient values and preferences, providing
social, emotional, information in understandable language,
cultural, spiritual, & promotes autonomy in decision making,
intellectual or attends to physical needs and psychological
knowledge aspect of comfort,
care supported by Holistic Quality
interdisciplinary team approach
and training of Life
Identification, impeccable
assessment of symptoms
Life Patient with treatment
threatening
/ limiting and
Illness Families
• Life limiting illness such as • Patients expected to die,
CCF, COPD, AAIDS, cancer so care of the families
which can shorten and including infected and
compromise QOL, spastic effected while alive and
children, CVA during bereavement
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Thanks to
Dr Qamar Abbas
Deputy Medical Director
St Clare Hospice
Hastingwood
Essex

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Shaheen Palliative Care
Project

Delivering care & improving lives..

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