Download 3. History of Palliative care.

MINISTRY OF HEALTH OF UKRAINE
VINNITSA NATIONAL PIROGOV MEMORIAL MEDICAL
UNIVERSITY
"CONFIRM"
at the methodical meeting
Department of Ray diagnostics,
Ray therapy and Oncology
Head of the department
As. of Prof., M.S.D. Kostyuk A.G.
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"______" ________ 2013 year
METHODICAL GUIDELINES
For self-study for students in preparing for the practical (seminary) lessons
Subject of Study
Oncology
Module No
1
Theme No
22
Topic of Lesson
Palliative and symptomatic therapy.
A concept about palliative and symptomatic therapy.
Symptomatic drugs. Therapy of pain.
Course
5
Faculty
General Medicine
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Topicality. Palliative care (from Latin palliare, to cloak) is an area of
healthcare that focuses on relieving and preventing the suffering of patients. Unlike
hospice care, palliative medicine is appropriate for patients in all disease stages,
including those undergoing treatment for curable illnesses and those living with
chronic diseases, as well as patients who are nearing the end of life. Palliative
medicine utilizes a multidisciplinary approach to patient care, relying on input from
physicians, pharmacists, nurses, chaplains, social workers, psychologists and other
allied health professionals in formulating a plan of care to relieve suffering in all
areas of a patient's life. This multidisciplinary approach allows the palliative care
team to address physical, emotional, spiritual and social concerns that arise with
advanced illness.
Medications and treatments are said to have a palliative effect if they relieve
symptoms without having a curative effect on the underlying disease or cause. This
can include treating nausea related to chemotherapy or something as simple as
morphine to treat the pain of broken leg or ibuprofen to treat aching related to an
influenza (flu) infection.
Although the concept of palliative care is not new, most physicians have traditionally
concentrated on trying to cure patients. Treatments for the alleviation of symptoms
were viewed as hazardous and seen as inviting addiction and other unwanted side
effects.
The focus on a patient's quality of life has increased greatly during the past twenty
years. In the United States today, 55% of hospitals with more than 100 beds offer a
palliative-care program, and nearly one-fifth of community hospitals have palliativecare programs. A relatively recent development is the palliative-care team, a
dedicated health care team that is entirely geared toward palliative treatment.
Learning Objectives:
1. A concept about palliative therapy.
2. A concept about symptomatic therapy.
3. History of Palliative care.
4. Symptomatic drugs.
5. Therapy of pain.
6. Hospice care in the world.
7. Euthanasia in the world.
Palliative and symptomatic therapy
Scope of the term
Palliative care is specialised medical care for people with serious illnesses. It is
focused on providing patients with relief from the symptoms, pain and stress of a
serious illness — whatever the prognosis. The goal is to improve quality of life for
both the patient and the family as they are the central system for care.
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Palliative care is provided by a team of doctors, nurses and other specialists who
work together with a patient's other doctors to provide an extra layer of support. It is
appropriate at any age and at any stage in a serious illness and can be provided along
with curative treatment.
A World Health Organisation statement describes palliative care as "an approach that
improves the quality of life of patients and their families facing the problems
associated with life-threatening illness, through the prevention and relief of suffering
by means of early identification and impeccable assessment and treatment of pain and
other problems, physical, psychosocial and spiritual." More generally, however, the
term "palliative care" may refer to any care that alleviates symptoms, whether or not
there is hope of a cure by other means; thus, palliative treatments may be used to
alleviate the side effects of curative treatments, such as relieving the nausea
associated with chemotherapy.
The term "palliative care" is increasingly used with regard to diseases other than
cancer such as chronic, progressive pulmonary disorders, renal disease, chronic heart
failure, HIV/AIDS and progressive neurological conditions. In addition, the rapidly
growing field of paediatric palliative care has clearly shown the need for services
geared specifically for children with serious illness.
Palliative care:
provides relief from pain, shortness of breath, nausea and other distressing
symptoms;
affirms life and regards dying as a normal process;
intends neither to hasten nor to postpone death;
integrates the psychological and spiritual aspects of patient care;
offers a support system to help patients live as actively as possible;
offers a support system to help the family cope;
uses a team approach to address the needs of patients and their families;
will enhance quality of life;
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.
While palliative care may seem to offer a broad range of services, the goals of
palliative treatment are concrete: relief from suffering, treatment of pain and other
distressing symptoms, psychological and spiritual care, a support system to help the
individual live as actively as possible and a support system to sustain and rehabilitate
the individual's family.
Comparison with hospice care
In the United States, a distinction may be made between palliative care and hospice
care. Hospice services and palliative care programs share similar goals of providing
symptom relief and pain management. Palliative care services can be offered to any
patient without restriction to disease or prognosis, and can be appropriate for anyone
with a serious, complex illness, whether they are expected to recover fully, to live
with chronic illness for an extended time, or to experience disease progression.
Hospice care under the Medicare Hospice Benefit, however, requires that two
physicians certify that a patient has less than six months to live if the disease follows
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its usual course. This does not mean, though, that if a patient is still living after six
months in hospice he or she will be discharged from the service.
The philosophy and multi-disciplinary team approach are similar with hospice and
palliative care, and indeed the training programs and many organizations provide
both. The biggest difference between hospice and palliative care is the patient: where
they are in their illness especially related to prognosis and their goals/wishes
regarding curative treatment.
Outside the United States there is generally no such division of terminology or
funding, and all such care with a primarily palliative focus, whether or not for
patients with terminal illness, is usually referred to as palliative care, without
restriction.
Outside the United States the term hospice usually refers to a building or institution
which specialises in palliative care, rather than to a particular stage of care
progression. Such institutions may predominantly specialise in providing care in an
end-of-life setting; but they may also be available for patients with other specific
palliative care needs.
History
Palliative care began in the hospice movement and is now widely used outside of
traditional hospice care. Hospices were originally places of rest for travellers in the
4th century. In the 19th century a religious order established hospices for the dying in
Ireland and London. The modern hospice is a relatively recent concept that originated
and gained momentum in the United Kingdom after the founding of St. Christopher's
Hospice in 1967. It was founded by Dame Cicely Saunders, widely regarded as the
founder of the modern hospice movement.
The hospice movement has grown dramatically in recent years. In the UK in 2005
there were just under 1,700 hospice services consisting of 220 inpatient units for
adults with 3,156 beds, 33 inpatient units for children with 255 beds, 358 home care
services, 104 hospice at home services, 263 day care services and 293 hospital teams.
These services together helped over 250,000 patients in 2003 & 2004. Funding varies
from 100% funding by the National Health Service to almost 100% funding by
charities, but the service is always free to patients.
Hospice in the United States has grown from a volunteer-led movement to improve
care for people dying alone, isolated or in hospitals, to a significant part of the health
care system. In 2005 more than 1.2 million persons and their families received
hospice care. Hospice is the only Medicare benefit that includes pharmaceuticals,
medical equipment, twenty-four hour/seven day a week access to care and support for
loved ones following a death. Most hospice care is delivered at home. Hospice care is
also available to people in home-like hospice residences, nursing homes, assisted
living facilities, veterans' facilities, hospitals and prisons.
The first United States hospital-based palliative care programs began in the late
1980s at a handful of institutions such as the Cleveland Clinic and Medical College
of Wisconsin. Since then there has been a dramatic increase in hospital-based
palliative care programs, now numbering more than 1,400. 80% of US hospitals with
more than 300 beds have a program.
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A 2009 study regarding the availability of palliative care in 120 US cancer center
hospitals reported the following: Only 23% of the centers have beds that are
dedicated to palliative care; 37% offer inpatient hospice; 75% have a median time of
referral to palliative care to the time of death of 30 to 120 days; research programs,
palliative care fellowships, and mandatory rotations for oncology fellows were
uncommon. The results of a 2010 study in The New England Journal of Medicine
showed that lung cancer patients receiving early palliative care experienced less
depression, increased quality of life and survived 2.7 months longer than those
receiving standard oncologic care.
Hospital palliative care programs today care for non-terminal patients as well as
hospice patients.
The first pan-European centre devoted to improving patient palliative care and endof-life care was established in Trondheim, Norway in 2009. The centre is based at
NTNU's Faculty of Medicine and at St. Olav's Hospital/Trondheim University
Hospital and coordinates efforts between groups and individual researchers across
Europe, specifically Scotland, England, Italy, Denmark, Germany and Switzerland,
along with the USA, Canada and Australia.
Indications
Immediate palliative care is indicated for patients with any serious illness and who
have physical, psychological, social, or spiritual distress as a result of the treatment
they are seeking or receiving. Palliative care increases comfort by lessening pain,
controlling symptoms, and lessening stress for the patient and family, and should not
be delayed when it is indicated. Palliative care is not reserved for patients in end-oflife care and can increase quality of life and lengthen the patient's life.
In some cases, medical specialty professional organizations recommend that patients
and physicians respond to an illness only with palliative care and not with a therapy
directed at the disease. The following items are indications named by the American
Society of Clinical Oncology as characteristics of a patient who should receive
palliative care but not any cancer-directed therapy.
patient has low performance status, corresponding with limited ability to care
for oneself
patient received no benefit from prior evidence-based treatments
patient is ineligible to participate in any appropriate clinical trial
the physician sees no strong evidence that treatment would be effective
These characteristics may be generally applicable to other disease conditions besides
cancer.
Practice
Assessment of symptoms
A method for the assessment of symptoms in patients admitted to palliative care is
the Edmonton Symptoms Assessment Scale (ESAS), in which there are eight visual
analog scales (VAS) of 0 to 10, indicating the levels of pain, activity, nausea,
depression, anxiety, drowsiness, appetite and sensation of well-being, sometimes with
the addition of shortness of breath. On the scales, 0 means that the symptom is absent
and 10 that it is of worst possible severity. It is completed either by the patient alone,
by the patient with nurse's assistance, or by the nurses or relatives.
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Symptom management
Medications used for palliative patients are used differently than standard
medications, based on established practices with varying degrees of evidence.
Examples include the use of antipsychotic medications to treat nausea,
anticonvulsants to treat pain, and morphine to treat dyspnea. Routes of administration
may differ from acute or chronic care, as many patients lose the ability to swallow. A
common alternative route of administration is subcutaneous, as it is less traumatic
and less difficult to maintain than intravenous medications. Other routes of
administration include sublingual, intramuscular and transdermal. Medications are
often managed at home by family or nursing support.
Dealing with distress
An elderly cat with chronic renal failure receives Lactated Ringer's solution, a form
of hydration, during her final days.
The key to effective palliative care is to provide a safe way for the individual to
address their physical and psychological distress, that is to say their total suffering, a
concept first thought up by Cicely Saunders, and now widely used, for instance by
authors like Twycross or Woodruff. Dealing with total suffering involves a broad
range of concerns, starting with treating physical symptoms such as pain, nausea and
breathlessness. The palliative care teams have become very skillful in prescribing
drugs for physical symptoms, and have been instrumental in showing how drugs such
as morphine can be used safely while maintaining a patient's full faculties and
function. However, when a patient exhibits a physiological symptom, there are often
psychological, social or spiritual symptoms as well. The interdisciplinary team, which
often includes a registered nurse, a licensed mental health professional, a licensed
social worker or a counselor and spiritual support such as a chaplain, can play a role
in helping the patient and family cope globally with these symptoms, rather than
depending on the medical/pharmacological interventions alone. Usually, a palliative
care patient's concerns are pain, fears about the future, loss of independence, worries
about their family and feeling like a burden. While some patients will want to discuss
psychological or spiritual concerns and some will not, it is fundamentally important
to assess each individual and their partners' and families' need for this type of
support. Denying an individual and their support system an opportunity to explore
psychological or spiritual concerns is just as harmful as forcing them to deal with
issues they either don't have or choose not to deal with. There are five principal
methods for addressing patient anxiety in palliative care settings. They are
counseling, visualisation, cognitive methods, drug therapy and relaxation therapy.
Palliative pets can play a role in this last category. (Pets as such may also receive
palliative care at the end of their lives.) For animal lovers approaching the end of life,
contact with the familiar positive interactions with pets helps to normalise the hospice
environment and reduce anxiety. Even for patients whose cognitive abilities have
been hampered by illnesses such as Alzheimer's disease, clinical research has shown
that the presence of a therapy dog enhanced nonverbal communication as shown by
increases in looks, smiles, tactile contact and physical warmth.
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Provision of services
Because palliative care sees an increasingly wide range of conditions in patients at
varying stages of their illness it follows that palliative care teams offer a range of
care. This may range from managing the physical symptoms in patients receiving
treatment for cancer, to treating depression in patients with advanced disease, to the
care of patients in their last days and hours. Much of the work involves helping
patients with complex or severe physical, psychological, social and spiritual
problems. In the UK over half of patients are improved sufficiently to return home.
Most hospice organisations offer grief counseling to the patient's partner or family
should he die.
In the United States hospice and palliative care represent two different aspects of care
with similar philosophy, but with different payment systems and location of services.
Palliative care services are most often provided in acute care hospitals organised
around an interdisciplinary consultation service with or without an acute inpatient
palliative care ward. Palliative care may also be provided in the dying person's home
as a "bridge" program between traditional US home care services and hospice care or
provided in long-term care facilities. In contrast over 80% of hospice care in the US
is provided in a patient's home with the remainder provided to patients residing in
long-term care facilities or in free standing hospice residential facilities. In the UK
hospice is seen as one part of the specialty of palliative care and no differentiation is
made between 'hospice' and 'palliative care'.
In the UK palliative care services offer inpatient care, home care, day care and
outpatient services, and work in close partnership with mainstream services. Hospices
often house a full range of services and professionals for both paediatric and adult
patients.
In the US palliative care services can be offered to any patient without restriction to
disease or prognosis. Hospice care under the Medicare Hospice Benefit, however,
requires that two physicians certify that a patient has less than six months to live if
the disease follows its usual course. This does not mean, though, that if a patient is
still living after six months in hospice he or she will be discharged from the service.
Such restrictions do not exist in other countries such as the United Kingdom.
Involved people
In most countries hospice and palliative care is provided by an interdisciplinary team
consisting of physicians, pharmacists, registered nurses, nursing assistants, social
workers, hospice chaplains, physiotherapists, occupational therapists, complementary
therapists, volunteers and, most important, the family. The team's focus is to optimise
the patient's comfort. Additional members of the team are likely to include certified
nursing assistants or home health care aides, volunteers from the community (largely
untrained but some being skilled medical personnel), and housekeepers. In the United
States, the physician subspecialty of hospice and palliative medicine was established
in 2006, to provide expertise in the care of patients with life-limiting, advanced
disease and catastrophic injury; the relief of distressing symptoms; the coordination
of interdisciplinary patient and family-centred care in diverse settings; the use of
specialised care systems including hospice; the management of the imminently dying
patient; and legal and ethical decision making in end-of-life care.
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Caregivers, both family and volunteers, are crucial to the palliative care system.
Caregivers and patients often form lasting friendships over the course of care. As a
consequence caregivers may find themselves under severe emotional and physical
strain. Opportunities for caregiver respite are some of the services hospices provide to
promote caregiver well-being. Respite may last a few hours up to several days (the
latter being done usually by placing the patient in a nursing home or in-patient
hospice unit for several days).
In the US, board certification for physicians in palliative care was through the
American Board of Hospice and Palliative Medicine; recently this was changed to be
done through any of 11 different specialty boards through an American Board of
Medical Specialties-approved procedure. Additionally, board certification is available
to osteopathic physicians (D.O.) in the United States through four medical specialty
boards through an American Osteopathic Association Bureau of Osteopathic
Specialists-approved procedure. More than 50 fellowship programs provide 1–2 years
of specialty training following a primary residency. In Britain palliative care has been
a full specialty of medicine since 1989 and training is governed by the same
regulations through the Royal College of Physicians as with any other medical
specialty.
Funding
Funding for hospice and palliative care services varies. In [UK|Great Britain] and
many other countries all palliative care is offered free to the patient and their family,
either through the National Health Service (as in the UK) or through charities
working in partnership with the local health services. Palliative care services in the
US are paid by philanthropy, fee-for service mechanisms, or from direct hospital
support while hospice care is provided as Medicare benefit; similar hospice benefits
are offered by Medicaid and most private health insurers. Under the Medicare
Hospice Benefit (MHB) a patient signs off their Medicare Part B (acute hospital
payment) and enrolls in the MHB through Medicare Part B with direct care provided
by a Medicare certified hospice agency. Under terms of the MHB the Hospice agency
is responsible for the Plan of Care and may not bill the patient for services. The
hospice agency, together with the patient's primary physician, is responsible for
determining the Plan of Care. All costs related to the terminal illness are paid from a
per diem rate (~US $126/day) that the hospice agency receives from Medicare - this
includes all drugs and equipment, nursing, social service, chaplain visits and other
services deemed appropriate by the hospice agency; Medicare does not pay for
custodial care. Patients may elect to withdraw from the MHB and return to Medicare
Part A and later re-enroll in hospice.
Acceptance
Physicians practicing palliative care do not always receive support from patients,
family members, healthcare professionals or their social peers for their work to
reduce suffering and follow patients' wishes for end-of-life care. More than half of
physicians in one survey reported that a patient's family members, another physician
or another health care professional had characterized their work as being "euthanasia,
murder or killing" during the last five years. A quarter of them had received similar
comments from their own friends or family member, or from a patient.
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Integrative Pain Therapy
The term, "integrative pain therapy," can be used to describe a broad therapeutic
approach to the management of chronic pain, which attempts to combine the best of
traditional treatments for pain and disability with the best of the therapies widely
considered complementary or alternative. It is part of a larger effort to develop an
"integrative
medicine
approach"
to
many
clinical
problems.
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This integrative medicine approach links traditional, so-called allopathic, medical
treatments with varied complementary and alternative treatments. It is a
comprehensive system of medicine, which emphasizes wellness and the healing of
the whole person (physical, psychological, social, and spiritual), above and beyond
the treatment of any specific symptom or disease (Bell, 2002). It involves the use of
all safe and effective therapeutic approaches that can potentially facilitate healing,
while empowering the patient to participate in the process of healing. Integrative
medicine acknowledges the complexity of health and illness by identifying multiple
causes of disease and multiple interventions based on the physical, biochemical,
psychological, social and spiritual aspects of health and disease. It recognizes that
multiple outcomes may be positive for the individual, and that these outcomes may
vary from one person to the next (Rosomoff, 1999).
The goals of an integrative pain therapy approach may include:
reducing or eliminating pain
using medicines that are appropriate, provide sustained benefits, have tolerable
side effects, and support the functional goals of the patient
reducing distress and enhancing comfort, peace of mind and quality of life
improving the understanding of the role of emotions, behavior and attitudes in
pain
improving the ability to function physically and perform activities of daily
living
improving the ability to function in social and family roles
supporting the patient's ability to return to work and function on the job
educating patients in ways to maintain rehabilitation gains and avoid re-injury
empowering patients to actively participate in pain control strategies
promoting awareness and understanding of the factors that contribute to
physical and emotional distress related to pain
developing the skills and knowledge needed to increase the patient's sense of
control over pain
Integrative pain therapy draws from a broad spectrum of therapeutic approaches. It
recognizes the value of multiple approaches to pain management (a multimodality
approach) and acknowledges the individualized nature of good medical care. The
goal is to employ the safest and most effective therapies to provide maximum benefit.
Foundations of Health
In developing an integrative approach to pain therapy, the starting point is a broad
view of health and well being. The foundations of health include at least four
elements:
stress management
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proper diet and nutrition
regular exercise
psychosocial support
There are literally thousands of studies confirming the importance of each of these
foundations. Careful attention to each can have profound effects on health and illness.
The work of Dean Ornish (Ornish, 1999), for example, demonstrated that
interventions targeted to these areas can not only halt, but actually reverse, coronary
artery disease.
Stress Management
All people experience stress and some degree of stress may be needed to generate
excitement, engage fully in tasks, and perform well. However, too much stress, or
poor coping with stress, can undermine health and well being.
There are many tools available to help reduce the debilitating effects of acute and
chronic stress. The most important approach is to recognize triggers and behavior
patterns, and to utilize emotional and spiritual approaches to reverse stress's negative
effects. These approaches can be learned in a variety of ways, such as psychotherapy,
education, and training in mind-body techniques. Sometimes, herbal, nutritional or
pharmacologic therapies are needed to assist in coping with persistent stress.
Proper Nutrition
Although science has a great deal more to learn about the role of nutrition in health
and disease, it is certain that poor nutrition can contribute to a range of problems.
Poor nutrition is common in many developing countries, and there is clear evidence
that people living in developed countries, such as the United States, may not obtain
enough of the essential nutrients needed for maintaining health (Fairfield & Fletcher,
2002). Because the diet may not be a complete source of all the nutrients needed for
optimum health, the use of supplements may be necessary, either to help prevent
disease or to aid in treatment.
Exercise
Proper exercise maintains fitness and is very helpful in reducing stress. Intense
aerobic exercise is not necessary to achieve these benefits. Brisk walking may be
sufficient for many people. Modest, regular exercise, particularly when combined
with stretching and relaxation, or approaches such as yoga and tai chi, provides
another essential element for optimum health.
Psychosocial Support
There is a huge body of research that demonstrates the importance of psychological
and social factors in health and disease. Emotions, thoughts, connections to others,
the response of others to our behaviors-all these factors contribute. Dealing with these
types of issues and problems is an essential part of pain management.
Literature.
Basic. 1. Sorcin V, Popovich A, Dumanskiy Yu, et al. Clinical oncology.
Simferopol, 2008; 192 p.
2. Schepotin IB, Evans SRT. Oncology. Kiev, 2008; 235 p.
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Additional. 1. National Comprehensive Cancer Network. NCCN Practice
Guidelines in Oncology: v. 2012.
2. Manual Of Clinical Oncology, - Dennis A. Casciato, Barry B. Lowitz, 2000
3. Oxford Handbook of Oncology, - Oxford University Press, 2002
4. Basics of Oncology, - Frederick O. Stephens · Karl R. Aigner, 2009
5. HARRISON’S Manual of Oncology, - Bruce A. Chabner, Thomas J. Lynch,
Jr., Dan L. Longo, 2008
Methodical guidelines written
by Assistant oncology department
PhD. Lysenko S.A.