Palliative Care and Pain Management at the End of Life ___________________________________________
The most surprising finding is the apparent survival advantage conferred by palliative and hospice care. One study showed that hospice care extended survival for many patients within a population of 4,493 patients with one of five types of cancer (lung, breast, prostate, pancreatic, or colorectal cancer) or heart failure [51]. For the population as a whole, survival was a mean of 29 days longer for patients who had hospice care than for those who did not. With respect to the specific diseases, heart failure was associated with the greatest increase in survival (81 days), followed by lung cancer (39 days), colorectal cancer (33 days), and pancreatic cancer (21 days) [51]. There was no survival benefit for patients with breast or prostate cancer. In a study of patients with metastatic non-small cell lung cancer, patients who received early palliative care (within three weeks after enrollment in the study) lived significantly longer than those who received standard oncologic care only (11.6 months vs. 8.9 months) [30]. In the same study, the quality of life and symptoms of depression were also significantly better for the cohort of patients who received early palliative care. Similarly, a retrospective study found a slight survival advantage to hos- pice care among older individuals (>65 years) with advanced lung cancer [52]. These observations prompted the American Society of Clinical Oncology (ASCO) to publish a Provisional Clinical Opinion in which it states that concurrent palliative care and standard oncologic care should be offered to people with metastatic non-small cell lung cancer at the time of initial diagnosis [53]. The ASCO Opinion also notes that although the evidence of survival benefit is not as strong for other types of cancer, the same approach should be considered for any patient with metastatic cancer and/or high symptom burden [53]. The 2013 American College of Chest Physicians (ACCP) guideline for the diagnosis and management of lung cancer also recommends that “palliative care combined with standard oncology care be introduced early in the treatment course” for patients with late-stage (i.e., stage IV) lung cancer and/or a high symptom burden [54]. The cost of care at the end of life is a controversial issue because of the disproportionate costs incurred for care within the last two years of life and the wide variation in costs related to the aggressiveness of care across healthcare facilities [55]. The simple act of discussing end-of-life issues can help patients and families better understand options, leading to reduced costs. In a study of 603 patients with advanced cancer, costs in the last week of life were approximately $1,000 lower for patients who had end-of-life discussions with their healthcare providers compared with patients who did not have such conversations [56]. Several studies have documented the cost-effectiveness of hospice care. A meta-analysis published in 1996 showed that hospice care reduced healthcare costs by as much as 40% dur- ing the last month of life and 17% over the last six months [57]. A later study demonstrated little difference in costs at the end of life, with the exception of costs for patients with cancer, which were 13% to 20% lower for those who had received hospice care than for those who had not [58]. In a study of 298 patients with end-stage organ failure diseases, in-home hospice
care significantly reduced healthcare costs by decreasing the number of hospitalizations and emergency department visits [46]. The strongest evidence of cost savings is found in a 2007 study in which hospice use reduced Medicare costs during the last year of life by an average of $2,309 per hospice user [59]. As was found earlier, the cost savings were greater for patients with cancer than for those with other diagnoses [59]. The greatest cost reduction (about $7,000) was associated with a primary diagnosis of cancer and length of stay of 58 to 103 days [59]. The maximum cost savings was much lower (approximately $3,500) for other life-limiting diagnoses but with a similar length of stay (50 to 108 days) [59]. Palliative care consultations also reduce costs. A review of data for Medicaid beneficiaries (with a variety of life-limiting diagnoses) at four hospitals in New York showed that hospital costs were an average of $6,900 lower during a given admission for patients who received palliative care than for those who received usual care [60]. The reduction in costs was greater ($7,563) for patients who died in the hospital compared with those who were discharged alive [60]. CHALLENGES TO OPTIMUM DELIVERY OF PALLIATIVE CARE AT THE END OF LIFE Despite the many benefits of palliative care and hospice, refer- rals are usually not timely and often are not made at all [61; 62; 63; 64; 65; 66]. Many challenges contribute to the low rate of optimum end-of-life care. Among the most important barriers to the optimum use of palliative care at the end of life are the lack of well-trained healthcare professionals; reimbursement policies; difficulty in determining accurate prognoses; and attitudes of patients, families, and clinicians. Lack of Well-Trained Healthcare Professionals Medical school and residency training programs emphasize disease recognition, diagnostic assessment, and treatment and management strategies that have restorative power, prolong life, and prevent death. The role of palliative care traditionally has not been sufficiently addressed [67]. Students who have participated in mandatory courses in palliative medicine have noted that they are better prepared to care for dying patients [68]. Efforts to enhance education have resulted in the devel- opment of more than 100 primary care residency programs that offer palliative medicine as part of the curriculum and 72 postgraduate medical fellowship programs in palliative care [69; 70]. In addition, hospital-based palliative care programs have integrated the eight NCP domains into graduate courses and residencies for physicians and registered nurses, and certifica- tions in palliative care have become available for physicians, nurses, and social workers [6]. Between 1996 and 2006, more than 2,100 physicians obtained certification in hospice and palliative medicine from the American Board of Hospice and Palliative Medicine [71]. As of January 2016, there were nearly 6,400 active certified hospice and palliative care physicians in the United States [72]. In 2006, subspecialty certification in hospice and palliative medicine was established for 10 Boards
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