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Introduction

Chronic illnesses are marked by fluctuations and variations over time. Individuals with chronic illness
experience pain and other symptoms that are not always adequately managed. Their caregivers often have to
deal with enormous burden as the illness progresses. Palliative care can serve as an intervention to manage
chronic illness, not just at the end of life but also in the early phases of illness.
The World Health Organization (WHO) defines palliative care as an intervention that improves the quality of
life of patients and their families experiencing intermittent illness, with the ultimate goal being to offer pain
and symptom relief, as well as spiritual and psychosocial support.
Non-cancer chronic illness
Chronic illnesses are characterized by fluctuations in trajectory, uncertainty in prognoses, extended disease
timelines and stress. The Centers for Disease Control states that chronic diseases—such as heart disease,
stroke, cancer, diabetes and arthritis—are among the most common, costly and preventable of all health
problems. Chronic diseases are also the leading causes of disability and death.
Palliative care can improve the quality of life of patients and their families through timely identification of
deteriorating health, holistic assessment of needs, management of pain and other problems (physical,
psychosocial, and spiritual), and person centered planning of care.
Common Symptoms at the End-of-Life

Symptom Domain Symptoms


Physical Symptoms Pain
Dyspnea
Nausea
Vomiting
Pruritis
Anorexia
Fatigue
Constipation
Iatrogenic symptoms
Psychological Depression
Symptoms Grief
Anxiety
Panic
Post traumatic stress syndrome
Agitation
Social Symptoms Isolation/loneliness
Anger/hostility
Financial issues and challenges
(Institute of Medicine ; Covinsky )
Fear of being a burden to loved
ones (Institute of Medicine)
Spiritual Symptoms Loss of meaning
Angst
INTEGRATING A PALLIATIVE APPROACH INTO THE MANAGEMENT OF CHRONIC, LIFE-THREATENING
DISEASES:
 provides relief from pain and other distressing symptoms;
 affirms life and regards dying as a normal process;
 intends neither to hasten or postpone death;
 integrates the psychological and spiritual aspects of patient care;
 offers a support system to help patients live as actively as possible until death;
 offers a support system to help the family cope during the patient’s illness and in their own
bereavement;
 uses a team approach to address the needs of patients and their families, including bereavement
counselling, if indicated;
 will enhance quality of life, and may also positively influence the course of illness;
 is applicable early in the course of illness, in conjunction with other therapies that are intended to
prolong life, and includes those investigations needed to better understand and manage distressing
clinical complications.

Addresses aspects of care with reference to key performance indicators (KPIs) of


 Safe and effective care, like reduced pain,
 Good nutrition,
 Reduced falls,
 Safe drug administration,
 Infection prevention and skin integrity and uses measures of somatic and cognitive function.

The palliative care team provides:


 Expert management of pain and other symptoms
 Emotional and spiritual support
 Close communication
 Help navigating the healthcare system
 Guidance with difficult and complex treatment choices

Variations
 Setting
 Task‐specific (Advanced Directives vs P&SM)
 Disease‐specific (Cancer vs CHF)
 Symptom‐specific (Pain)
 Delivery method (Face to face, telephonic, video)
Palliative care may include the following
 Building rapport and relationships with patients and family caregivers
 Managing symptoms, distress, and functional status (eg, pain, dyspnea, fatigue, sleep disturbance,
mood, nausea, constipation).
 Exploration of understanding and education about illness and prognosis.
 Clarification of treatment goals
 Assessment and support of coping needs (eg, provision of dignity therapy)
 Assistance with medical decision making
 Coordination with other care providers
 Provision of referrals to other care providers as indicated
Palliative Care “Triggers”
General considerations clinicians should use to identify patients who would benefit from palliative care
include:
1) Disease progression, especially with functional decline.
2) Pain and/or other symptoms not responding to optimal medical treatment
3) Need for advanced care planning
4. Not surprised if the patient were to die within 12 to 24 months

Conditions that may prompt the initiation of palliative care include, but are not limited to:
 Debility/Failure to Thrive
 Dementia
 Complex care requirements
 Cancer
 Metastatic/recurrent
 Patient desires continued curative treatment(s)
 Advanced COPD
 Advanced congestive heart failure
 Stroke
 Decreased function by at least 50%
 End stage renal disease
 Ventilator dependent
 Chronic disease that is now life-limiting
 Catastrophic illness/injury
 Concomitant disease process
 Liver disease
 Diabetes
 Moderate renal disease
 Moderate COPD
 Moderate congestive heart failure
Common Symptoms Across Life-limiting Disease Settings:
 Overall Fatigue
Pain
Dyspnea
Delirium
Anorexia
 Cancer o Pain
Fatigue
Anorexia
Anxiety
Depression
 Heart Failure o Dyspnea
Fatigue
Pain
Anxiety
Sleep disturbances
 COPD o Dyspnea
Fatigue
Xerotomia
Coughing
Anxiety
 Renal Disease o Fatigue
Sleep disturbances
Pain
Anxiety
Constipation
 End-stage Liver Disease
Depression
Sleep disturbances
Fatigue
Muscle cramps
Cachexia
 HIV/AIDS
Diarrhea
Fatigue
Depression
Pain
Delirium

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