On the Need to Scale Up Palliative Care

A lack of awareness of palliative care and dearth of training remain large obstacles.

Healthcare professionals need to graduate with at least 40 hours of basic training in palliative care, and it should be a required course in continuing education, according to Stephen R Connor, PhD, Executive Director of the Worldwide Hospice and Palliative Care Alliance based in London, United Kingdom, which celebrated Worldwide Hospice and Palliative Care Day on October 8, 2016.

Around 20 million people worldwide need end of life palliative care each year — about 6% of those are children — and another 20 million more people may require palliative care in the years before death, according to the World Health Organization/WHPCA Global Atlas of Palliative Care at the End of Life report.

More specialist doctors and nurses are also needed as well as mental health professionals with palliative care skills including bereavement support to address the growing number of people requiring these services, Dr Connor said.

“Hospice and palliative care are neglected by essential parts of the health care system,” Dr Connor told Clinical Pain Advisor. “The global population is aging at unprecedented rates, and death from cancer and other non-communicable diseases is climbing. The public still is largely unaware of the benefits hospice and palliative care can bring.”

The WHPCA is a non-governmental organization focused on the worldwide development of hospice and palliative care with a vision to see universal access to care.

In the United States (US), an area of concern for the palliative care sector, is the reduction in manufacturing quotas for opioids in 2017, told  Judi Lund Person, MPH, CHC, Vice President, Regulatory and Compliance at the National Hospice and Palliative Care Organization based in Alexandria, Virginia, Clinical Pain Advisor.

“While we are not necessarily right this instant seeing patients coming to hospice in greater pain, as we see supply tighten up next year, we are definitely quite concerned about availability of medications for hospice patients or patients with severe illness,” Ms Lund Person said.

“We need to spend a lot more time in this area. We now need to focus on ways to address pain issues that include not just treating with opioids. We need to see a lot more training for health care professionals,” she added.

Christian Sinclair, MD, FAAHPM, President of the American Academy of Hospice and Palliative Medicine and Assistant Professor at the University of Kansas Medical Center in Kansas City, Kansas, said physicians should be confident in prescribing opioids to hospice and palliative care patients who are exempt from US guidelines regulating their use.

Dr Sinclair told Clinical Pain Advisor he is concerned that any potential shortages from manufacturing quotas may make it more difficult for patients to obtain needed opioids and community pharmacies may be more unlikely to stock the medicines on fears of theft.

Hospice care is given when a patient has 6 months or less to live, while palliative care, a term that also includes hospice care, is focused on improving quality of life and symptom control for patients with serious significant illnesses, said Lonnie Zeltzer, MD, Director of the Pediatric Pain and Comfort Care Program at the University of California Los Angeles Mattel Children’s Hospital.

Under palliative care, active curative treatment may still be ongoing. Some patients may transition out of palliative care while others continue on with hospice care when curative treatments are no longer an option, she told Clinical Pain Advisor.

Most hospice care in the US is covered by the Medicare Hospice Benefit, Dr Connor said. Palliative care is not funded directly.“Clinicians can bill for services and procedures but there is no palliative care benefit per se,” said he added.

This aspect added to a lack of education and training fellowship opportunities continues to represent barriers to adequate palliative care, Dr Connor said.

 “There continues to be a lack of palliative care content in health profession education for nurses, physicians, social workers, psychologists, pharmacists, clergy, and so forth,” Dr Connor said. “There are not enough fellowship programs to train the physician workforce that is needed.”

Dr Zeltzer said a lack of understanding and awareness of palliative care in addition to the dearth of training and fellowships for pediatricians remain large obstacles.

 “It has been very hard to recruit good, trained, board-certified pediatricians who have gone through pediatric palliative care fellowships just because there are not that many of those,” Dr Zeltzer said. “It is growing, but it is a relatively new field.”

Listen to Jim Cleary talk about the World Hospice and Palliative Care Day theme “Living and dying with pain: it does not have to happen”:

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  1. The Worldwide Palliative Care Alliance. Global Atlas of Palliative Care at the End of Life. Worldwide Palliative Care Alliance. Available at: http://www.thewhpca.org/resources/global-atlas-on-end-of-life-care. Accessed October 17, 2016.