Chapter 22: Palliative Care and Nonpain Symptom Management

INTRODUCTION

Palliative care is defined by the World Health Organization as an approach to end-of-life healthcare “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.”¹ Palliative care is provided by a wide array of healthcare professionals in a wide spectrum of settings, from the patient’s home to an acute care hospital. Hospice is an approach to providing palliative care in the patient’s home or a home-like setting involving the patient’s family in the care of the terminal patient. Hospice care is generally reserved for the last 6 months of life; however, it is often difficult to predict the date a patient will die, and often hospice care is instituted too late for the patient and the patient’s family to receive the full benefits of hospice care. Hospice care is provided by physicians, nurses, social workers, clergy/chaplains/spiritual guides, and volunteers, all of whom are often specifically trained in end-of-life care. There are over 4,000 hospice agencies across the United States, and over 60% are nonprofit organizations. Two major differences between hospice care and palliative care are that the patient’s life expectancy in hospice care is months and treatment involves relief of symptoms to reduce suffering, and there is no treatment directed at curing the underlying terminal disease. There is no expected life expectancy for patients receiving palliative care, and patients may continue to receive treatment for their underlying disease. This chapter focuses on overall palliative care management, including non-pain symptom management. Principles of pain management are discussed in Chapter 21, Pain Management.

Whether engaged in the co-management of symptoms of a patient with restorative or disease-oriented goals, or a patient who has prioritized symptom management over curative treatments, the methodological assessment of symptoms is essential. Using objective and validated instruments is beneficial. The Revised Edmonton Symptom Assessment Scale (ESAS) is a useful symptom assessment tool that allows for simple and rapid documentation of multiple patient-reported symptoms simultaneously (see Table 22-1²).