Models of Care in Palliative Medicine

In resource-rich countries, chronic complex diseases have largely replaced acute causes of disability and death. There is now a need for every clinician to be able to take a palliative approach. This is defined as the ability to deal with key elements of clinical care for someone who has a progressive illness that is likely to lead to death and their caregivers. The key elements of a palliative approach are access; collaborative interdisciplinary team-based care; defining the goals of care; evaluating the net effect of any treatments or interventions addressing, where relevant, issues of withholding and withdrawing treatment; determining preferred place of care and, separately, the preferred place at the time of death; and managing care transitions. For patients, there is evidence of improved symptom control, better met needs, better satisfaction with care and better quality of dying and improved comfort in the last 2 weeks of life. Having relinquished their roles, caregivers for people at the end of life who have used specialist palliative care services had better long-term survival and were better able to adjust to their changed circumstances. Specialist palliative care services are also associated with better met caregiver needs, improved satisfaction with care and less caregiver anxiety. For health systems, benefits include reduced inpatient stays, fewer presentations to the emergency department and reduced overall costs. Patient-defined areas of importance include the ability to carry out one's affairs as the end-of-life approaches, resolving relationship issues and being involved in decision-making. Specialist supportive and palliative care has services which are charged with providing team-based clinical care to people with the most complex end-of-life care needs and their families, as well as and consultative support for colleagues providing care where the patient or family have less complex needs. Ensuring all people have access to best palliative care is dependent upon an on going committment to ensuring that: There is adequate education at an undergraduate, postgraduate and post-registration level; and high-quality research that continues to refine the evidence base for clinical care that is offered; and health services are structured to optimally deliver these services.