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Identifying disparities in palliative care among cancer and non-cancer patients

Earlier this month, the New York Times reported on financial and ethical considerations for entering a hospital's palliative care unit, which serves people with chronic illnesses near the end of life who need comfort more than intensive care but are not yet ready for hospice.

Now a study conducted in the U.K. has found that only 20 percent of non-cancer patients there (those with advanced stages of heart, lung, liver or kidney conditions, or dementia) requested or were properly identified as candidates to receive palliative care. That's compared with 75 percent of cancer patients.

The study (subscription required), published in the European Journal of Palliative Care, examined 684 patients under general practitioner care in Scotland. Researchers found that most of the non-cancer patients began receiving palliative care too late to fully benefit from it - usually eight weeks before dying - and that non-cancer conditions were more difficult to prescribe palliative care for during a less-clear decline.

In a release, Scott Murray, MD, who leads the Primary Palliative Care Research Group at the University of Edinburgh, commented:

Patients with cancer are generally well served by palliative care services, while people with other conditions often miss out on this opportunity for more psychological, emotional, spiritual and practical support. Better and earlier identification of all patients who may benefit from these services is vital so that they can receive the care they need, and not slip through the net.

hospiceAfter hearing about the study, I asked palliative care expert VJ Periyakoil, MD, director of the Stanford Palliative Care Education & Training Program and the Stanford Hospice & Palliative Medicine Fellowship Program, to comment on the findings. She replied:

The study results aren't surprising. Clinicians refer their seriously ill patients to hospice care based on their functional status, which is defined as an individual's ability to perform normal daily activities required to meet basic needs, fulfill usual roles. As you can see in the image here, most cancer patients have a clear and steady decline in functional status when they get closer to death. Thus when people with advanced cancer spend most of the day in bed and are not able to care for themselves, it's pretty clear that they're nearing death and need to be referred to hospice. However, in non-cancer illnesses like end stage heart disease, end stage lung disease, the patient’s functional status undulates (i.e. when they have an infection their functional status becomes temporarily low only to rebound when they recover from the infection). Thus, it's hard to predict when the patients are in the last six months of their life, and so they're often referred too late to hospice care. We can overcome these challenges easily by providing concurrent palliative care along with disease directed care for all seriously ill patients.

Previously: Examining end-of-life practices and Katy Butler’s “Knocking on Heaven’s Door”How a Stanford physician became a leading advocate for palliative careOn a mission to transform end-of-life care and The importance of patient/doctor end-of-life discussions

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