Palliative care

Palliative care (derived from the Latin root palliare, or "to cloak") is an interdisciplinary medical caregiving approach aimed at optimizing quality of life and mitigating suffering among people with serious, complex illness.[1] Within the published literature, many definitions of palliative care exist; most notably, the World Health Organization describes palliative care as "an approach 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."[2] In the past, palliative care was a disease specific approach, but today the World Health Organization takes a more broad approach, that the principles of palliative care should be applied as early as possible to any chronic and ultimately fatal illness.[3]

"Palliative Medicine" redirects here. For the journal, see Palliative Medicine (journal).

Palliative care is appropriate for individuals with serious illnesses across the age spectrum and can be provided as the main goal of care or in tandem with curative treatment. It is provided by an interdisciplinary team which can include physicians, nurses, occupational and physical therapists, psychologists, social workers, chaplains, and dietitians. Palliative care can be provided in a variety of contexts including hospitals, outpatient, skilled-nursing, and home settings. Although an important part of end-of-life care, palliative care is not limited to individuals near the end of life.[1]

Evidence supports the efficacy of a palliative care approach in improvement of a patient's quality of life.[4][5]

Palliative care's main focus is to improve the quality of life for those with chronic illnesses. It is commonly the case that palliative care is provided at the end of life, but it can be for a patient of any age.[6]

Scope

The overall goal of palliative care is to improve quality of life of individuals with serious illness, any life-threatening condition which either reduces an individual's daily function or quality of life or increases caregiver burden, through pain and symptom management, identification and support of caregiver needs, and care coordination. Palliative care can be delivered at any stage of illness alongside other treatments with curative of life-prolonging intent and is not restricted to people receiving end-of-life care.[7][8] Historically, palliative care services were focus on individuals with incurable cancer, but this framework is now applied to other diseases, like severe heart failure,[9] chronic obstructive pulmonary disease, and multiple sclerosis and other neurodegenerative conditions.[10]

Palliative care can be initiated in a variety of care settings, including emergency rooms, hospitals, hospice facilities, or at home. For some severe disease processes, medical specialty professional organizations recommend initiating palliative care at the time of diagnosis or disease-directed options would not improve a patient's trajectory. For example, the American Society of Clinical Oncology recommends that patients with advanced cancer should be "referred to interdisciplinary palliative care teams that provide inpatient and outpatient care early in the course of disease, alongside active treatment of their cancer" within eight weeks of diagnosis.[7]

Appropriately engaging palliative care providers as a part of patient care improves overall symptom control, quality of life, and family satisfaction of care while reducing overall healthcare costs.[11][12]

Palliative care versus hospice care
See also: Hospice care in the United States

The distinction between palliative care and hospice differs depending on global context.

In the United States, hospice services and palliative care programs share similar goals of mitigating unpleasant symptoms, controlling pain, optimizing comfort, and addressing psychological distress. Hospice care focuses on comfort and psychological support and curative therapies are not pursued. Under the Medicare Hospice Benefit, individuals certified by two physicians to have less than six months to live (assuming a typical course) have access to specialized hospice services through various insurance programs (Medicare, Medicaid, and most health maintenance organizations and private insurers). An individual's hospice benefits are not revoked if that individual lives beyond a six-month period.

Outside the United States the term hospice usually refers to a building or institution that specializes in palliative care. These institutions provide care to patients with end of life and palliative care needs. In the common vernacular outside of the United States, hospice care and palliative care are synonymous and are not contingent on different avenues of funding.[13]

Over 40% of all dying patients in America currently undergo hospice care. Most of the hospice care occurs at a home environment during the last weeks/months of their lives. Of those patients, 86.6% believe their care is "excellent." [14] Hospice's philosophy is that death is a part of life, so it is personal and unique. Caregivers are encouraged to discuss death with the patients and encourage spiritual exploration (if they so wish).[15]

History of palliative care in the United States

The field of palliative care grew out of the hospice movement, which is commonly associated with Dame Cicely Saunders, who founded St. Christopher's Hospice for the terminally ill in 1967, and Elisabeth Kübler-Ross who published her seminal work "On Death and Dying" in 1969.[16] In 1973, Balfour Mount, a urologist familiar with Drs. Saunders and Kübler-Ross's work, coined the term "palliative care" and created the first palliative care ward at the Royal-Victoria Hospital in Montreal.[16] In 1987, Declan Walsh established a palliative medicine service at the Cleveland Clinic Cancer Center in Ohio which later expanded to become the training site of the first palliative care clinical and research fellowship as well as the first acute pain and palliative care inpatient unit in the United States.[17] The program evolved into The Harry R. Horvitz Center for Palliative Medicine which was designated as an international demonstration project by the World Health Organization and accredited by the European Society for Medical Oncology as an Integrated Center of Oncology and Palliative Care.[18]

Advances in palliative care have since inspired a dramatic increase in hospital-based palliative care programs. Notable research outcomes forwarding the implementation of palliative care programs include:

  • Evidence that hospital palliative care consult teams are associated with significant hospital and overall health system cost savings.[19][20]
  • Evidence that palliative care services increase the likelihood of dying at home and reduce symptom burden without impacting on caregiver grief among the vast majority of Americans who prefer to die at home.[21]
  • Evidence that providing palliative care in tandem with standard oncologic care among patients with advanced cancer is associated with lower rates of depression, increased quality of life, and increased length of survival compared to those receiving standard oncologic care.[22][23]

Over 90% of US hospitals with more than 300 beds have palliative care teams, yet only 17% of rural hospitals with 50 or more beds have palliative care teams.[24] Palliative medicine has been a board certified sub-specialty of medicine in the United States since 2006. Additionally, in 2011, The Joint Commission began an Advanced Certification Program for Palliative Care that recognizes hospital inpatient programs demonstrating outstanding care and enhancement of the quality of life for people with serious illness.[25]

Practice

Symptom assessment

One instrument used in palliative care is the Edmonton Symptom Assessment Scale (ESAS), which consists of 8 visual analog scales (VAS) ranging from 0–100 mm, indicating the levels of pain, activity, nausea, depression, anxiety, drowsiness, appetite, sensation of well-being,[26] and sometimes shortness of breath.[27] A score of 0 indicates absence of the symptom, and a score of 10 indicates the worst possible severity.[27] The instrument can be completed by the patient, with or without assistance, or by nurses and relatives.[26]

End of life care
Further information: End-of-life care

Medications used in palliative care can be common medications but used for a different indication based on established practices with varying degrees of evidence.[28] Examples include the use of antipsychotic medications to treat nausea, anticonvulsants to treat pain, and morphine to treat dyspnea. Routes of administration may differ from acute or chronic care, as many people in palliative care lose the ability to swallow. A common alternative route of administration is subcutaneous, as it is less traumatic and less difficult to maintain than intravenous medications. Other routes of administration include sublingual, intramuscular and transdermal. Medications are often managed at home by family or nursing support.[29]

Palliative care interventions in care homes may contribute to lower discomfort for residents with dementia and to improve family member's views of the quality of care.[30] However, higher quality research is needed to support the benefits of these interventions for older people dying in these facilities.[30]

Dealing with distress
See also: Distress in cancer caregiving

For many patients, end of life care can cause emotional and psychological distress, contributing to their total suffering.[31] An interdisciplinary palliative care team consisting of a mental health professional, social worker, counselor, as well as spiritual support such as a chaplain, can play important roles in helping people and their families cope using various methods such as counseling, visualization, cognitive methods, drug therapy and relaxation therapy to address their needs. Palliative pets can play a role in this last category.[32]

Total pain

In the 1960s, hospice pioneer Cicely Saunders first introduced the term "total pain" to describe the heterogenous nature of pain.[33] This is the idea that a patient's experience of total pain has distinctive roots in the physical, psychological, social and spiritual realm but that they are all still closely linked to one another. Identifying the cause of pain can help guide care for some patients, and impact their quality of life overall.[34]

Physical pain

Physical pain can be managed using pain medications as long as they do not put the patient at further risk for developing or increasing medical diagnoses such as heart problems or difficulty breathing.[34] Patients at the end of life can exhibit many physical symptoms that can cause extreme pain such as dyspnea[35] (or difficulty breathing), coughing, xerostomia (dry mouth), nausea and vomiting, constipation, fever, delirium, excessive oral and pharyngeal secretions (“Death Rattle”).[36]

Psychosocial pain

Once the immediate physical pain has been dealt with, it is important to remember to be a compassionate and empathetic caregiver that is there to listen and be there for their patients. Being able to identify the distressing factors in their life other than the pain can help them be more comfortable.[37] When a patient has their needs met then they are more likely to be open to the idea of hospice or treatments outside of comfort care. Having a Psychosocial assessment allows the medical team to help facilitate a healthy patient-family understanding of adjustment, coping and support. This communication between the medical team and the patients and family can also help facilitate discussions on the process of maintaining and enhancing relationships, finding meaning in the dying process, and achieving a sense of control while confronting and preparing for death.[34]

Spiritual pain

Spirituality is a fundamental component of palliative care. According to the Clinical Practice Guidelines for Quality Palliative Care, spirituality is a "dynamic and intrinsic aspect of humanity..." and has been associated with "an improved quality of life for those with chronic and serious illness..." .[38] Spiritual beliefs and practices can influence perceptions of pain and distress, as well as quality of life among advanced cancer patients.[37]

Pediatric palliative care

Pediatric palliative care is family-centered, specialized medical care for children with serious illnesses that focuses on mitigating the physical, emotional, psychosocial, and spiritual suffering associated with illness to ultimately optimize quality of life.

Pediatric palliative care practitioners receive specialized training in family-centered, developmental and age-appropriate skills in communication and facilitation of shared decision making; assessment and management of pain and distressing symptoms; advanced knowledge in care coordination of multidisciplinary pediatric caregiving medical teams; referral to hospital and ambulatory resources available to patients and families; and psychologically supporting children and families through illness and bereavement.[39]

Symptoms assessment and management of children

As with palliative care for adults, symptom assessment and management is a critical component of pediatric palliative care as it improves quality of life, gives children and families a sense of control, and prolongs life in some cases.[13] The general approach to assessment and management of distressing symptoms in children by a palliative care team is as follows:

  • Identify and assess symptoms through history taking (focusing on location, quality, time course, as well as exacerbating and mitigating stimuli). Symptoms assessment in children is uniquely challenging due to communication barriers depending on the child's ability to identify and communicate about symptoms. Thus, both the child and caregivers should provide the clinical history. With this said, children as young as four years of age can indicate the location and severity of pain through visual mapping techniques and metaphors.[40]
  • Perform a thorough exam of the child. Special attention to the child's behavioral response to exam components, particularly in regards to potentially painful stimuli. A commonly held myth is that premature and neonatal infants do not experience pain due to their immature pain pathways, but research demonstrates pain perception in these age groups is equal or greater than that of adults.[41][42] With this said, some children experiencing intolerable pain present with 'psychomotor inertia,' a phenomenon where a child in severe chronic pain presents overly well behaved or depressed.[43] These patients demonstrate behavioral responses consistent with pain relief when titrated with morphine. Finally, because children behaviorally respond to pain atypically, a playing or sleeping child should not be assumed to be without pain.[13]
  • Identify the place of treatment (tertiary versus local hospital, intensive care unit, home, hospice, etc.).
  • Anticipate symptoms based on the typical disease course of the hypothesized diagnosis.
  • Present treatment options to the family proactively, based on care options and resources available in each of the aforementioned care settings. Ensuing management should anticipate transitions of palliative care settings to afford seamless continuity of service provision across health, education, and social care settings.
  • Consider both pharmacologic and non-pharmacologic treatment modalities (education and mental health support, administration of hot and cold packs, massage, play therapy, distraction therapy, hypnotherapy, physical therapy, occupational therapy, and complementary therapies) when addressing distressing symptoms. Respite care is an additional practice that can further aid alleviating the physical and mental pain from the child and its family. By allowing the caregiving to ensue by other qualified individuals, it allows the family time to rest and renew themselves[44]
  • Assess how the child perceives their symptoms (based on personal views) to create individualized care plans.
  • After the implementation of therapeutic interventions, involve both the child and family in the reassessment of symptoms.[13]

The most common symptoms in children with severe chronic disease appropriate for palliative care consultation are weakness, fatigue, pain, poor appetite, weight loss, agitation, lack of mobility, shortness of breath, nausea and vomiting, constipation, sadness or depression, drowsiness, difficulty with speech, headache, excess secretions, anemia, pressure area problems, anxiety, fever, and mouth sores.[45][46] The most common end of life symptoms in children include shortness of breath, cough, fatigue, pain, nausea and vomiting, agitation and anxiety, poor concentration, skin lesions, swelling of the extremities, seizures, poor appetite, difficulty with feeding, and diarrhea.[47][48] In older children with neurologic and neuromuscular manifestations of disease, there is a high burden of anxiety and depression that correlates with disease progression, increasing disability, and greater dependence on carers.[49] From the caregiver's perspective, families find changes in behavior, reported pain, lack of appetite, changes in appearance, talking to God or angels, breathing changes, weakness, and fatigue to be most the most distressing symptoms to witness in their loved ones.[50]

As discussed above, within the field of adult palliative medicine, validated symptoms assessment tools are frequently utilized by providers, but these tools lack essential aspects of children's symptom experience.[51] Within pediatrics, there is not a comprehensive symptoms assessment widely employed. A few symptoms assessment tools trialed among older children receiving palliative care include the Symptom Distress Scale, and the Memorial Symptom Assessment Scale, and Childhood Cancer Stressors Inventor.[52][53][54] Quality of life considerations within pediatrics are unique and an important component of symptoms assessment. The Pediatric Cancer Quality of Life Inventory-32 (PCQL-32) is a standardized parent-proxy report which assesses cancer treatment-related symptoms (focusing mainly on pain and nausea). But again, this tool does not comprehensively assess all palliative are symptoms issues.[55][56] Symptom assessment tools for younger age groups are rarely utilized as they have limited value, especially for infants and young children who are not at a developmental stage where they can articulate symptoms.

Communication with children and families

Within the realm of pediatric medical care, the palliative care team is tasked with facilitating family-centered communication with children and their families, as well as multidisciplinary pediatric caregiving medical teams to forward coordinated medical management and the child's quality of life.[57] Strategies for communication are complex as the pediatric palliative care practitioners must facilitate a shared understanding of and consensus for goals of care and therapies available to the sick child amongst multiple medical teams who often have different areas of expertise. Additionally, pediatric palliative care practitioners must assess both the sick child and their family's understanding of complex illness and options for care, and provide accessible, thoughtful education to address knowledge gaps and allow for informed decision making. Finally, practitioners are supporting children and families in the queries, emotional distress, and decision making that ensues from the child's illness.

Many frameworks for communication have been established within the medical literature, but the field of pediatric palliative care is still in relative infancy. Communication considerations and strategies employed in a palliative setting include:

  • Developing supportive relationships with patients and families. An essential component of a provider's ability to provide individualized palliative care is their ability to obtain an intimate understanding of the child and family's preferences and overall character. On initial consultation, palliative care providers often focus on affirming a caring relationship with the pediatric patient and their family by first asking the child how they would describe themself and what is important to them, communicating in an age and developmentally cognizant fashion. The provider may then gather similar information from the child's caregivers. Questions practitioners may ask include 'What does the child enjoy doing? What do they most dislike doing? What does a typical day look like for the child?' Other topics potentially addressed by the palliative care provider may also include familial rituals as well as spiritual and religious beliefs, life goals for the child, and the meaning of illness within the broader context of the child and their family's life.[39]
  • Developing a shared understanding of the child's condition with the patient and their family. The establishment of shared knowledge between medical providers, patients, and families is essential when determining palliative goals of care for pediatric patients. Initially, practitioners often elicit information from the patient and child to ascertain these parties' baseline understanding of the child's situation.[58] Assessing for baseline knowledge allows the palliative care provider to identify knowledge gaps and provide education on those topics. Through this process, families can pursue informed, shared medical decision making regarding their child's care. A framework often employed by pediatric palliative care providers is 'ask, tell, ask' where the provider asks the patient and their family for a question to identify their level of comprehension of the situation, and then subsequently supplements the family's knowledge with additional expert knowledge.[58][59] This information is often conveyed without jargon or euphemism to maintain trust and ensure understanding. Providers iteratively check for comprehension of this knowledge supplementation by asking questions related to previous explanations, as information retention can be challenging when undergoing a stressful experience.[58]
  • Establishing meaning and dignity regarding the child's illness. As part of developing a shared understanding of a child's illness and character, palliative providers will assess both the child and their family's symbolic and emotional relationship to disease. As both the somatic and psychologic implications of illness can be distressing to children, palliative care practitioners look for opportunities to establish meaning and dignity regarding the child's illness by contextualizing disease within a broader framework of the child's life.[60][61] Derived from the fields of dignity therapy and meaning-centered psychotherapy, the palliative care provider may explore the following questions with the sick child and their family:
    • What gives your life meaning, worth, or purpose?
    • Where do you find strength and support?
    • What inspires you?
    • How do you like to be thought of?
    • What are you most proud of?
    • What are the particular things you would like your family to know or remember about you?
    • When was the last time you laughed really hard?
    • Are you frightened by all of this? What, in particular, are you most frightened of?
    • What is the meaning of this (illness) experience for you? Do you ever think about why this happened to you?[60][61]
  • Assessing preferences for decision making. Medical decision making in a pediatric setting is unique in that it is often the child's legal guardians, not the patient, who ultimately consent for most medical treatments. Yet within a palliative care setting, it is particularly consequential to incorporate the child's preferences within the ultimate goals of care. Equally important to consider, families may vary in the level of responsibility they want in this decision making process.[62] Their preference may range from wanting to be the child's sole decision makers, to partnering with the medical team in a shared decision making model, to advocating for full deferral of decision-making responsibility to the clinician.[62] Palliative care providers clarify a family's preferences and support needs for medical decision making by providing context, information, and options for treatment and medical palliation.
  • Optimizing the environment for effective conversations around prognosis and goals of care. Essential to facilitating supportive, clear communication around potentially distressing topics such as prognosis and goals of care for seriously ill pediatric patients is optimizing the setting where this communication will take place and developing informed consensus among the child's caregiving team regarding goals and options for care. Often, these conversations occur within the context of family meetings, which are formal meetings between families and the child's multidisciplinary medical team. Prior to the family meeting, providers often meet to discuss the child's overall case, reasonably expected prognosis, and options for care, in addition to clarifying specific roles each provider will take on during the family meeting. During this meeting, the multidisciplinary medical team may also discuss any legal or ethical considerations related to the case. Palliative care providers often facilitate this meeting and help synthesize its outcome for children and their families. Experts in optimized communication, palliative care providers may opt to hold the family meeting in a quiet space where the providers and family can sit and address concerns during a time when all parties are not constrained. Additionally, parents' preferences regarding information exchange with the sick child present should be clarified.[63][64] If the child's guardians are resistant to disclosing information in front of their child, the child's provider may explore parental concerns on the topic. When excluded from family meetings and moments of challenging information exchange, adolescents, in particular, may have challenges with trusting their medical providers if they feel critical information is being withheld. It is important to follow the child's lead when deciding whether to disclose difficult information. Additionally, including them in these conversations can help the child fully participate in their care and medical decision making.[57][62][65] Finally, it is important to prioritize the family's agenda while additionally considering any urgent medical decisions needed to advance the child's care.
  • Supporting emotional distress. A significant role of the pediatric palliative care provider is to help support children, their families, and their caregiving teams through the emotional stress of illness. Communication strategies the palliative care provider may employ in this role are asking for permission when engaging with potentially distressing conversations, naming emotions witnessed to create opportunities to discuss complex emotional responses to illness, actively listening, and allowing for invitational silence.[66] The palliative care provider may iteratively assess the child and family's emotional responses and needs during challenging conversations. At times, the medical team may be hesitant to discuss a child's prognosis out of fear of increasing distress. This sentiment is not supported by the literature; among adults, end of life discussions are not associated with increased rates of anxiety or depression.[67] Though this topic is not well studied in pediatric populations, conversations about prognosis have the potential to increase in parental hope and peace of mind.[68]
  • SPIKE framework. This is a framework that is designed to assist healthcare workers deliver bad news.[69] The acronym stands for: setting, perception, invitation, knowledge, empathy, and summarize/strategy. When giving bad news it is important to consider the setting, which considers the environment in which you are delivering the news including privacy, sitting, time, and the inclusion of family members. What you plan to say should also be considered, as well as rehearsed. It is important to understand how a patient is receiving the information by asking open ended questions and asking them to repeat what they learned in their own words, which is perception aspect of the framework. You should seek an invitation from the patient to disclose additional information before doing so in order to prevent overwhelming or distressing the patient further. In order to ensure the patient understands what is being told, knowledge must be used. This includes speaking in a way that the patient will understand, using simple words, not being excessively blunt, giving information in small chunks and checking in with the patient to confirm that they understand, and not providing poor information that may not be completely true. In order to alleviate some of a patient's distress it is crucial to be empathetic in the sense of understanding how a patient is feeling and the reactions they are having. This can allow you to change how you are delivering information, allow them to have time to process the information, or console them if needed. Connecting with patients is an important step in delivering bad news, maintaining eye contact proves that you are present and the patient and family has your full attention. Furthermore, make a connection by touching the patients shoulder or hand, giving them a physical connection to know that they are not alone.[70][71] Finally, it is important to summarize all the information given in order to ensure the patient fully understands and takes away the major points. Additionally, patients who have a clear plan for the future are less likely to feel anxious and uncertain, but it is important to ask patients if they are ready for that information before providing them with it.[72][73]

Society

Costs and funding

Funding for hospice and palliative care services varies. In Great Britain and many other countries all palliative care is offered free, either through the National Health Service or through charities working in partnership with the local health services. Palliative care services in the United States are paid by philanthropy, fee-for service mechanisms, or from direct hospital support while hospice care is provided as a Medicare benefit; similar hospice benefits are offered by Medicaid and most private health insurers. Under the Medicare Hospice Benefit (MHB), a person signs off their Medicare Part B (acute hospital payment) and enrolls in the MHB through Medicare Part B with direct care provided by a Medicare certified hospice agency. Under terms of the MHB, the hospice agency is responsible for the care plan and may not bill the person for services. The hospice agency, together with the person's primary physician, is responsible for determining the care plan. All costs related to the terminal illness are paid from a per diem rate (~US $126/day) that the hospice agency receives from Medicare – this includes all drugs and equipment, nursing, social service, chaplain visits, and other services deemed appropriate by the hospice agency; Medicare does not pay for custodial care. People may elect to withdraw from the MHB and return to Medicare Part A and later re-enroll in hospice.

Certification and training for services

In most countries, hospice care and palliative care is provided by an interdisciplinary team consisting of physicians, pharmacists, nurses, nursing assistants, social workers, chaplains, and caregivers. In some countries, additional members of the team may include certified nursing assistants and home healthcare aides, as well as volunteers from the community (largely untrained but some being skilled medical personnel), and housekeepers. In the United States, the physician sub-specialty of hospice and palliative medicine was established in 2006[74] to provide expertise in the care of people with life-limiting, advanced disease, and catastrophic injury; the relief of distressing symptoms; the coordination of interdisciplinary care in diverse settings; the use of specialized care systems including hospice; the management of the imminently dying patient; and legal and ethical decision making in end of life care.[75]

Caregivers, both family and volunteers, are crucial to the palliative care system. Caregivers and people being treated often form lasting friendships over the course of care. As a consequence caregivers may find themselves under severe emotional and physical strain. Opportunities for caregiver respite are some of the services hospices provide to promote caregiver well-being. Respite may last a few hours up to several days (the latter being done by placing the primary person being cared for in a nursing home or inpatient hospice unit for several days).[76]

In the US, board certification for physicians in palliative care was through the American Board of Hospice and Palliative Medicine; recently this was changed to be done through any of 11 different speciality boards through an American Board of Medical Specialties-approved procedure. Additionally, board certification is available to osteopathic physicians (D.O.) in the United States through four medical specialty boards through an American Osteopathic Association Bureau of Osteopathic Specialists-approved procedure.[77] More than 50 fellowship programs provide one to two years of specialty training following a primary residency. In Britain palliative care has been a full specialty of medicine since 1989 and training is governed by the same regulations through the Royal College of Physicians as with any other medical speciality.[78] Nurses, in the United States and internationally, can receive continuing education credits through Palliative Care specific trainings, such as those offered by End of Life Nursing Education Consortium (ELNEC) [79]

In India Tata Memorial Centre, Mumbai has started a physician course in palliative medicine for the first time in the country since 2012.

Regional variation in services
See also: Hospice care in the United States

In the United States, hospice and palliative care represent two different aspects of care with similar philosophy, but with different payment systems and location of services. Palliative care services are most often provided in acute care hospitals organized around an interdisciplinary consultation service, with or without an acute inpatient palliative care unit. Palliative care may also be provided in the dying person's home as a "bridge" program between traditional US home care services and hospice care or provided in long-term care facilities.[80] In contrast over 80% of hospice care in the US is provided at home with the remainder provided to people in long-term care facilities or in free standing hospice residential facilities. In the UK hospice is seen as one part of the speciality of palliative care and no differentiation is made between 'hospice' and 'palliative care'.

In the UK palliative care services offer inpatient care, home care, day care and outpatient services, and work in close partnership with mainstream services. Hospices often house a full range of services and professionals for children and adults. In 2015 the UK's palliative care was ranked as the best in the world "due to comprehensive national policies, the extensive integration of palliative care into the National Health Service, a strong hospice movement, and deep community engagement on the issue."[81]

Acceptance

The focus on a person's quality of life has increased greatly since the 1990s. In the United States today, 55% of hospitals with more than 100 beds offer a palliative-care program,[82] and nearly one-fifth of community hospitals have palliative-care programs.[83] A relatively recent development is the palliative-care team, a dedicated health care team that is entirely geared toward palliative treatment.

Physicians practicing palliative care do not always receive support from the people they are treating, family members, healthcare professionals or their social peers. More than half of physicians in one survey reported that they have had at least one experience where a patient's family members, another physician or another health care professional had characterized their work as being "euthanasia, murder or killing" during the last five years. A quarter of them had received similar comments from their own friends or family member, or from a patient.[84]

Despite significant progress has been made to increase the access to palliative care within the United States and other countries as well, many countries have not yet considered palliative care as a public health problem and therefore, do not include it in their public health agenda.[3] Resources and cultural attitudes both play significant roles in the acceptance and implementation of palliative care in the health care agenda.

The Official Publication of The College of Family Physicians of Canada provides an article on the stigma around palliative patient care. In this article, it states that many patients with chronic pain are treated as opioid addicts. Patients can build a tolerance to drugs and have to take more and more to manage their pain. The symptoms of chronic pain patients do not show up on scans, so the doctor must go off trust alone. This is the reason that some wait to consult their doctor and endure sometimes years of pain before seeking help.[85]

Palliative care was the subject of the 2018 Academy Award-nominated[86] Netflix short documentary, End Game by directors Rob Epstein and Jeffrey Friedman[87] about terminally ill patients in a San Francisco hospital and features the work of palliative care physician, BJ Miller. The film was executive produced by Steven Ungerleider, David C. Ulich and Shoshana R. Ungerleider.[88]

gollark: It may have good ideas, but I like medicine and running water and computers.
gollark: Spiders aren't really smart enough to do that.
gollark: I have not been to Ohio because it is wildly unsafe.
gollark: Anyway, ignoring the wrong people, anarchoprimalism/primitivism is actually bad.
gollark: Yes.

See also

References
  1. Zhukovsky D (2019). Primer of Palliative Care. American Association of Hospice and Palliative Medicine. ISBN 9781889296081.
  2. "WHO | WHO Definition of Palliative Care". WHO. Retrieved 2019-12-04.
  3. Sepulveda, Cecilia; Marlin, Amanda; Yoshida, Tokuo; Ullrich, Andreas (2 August 2002). "Palliative Care: The World Health's Global Perspective". Journal of Pain and Symptom Management. 24 (2): 91–96. doi:10.1016/S0885-3924(02)00440-2. PMID 12231124.
  4. Kavalieratos D, Corbelli J, Zhang D, Dionne-Odom JN, Ernecoff NC, Hanmer J, et al. (November 2016). "Association Between Palliative Care and Patient and Caregiver Outcomes: A Systematic Review and Meta-analysis". JAMA. 316 (20): 2104–2114. doi:10.1001/jama.2016.16840. PMC 5226373. PMID 27893131.
  5. Hoerger M, Wayser GR, Schwing G, Suzuki A, Perry LM (June 2019). "Impact of Interdisciplinary Outpatient Specialty Palliative Care on Survival and Quality of Life in Adults With Advanced Cancer: A Meta-Analysis of Randomized Controlled Trials". Annals of Behavioral Medicine. 53 (7): 674–685. doi:10.1093/abm/kay077. PMC 6546936. PMID 30265282.
  6. "What is Palliative Care? | Definition of Palliative Care | Get Palliative Care". Retrieved 2020-05-12.
  7. National Consensus Project for Quality Palliative Care (2018). "Clinical Practice Guidelines for Quality Palliative Care, 4th edition". Retrieved 2019-12-18.
  8. Ahluwalia, Sangeeta; Walling, Anne; Lorenz, Karl; Goldstein, Nathan (Feb 2019). "Current Evidence in Palliative Care: A Systematic Review in Support of the National Consensus Project's Clinical Practice Guidelines for Quality Palliative Care, 4th edition (NCP Guidelines) (SA524)". Journal of Pain and Symptom Management. 57 (2): 451–452. doi:10.1016/j.jpainsymman.2018.12.201. ISSN 0885-3924.
  9. "Heart failure - palliative care: MedlinePlus Medical Encyclopedia". medlineplus.gov. Retrieved 2020-04-30.
  10. Foley, Peter; Hampton, Justine; Hampton, Andy; Hampton, Ruth; Oleksy, Danny; Oliver, David; Weller, Belinda J (2012). "Lesley's story: a case report, and discussion of challenges faced in end-of-life care for progressive neurological disease". Practical Neurology. 12 (4): 244–248. doi:10.1136/practneurol-2012-000263. ISSN 1474-7758. PMID 22869768.
  11. Dy, Sydney M.; Apostol, Colleen; Martinez, Kathryn A.; Aslakson, Rebecca A. (Apr 2013). "Continuity, Coordination, and Transitions of Care for Patients with Serious and Advanced Illness: A Systematic Review of Interventions". Journal of Palliative Medicine. 16 (4): 436–445. doi:10.1089/jpm.2012.0317. hdl:2027.42/140114. ISSN 1096-6218. PMID 23488450.
  12. Fawole, Oluwakemi A.; Dy, Sydney M.; Wilson, Renee F.; Lau, Brandyn D.; Martinez, Kathryn A.; Apostol, Colleen C.; Vollenweider, Daniela; Bass, Eric B.; Aslakson, Rebecca A. (2012-10-26). "A Systematic Review of Communication Quality Improvement Interventions for Patients with Advanced and Serious Illness". Journal of General Internal Medicine. 28 (4): 570–577. doi:10.1007/s11606-012-2204-4. ISSN 0884-8734. PMC 3599019. PMID 23099799.
  13. Sibson K, Craig F, Goldman A (2005). "Palliative Care for Children". Handbook of Palliative Care. Blackwell Publishing Ltd. pp. 295–316. doi:10.1002/9780470755877.ch15. ISBN 978-0-470-75587-7.
  14. "Hospice Facts & Figures". NHPCO. Retrieved 2020-05-12.
  15. Werner, Darlys (2011-01-31). "Communicating About Health: Current Issues and Perspectives, by Athena du Pre". Health Communication. 26 (1): 110. doi:10.1080/10410236.2011.527626. ISSN 1041-0236.
  16. Clark, David (May 2007). "From margins to centre: a review of the history of palliative care in cancer". The Lancet Oncology. 8 (5): 430–438. doi:10.1016/S1470-2045(07)70138-9. ISSN 1470-2045. PMID 17466900.
  17. LeGrand, Susan B.; Walsh, Declan; Nelson, Kristine A.; Davis, Mellar P. (July 2003). "A syllabus for fellowship education in palliative medicine". The American Journal of Hospice & Palliative Care. 20 (4): 279–289. doi:10.1177/104990910302000410. ISSN 1049-9091. PMID 12911073.
  18. Goldstein, P.; Walsh, D.; Horvitz, L. U. (Sep 1996). "The Cleveland Clinic Foundation Harry R. Horvitz Palliative Care Center". Supportive Care in Cancer. 4 (5): 329–333. doi:10.1007/bf01788838. ISSN 0941-4355. PMID 8883225.
  19. Morrison, R. Sean; Penrod, Joan D.; Cassel, J. Brian; Caust-Ellenbogen, Melissa; Litke, Ann; Spragens, Lynn; Meier, Diane E.; Palliative Care Leadership Centers' Outcomes Group (2008-09-08). "Cost savings associated with US hospital palliative care consultation programs". Archives of Internal Medicine. 168 (16): 1783–1790. doi:10.1001/archinte.168.16.1783. ISSN 1538-3679. PMID 18779466.
  20. Kelley, Amy S.; Deb, Partha; Du, Qingling; Aldridge Carlson, Melissa D.; Morrison, R. Sean (Mar 2013). "Hospice enrollment saves money for Medicare and improves care quality across a number of different lengths-of-stay". Health Affairs (Project Hope). 32 (3): 552–561. doi:10.1377/hlthaff.2012.0851. ISSN 1544-5208. PMC 3655535. PMID 23459735.
  21. Gomes, Barbara; Calanzani, Natalia; Curiale, Vito; McCrone, Paul; Higginson, Irene J. (2013-06-06). "Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers". The Cochrane Database of Systematic Reviews (6): CD007760. doi:10.1002/14651858.CD007760.pub2. ISSN 1469-493X. PMC 4473359. PMID 23744578.
  22. Temel, Jennifer S.; Greer, Joseph A.; Muzikansky, Alona; Gallagher, Emily R.; Admane, Sonal; Jackson, Vicki A.; Dahlin, Constance M.; Blinderman, Craig D.; Jacobsen, Juliet; Pirl, William F.; Billings, J. Andrew (2010-08-19). "Early palliative care for patients with metastatic non-small-cell lung cancer". The New England Journal of Medicine. 363 (8): 733–742. doi:10.1056/NEJMoa1000678. ISSN 1533-4406. PMID 20818875.
  23. Hoerger, Michael; Wayser, Graceanne R.; Schwing, Gregory; Suzuki, Ayako; Perry, Laura M. (2019-06-04). "Impact of Interdisciplinary Outpatient Specialty Palliative Care on Survival and Quality of Life in Adults With Advanced Cancer: A Meta-Analysis of Randomized Controlled Trials". Annals of Behavioral Medicine. 53 (7): 674–685. doi:10.1093/abm/kay077. ISSN 1532-4796. PMC 6546936. PMID 30265282.
  24. America's Care of Serious Illness: A State-by-State Report Card on Access to Palliative Care in Our Nation's Hospitals. Center to Advance Palliative Care and the National Palliative Care Research Center. September 2019.
  25. "Advanced Certification for Palliative Care Programs". Joint Commission. 2014-04-30. Retrieved 2014-08-17.
  26. Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K (1991). "The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients". Journal of Palliative Care. 7 (2): 6–9. doi:10.1177/082585979100700202. PMID 1714502.
  27. Edmonton Symptom Assessment System (ESAS) from Cancer Care Ontario. Revised 2005 February
  28. Currow D, Agar MR, Abernethy AP (2011). "Tackling the Challenges of Clinical Trials in Palliative Care". Pharm Med. 25 (1): 7–15. doi:10.1007/bf03256842.
  29. "Palliative Medications". Caresearch: Palliative care knowledge network. Retrieved 28 October 2010.
  30. Hall S, Kolliakou A, Petkova H, Froggatt K, Higginson IJ (March 2011). "Interventions for improving palliative care for older people living in nursing care homes". The Cochrane Database of Systematic Reviews (3): CD007132. doi:10.1002/14651858.CD007132.pub2. PMC 6494579. PMID 21412898.
  31. Strang P, Strang S, Hultborn R, Arnér S (March 2004). "Existential pain--an entity, a provocation, or a challenge?". Journal of Pain and Symptom Management. 27 (3): 241–50. doi:10.1016/j.jpainsymman.2003.07.003. PMID 15010102.
  32. Kathryn Batson et al. "The Effect of a Therapy Dog on Socialization and Physiological Indicators of Stress in Persons Diagnosed with Alzheimer's Disease" in 'Companion Animals in Human Health' Editors – Cindy C. Wilson and Dennis C. Turner, Sage Publications 1998, ISBN 0-7619-1062-X
  33. Saunders C (14 Feb 1964). "Care of patients suffering from terminal illness at St Joseph's Hospice, Hackney, London". Nursing Mirror: vii–x.
  34. Rome RB, Luminais HH, Bourgeois DA, Blais CM (2011). "The role of palliative care at the end of life". The Ochsner Journal. 11 (4): 348–52. PMC 3241069. PMID 22190887.
  35. "Palliative care - shortness of breath: MedlinePlus Medical Encyclopedia". medlineplus.gov. Retrieved 2020-04-30.
  36. Blinderman CD, Billings JA (December 2015). "Comfort Care for Patients Dying in the Hospital". The New England Journal of Medicine. 373 (26): 2549–61. doi:10.1056/NEJMra1411746. PMID 26699170.
  37. Kelley AS, Morrison RS (August 2015). "Palliative Care for the Seriously Ill". The New England Journal of Medicine. 373 (8): 747–55. doi:10.1056/nejmra1404684. PMC 4671283. PMID 26287850.
  38. Thuné-Boyle IC, Stygall JA, Keshtgar MR, Newman SP (July 2006). "Do religious/spiritual coping strategies affect illness adjustment in patients with cancer? A systematic review of the literature". Social Science & Medicine. 63 (1): 151–64. doi:10.1016/j.socscimed.2005.11.055. PMID 16427173.
  39. Faull, Christina; Carter, Yvonne; Daniels, Lilian (2005). Handbook of palliative care (2nd ed.). Malden, MA: Blackwell Pub. ISBN 978-0-470-75587-7. OCLC 212125356.
  40. Savedra, Marilyn C.; Tesler, Mary D.; Holzemer, William L.; Wilkie, Diana J.; Ward, Judith Ann (Oct 1989). "Pain location: Validity and reliability of body outline markings by hospitalized children and adolescents". Research in Nursing & Health. 12 (5): 307–314. doi:10.1002/nur.4770120506. PMID 2798951.
  41. Anand, K. J. S.; Hickey, P. R. (Aug 1988). "Pain and Its Effects on the Human Neonate and Fetus". Survey of Anesthesiology. XXXII (4): 252. doi:10.1097/00132586-198808000-00042. ISSN 0039-6206. PMID 3317037.
  42. Schechter, Neil L.; Berde, Charles B.; Yaster, Myron (2003). Pain in infants, children, and adolescents (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. ISBN 978-0-7817-2644-3. OCLC 808596673.
  43. Gauvain-Piquard, Annie; Rodary, Chantal; Rezvani, Ali; Serbouti, Saı̈d (June 1999). "The development of the DEGRR: A scale to assess pain in young children with cancer". European Journal of Pain. 3 (2): 165–176. doi:10.1053/eujp.1999.0118. PMID 10700346.
  44. Committee on Bioethics (August 2000). "Palliative Care for Children". American Academy of Pediatrics.
  45. Wolfe, Joanne; Grier, Holcombe E.; Klar, Neil; Levin, Sarah B.; Ellenbogen, Jeffrey M.; Salem-Schatz, Susanne; Emanuel, Ezekiel J.; Weeks, Jane C. (2000-02-03). "Symptoms and Suffering at the End of Life in Children with Cancer". New England Journal of Medicine. 342 (5): 326–333. doi:10.1056/NEJM200002033420506. ISSN 0028-4793. PMID 10655532.
  46. World Health Organization (2012). The selection and use of essential medicines : report of the WHO Expert Committee, March 2011 (including the 17th WHO model list of essential medicines and the 3rd WHO model list of essential medicines for children). Geneva: World Health Organization. hdl:10665/44771. ISBN 9789241209656. ISSN 0512-3054. WHO technical report series;965.
  47. Stockman, J.A. (Jan 2008). "Symptoms Affecting Children With Malignancies During the Last Month of Life: A Nationwide Follow-up". Yearbook of Pediatrics. 2008: 448–449. doi:10.1016/S0084-3954(08)70519-0.
  48. Drake, Ross; Frost, Judy; Collins, John J (July 2003). "The symptoms of dying children". Journal of Pain and Symptom Management. 26 (1): 594–603. doi:10.1016/S0885-3924(03)00202-1. PMID 12850642.
  49. Hilton, Tony; Orr, Robert D.; Perkin, Ron M.; Ashwal, Stephen (May 1993). "End of life care in Duchenne muscular dystrophy". Pediatric Neurology. 9 (3): 165–177. doi:10.1016/0887-8994(93)90080-V. PMID 8352847.
  50. Pritchard, M.; Burghen, E.; Srivastava, D. K.; Okuma, J.; Anderson, L.; Powell, B.; Furman, W. L.; Hinds, P. S. (May 2008). "Cancer-Related Symptoms Most Concerning to Parents During the Last Week and Last Day of Their Child's Life". Pediatrics. 121 (5): e1301–e1309. doi:10.1542/peds.2007-2681. ISSN 0031-4005. PMID 18450873.
  51. Woodgate, Roberta Lynn; Degner, Lesley Faith; Yanofsky, Rochelle (Sep 2003). "A different perspective to approaching cancer symptoms in children". Journal of Pain and Symptom Management. 26 (3): 800–817. doi:10.1016/S0885-3924(03)00285-9. PMID 12967729.
  52. Hinds, Pamela S.; Quargnenti, Alice G.; Wentz, Tori J. (Apr 1992). "Measuring Symptom Distress in Adolescents With Cancer". Journal of Pediatric Oncology Nursing. 9 (2): 84–86. doi:10.1177/104345429200900238. ISSN 1043-4542. PMID 1596393.
  53. Collins, John J.; Byrnes, Maura E.; Dunkel, Ira J.; Lapin, Jeanne; Nadel, Traci; Thaler, Howard T.; Polyak, Tanya; Rapkin, Bruce; Portenoy, Russell K. (May 2000). "The Measurement of Symptoms in Children with Cancer". Journal of Pain and Symptom Management. 19 (5): 363–377. doi:10.1016/S0885-3924(00)00127-5. PMID 10869877.
  54. Hockenberryeaton, M (July 1997). "Development of two instruments examining stress and adjustment in children with cancer". Journal of Pediatric Oncology Nursing. 14 (3): 178–185. doi:10.1016/S1043-4542(97)90054-0. PMID 9260409.
  55. Varni; Katz; Seid; Quiggins; Friedman-Bender; Castro (2018). "Pediatric Cancer Quality of Life Inventory". doi:10.1037/t65932-000. Cite journal requires |journal= (help)
  56. Varni, James W.; Seid, Michael; Kurtin, Paul S. (2001). "Pediatric Quality of Life Inventory 4.0 Generic Core Scales". doi:10.1037/t54487-000. Cite journal requires |journal= (help)
  57. Levetown M (May 2008). "Communicating with children and families: from everyday interactions to skill in conveying distressing information". Pediatrics. 121 (5): e1441-60. doi:10.1542/peds.2008-0565. PMID 18450887.
  58. Garwick AW, Patterson J, Bennett FC, Blum RW (September 1995). "Breaking the news. How families first learn about their child's chronic condition". Archives of Pediatrics & Adolescent Medicine. 149 (9): 991–7. doi:10.1001/archpedi.1995.02170220057008. PMID 7655604.
  59. Baile, W. F.; Buckman, R.; Lenzi, R.; Glober, G.; Beale, E. A.; Kudelka, A. P. (March 2, 2000). "SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer". The Oncologist. 5 (4): 302–311. doi:10.1634/theoncologist.5-4-302. PMID 10964998.
  60. Chochinov HM (2012). Dignity therapy : final words for final days. Oxford: Oxford University Press. ISBN 978-0-19-517621-6. OCLC 714030350.
  61. Cassell EJ (2004). The nature of suffering and the goals of medicine (2nd ed.). New York: Oxford University Press. ISBN 1-60256-743-3. OCLC 173843216.
  62. Hinds PS (September 2004). "The hopes and wishes of adolescents with cancer and the nursing care that helps". Oncology Nursing Forum. 31 (5): 927–34. doi:10.1188/04.ONF.927-934. PMID 15378093.
  63. Mack JW, Grier HE (February 2004). "The Day One Talk". Journal of Clinical Oncology. 22 (3): 563–6. doi:10.1200/JCO.2004.04.078. PMID 14752081.
  64. Mack JW, Hilden JM, Watterson J, Moore C, Turner B, Grier HE, et al. (December 2005). "Parent and physician perspectives on quality of care at the end of life in children with cancer". Journal of Clinical Oncology. 23 (36): 9155–61. doi:10.1200/JCO.2005.04.010. PMID 16172457.
  65. Snethen JA, Broome ME, Knafl K, Deatrick JA, Angst DB (June 2006). "Family patterns of decision-making in pediatric clinical trials". Research in Nursing & Health. 29 (3): 223–32. doi:10.1002/nur.20130. PMID 16676342.
  66. Back AL, Bauer-Wu SM, Rushton CH, Halifax J (December 2009). "Compassionate silence in the patient-clinician encounter: a contemplative approach". Journal of Palliative Medicine. 12 (12): 1113–7. doi:10.1089/jpm.2009.0175. PMC 2939848. PMID 19698026.
  67. Wright AA, Zhang B, Ray A, Mack JW, Trice E, Balboni T, et al. (October 2008). "Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment". JAMA. 300 (14): 1665–73. doi:10.1001/jama.300.14.1665. PMC 2853806. PMID 18840840.
  68. Mack JW, Joffe S (February 2014). "Communicating about prognosis: ethical responsibilities of pediatricians and parents". Pediatrics. 133 (Suppl 1): S24-30. doi:10.1542/peds.2013-3608E. PMID 24488537.
  69. Baile, W. F.; Buckman, R.; Lenzi, R.; Glober, G.; Beale, E. A.; Kudelka, A. P. (March 2, 2000). "SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer". The Oncologist. 5 (4): 302–311. doi:10.1634/theoncologist.5-4-302.
  70. "John Hausdorff, MD". pub.hematology.org. 2017-07-01. Retrieved 2020-05-12.
  71. du Pre, Athena (2017). "Social Support, Family Caregivers, and End of Life". Communicating About Health: Current Issues and Perspectives. New York, New York: Oxford University Press. pp. 208–209. ISBN 9780190275686.
  72. Saraiya, Biren; Bodnar-Deren, Susan; Leventhal, Elaine; Leventhal, Howard (2008-12-15). "End of Life Planning and its Relevance for Patients and Oncologists' Decisions in Choosing Cancer Therapy". Cancer. 113 (12 Suppl): 3540–3547. doi:10.1002/cncr.23946. ISSN 0008-543X. PMC 2606925. PMID 19058149.
  73. O'Leary, Kevin J.; Kulkarni, Nita; Landler, Matthew P.; Jeon, Jiyeon; Hahn, Katherine J.; Englert, Katherine M.; Williams, Mark V. (January 2010). "Hospitalized Patients' Understanding of Their Plan of Care". Mayo Clinic Proceedings. 85 (1): 47–52. doi:10.4065/mcp.2009.0232. ISSN 0025-6196. PMC 2800283. PMID 20042561.
  74. American Board of Medical Specialties, ABMS Establishes New Subspecialty Certificate in Hospice and Palliative Medicine Archived 2010-11-16 at the Wayback Machine, October 6, 2006, accessed 11/9/2010.
  75. American Board of Medical Specialties, ABMS Guide to Physician Specialties, 2011, p. 2, accessed 11/9/2010.
  76. Thayyil J, Cherumanalil JM (September 2012). "Assessment of status of patients receiving palliative home care and services provided in a rural area-kerala, India". Indian Journal of Palliative Care. 18. 18 (3): 213–8. doi:10.4103/0973-1075.105693. PMC 3573477. PMID 23440060.
  77. "Specialties & Subspecialties". American Osteopathic Association. Archived from the original on 13 August 2015. Retrieved 23 September 2012.
  78. American Academy of Hospice & Palliative Medicine. "American Academy of Hospice and Palliative Medicine". Aahpm.org. Retrieved 21 November 2014.
  79. Ferrell BR, Virani R, Grant M, Rhome A, Malloy P, Bednash G, Grimm M (February 2005). "Evaluation of the End-of-Life Nursing Education Consortium undergraduate faculty training program". Journal of Palliative Medicine. 8 (1): 107–14. doi:10.1089/jpm.2005.8.107. PMID 15662179.
  80. "In-Home Palliative Care Allows More Patients to Die at Home, Leading to Higher Satisfaction and Lower Acute Care Utilization and Costs". Agency for Healthcare Research and Quality. 2013-04-03. Retrieved 2013-07-09.
  81. "Quality of Death Index 2015: Ranking palliative care across the world". The Economist Intelligence Unit. 6 October 2015. Retrieved 8 October 2015; "UK end-of-life care 'best in world'". BBC. 6 October 2015. Retrieved 8 October 2015.
  82. Center to Advance Palliative Care, www.capc.org
  83. Lynn, Joanne (2004). Sick to death and not going to take it anymore!: reforming health care for the last years of life. Berkeley: University of California Press. p. 72. ISBN 978-0-520-24300-2.
  84. Goldstein NE, Cohen LM, Arnold RM, Goy E, Arons S, Ganzini L (March 2012). "Prevalence of formal accusations of murder and euthanasia against physicians". Journal of Palliative Medicine. 15 (3): 334–9. doi:10.1089/jpm.2011.0234. PMC 3295854. PMID 22401355.
  85. Dubin, Ruth E.; Kaplan, Alan; Graves, Lisa; Ng, Victor K. (December 2017). "Acknowledging stigma". Canadian Family Physician. 63 (12): 906–908. ISSN 0008-350X. PMC 5729132. PMID 29237624.
  86. "'The 2019 Oscar Nominated Short Films' Review". The New York Times. 2019-02-06. Retrieved 2020-04-10.
  87. "Stream It Or Skip It: 'End Game' On Netflix, A Short Documentary About Dying Gracefully". Decider. 2018-05-07. Retrieved 2020-04-10.
  88. "How This Doctor Is Bringing Human Connection Back to End-of-Life Care". Forbes. 2018-08-29. Retrieved 2020-04-10.
This article is issued from Wikipedia. The text is licensed under Creative Commons - Attribution - Sharealike. Additional terms may apply for the media files.