There is a tendency among health care providers to characterize palliative care programs in terms of what they are not: They are not hospice programs, nor are they traditional treatment programs that aim to achieve a cure. Defining palliative programs negatively in this way can lead to a distorted view of these programs as separate and set apart from other patient care programs. We lose sight of the connections between traditional care, palliative care, and hospice. In fact, the connections are quite strong.
Under traditional models of care, curative and restorative therapy is emphasized during the acute and chronic phases of a patient's illness, as depicted in Figure 1.
Palliative care is seldomly provided during this period. Not until the very last phase of life, when the patient's condition is clearly life threatening, are hospice services offered. By then, it is nearly impossible for the patient and family to benefit from the comfort care these programs provide. With this traditional model of care, there is an abrupt division between
curative and restorative therapy for patients during acute and chronic phases of their illness and hospice care during their final stage of life. In an almost literal sense, this model forces seriously ill patients to chose sides. Often they experience this decision as a choice between less than ideal options; for as their illness progresses, what many of these patients want is a service that blends curative practices with comfort care. What they want, in other words, is palliative care.
In its consummate form, palliative care is most effective for patients and their families when it is seamlessly integrated across the health care continuum: initiated in the curative phase, continuing through the illness course, and culminating in the hospice trajectory, as depicted in Figure 2.
With this integrated model of care, all patients diagnosed with a life-threatening illness are offered some degree of palliative care from the time of diagnosis. Often, only limited palliative services are offered during the acute phase of a patient's illness, when most of the focus is on curative or restorative treatment. If the patient's disease progresses, however, more palliative services are integrated into the patient's care as needed. At the same time, the emphasis on curative and restorative therapies gradually diminishes. In contrast to the dichotomy that exists in traditional models of care, this integrated model blends
curative and palliative care continuously across the continuum of care.
The TCPC Program aims to achieve an integrated palliative care prototype with the "traditional" health care model, which results in the development of efficient pathways to care for specific patient populations across the health care continuum. A recent evaluation of the program demonstrates that this vision is being realized.
This evaluation showed that by integrating palliative care into curative care practices earlier in the disease trajectory, chronically ill patients near the need of life received the services they needed and wanted — pain and other symptom relief, emotional support, 24-hour medical support, and patient and family education — which enabled them to better manage their own care at home and reduced the need for inpatient and emergency services. The study compared 210 patients in the TCPC Program with a matched sample of 348 home health patients. Overall, TCPC patients had significantly fewer emergency room visits, hospital days, skilled nursing facility days, and physician visits, though they had more home health visits than the comparison group. The study demonstrates the ability of palliative care programs to effectively transfer end-of-life care from high-cost acute-care services to a lower cost home-based arena that allows patients to die in the comfort of their home. The findings suggest that palliative care programs may offer a more effective and compassionate model of care for those who are nearing end of life.
For more information about the TriCentral Palliative Care Toolkit visit www.growthhouse.org/palliative/. All content is Copyright © 2002, 2003 by Richard D. Brumley, M.D. All rights reserved. No part of this toolkit may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without written permission from the publishers. This guide to developing home-based outpatient palliative care services was developed through a grant to the Kaiser Permanente TriCentral Service Area from The Project on Death In America. The Kaiser Permanente TriCentral Palliative Care Program is a Sustaining Member of the Inter-Institutional Collaborating Network On End-of-life Care (IICN) which links major organizations internationally.
