Professor Richard Harding is Herbert Dunhill Chair, Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation and the Vice Dean (International), Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, both in King’s College London. In an interaction with S Harachand, Prof Harding says that there is no need to wait until a patient is dying to introduce the benefits of palliative care, as integrating palliative care much earlier into the treatment cycle of a terminally ill patient will not only improve outcomes but can at times even prolong the life of the patient. Emphasizing the importance of healthcare professionals having basic palliative care skills, he highlights the need for the public to better understand what is available to them and to ask for the best care even if their disease is progressive and incurable.
The general notion is that palliative care is end-of-life care. In what ways can administering palliative care in the earlier stages improve the quality of life of a terminally ill patient?
We already know that for patients and their families facing a life-limiting illness, introducing palliative care can improve their outcome. The challenge is that palliative care, which involves careful and detailed identification of what matters to the patients, their goals of care, their symptoms and concerns and family support needs, is often given quite late — for example when all treatments have been tried and the patient is approaching death. Research has shown that we can and should introduce palliative care much earlier. This improves psychological wellbeing, quality of life, symptom control and family wellbeing. Some studies have even shown that taking this careful approach to patient wellbeing can even extend life. There is no need to wait until a patient is dying to introduce these benefits. Evidence also shows that it does not cost more.
Palliative care is hugely important for most patients with incurable, progressive diseases. Despite this fact, why do you think it is one of the most neglected aspects of medicine?
Modern palliative care was founded by Dame Cicely Saunders in the 1960s and is now part of healthcare in most parts of the world, although it remains a fact that there is still not enough palliative care to meet patient needs. Firstly, the education of clinicians needs to grow — all health care professionals should have basic palliative care skills, and also ongoing professional education [should be modified]. Second, the public needs to better understand what is available to them and to know that they should ask for the best care even if their disease is progressive and incurable. Third, policy needs to focus on the inclusion of palliative care to ensure that it is part of all health systems. We must start changing things now. Data shows that by 2060, there will be a 155% increase in the number of people with serious health-related suffering in low-income countries, predominantly cancer.
How efficient are the doctors generally when it comes to delivering crucial aspects of care like communicating the news of a condition with a poor prognosis?
Communicating bad news can be difficult. Education and mentoring for this aspect of care are crucial. Clinicians generally want to do the right thing but there are impediments. Patients and families want a cure from their health care team and so communicating a poor prognosis is difficult. There are also drivers against communication to the patient. For example, families in India often want the clinician to collude with them in concealing information.
Home care for end-of-life patients is currently becoming popular in many places. Do you think this is a workable proposition in low-resource settings like that of India?
Home care is crucial. If we don’t support patients and families in the community, then they risk burdensome and costly admissions or unnecessary suffering. Innovations are taking place.
Data from India and Africa show that use of a simple, app-enabled community health workers to assess patients and families, share the data with a palliative care team online and for the palliative care team to allocate their human resources to those patients most in need.
Many clinicians often find delivering palliative care, particularly end-of-life care, really challenging. How do you comment?
It’s important that clinicians are supported in their attempts to provide palliative care. Ongoing training, the availability of pain and symptom-relieving drugs and local services to refer to are crucial. Partnerships are important. In order to engineer palliative care into the health system then local specialist services and government must work together. Such system-wide efforts can help and patients and families by ensuring their clinical teams are supported.