Changing ideas: Palliative Care Does Not Necessarily Mean End-of-Life Care

Arun Ghoshal, MD, MRes

Hello. I am Dr Arun Ghoshal, palliative care physician from Mumbai. I wanted to briefly discuss a very important topic and two scientific papers that appeared on the topic, which is palliative care (PC) among patients with cancer.

A very interesting paper appeared in the Indian Journal of Palliative Care in 2018, entitled ” Initial Perceptions about Palliative Care in Patients with Advanced Cancer: A Prospective Cross-Sectional Audit.” [1] This paper from New Delhi noted that the perceptions of palliative care—to quote the authors in the abstract— ” majority of the patients had not heard the term PC before and were not aware of its meaning. Most of them (90%) were send to control pain which was too severe to be managed by the oncologists.” Clearly, palliative care encompasses that group of patients who are in that situation. However, scientific evidence clearly points out that palliative care is intended to include patients at an earlier point in their journey. [2] In fact, there is very strong evidence, including a landmark randomized phase 3 trial,[3] demonstrating that a palliative care approach can significantly improve survival by focusing on the palliative aspects of a patient’s care, which includes pain management as well as other aspects of the palliation of symptoms. The situation is similar in a South Asian community in Canada as has been pointed out by Dosani et al. in their 2020 paper “Perceptions of palliative care in a South Asian community: findings from an observational study”. [4]

There is a perception issue here that needs to be tackled head-on by the oncology and medical communities. However, the difficulty with that goal is heightened when one sees review such as one that was recently published in Ann Palliat Med, entitled ” Early palliative care and the opioid crisis: ten pragmatic steps towards a more rational use of opioids.”[5] Clearly, the question of opioid overdose and addiction is very serious and needs to be taken very seriously by all physicians, including oncologists. Yet, this document states, ” Palliative care has a critical role educating patients about the safe use of opioids, providing universal screening and close monitoring, and prescribing opioids appropriately balancing the risks and benefits. This is particularly important in the era of early palliative care, when patients have much longer survival and potentially greater risk of misuse while on chronic opioid therapy.” and suggests a pragmatic 10-step approach for the judicious use of opioids.

The issue here is that we need to somehow change the idea. The word “palliative” needs to be associated with focusing on a patient’s symptoms rather than saying that “palliative” means end-of-life care. This is obviously a conversation that is important, and it is certainly relevant to optimizing the quality of life and the duration of life for patients with cancer at all stages, particularly advanced cancer. I hope that this conversation will become increasingly relevant within the oncology community as well as within the general medical community and the media and lay audiences, because palliative care is such an important part of the management of cancer patients. I thank you for your attention.

1. Gupta N, Kumar V, Garg R, Bharati SJ, Mishra S, Bhatnagar S. Initial Perceptions about Palliative Care in Patients with Advanced Cancer: A Prospective Cross-Sectional Audit. Indian J Palliat Care. 2018;24(4):512-516. doi:10.4103/IJPC.IJPC_94_18
2. Howie L, Peppercorn J. Early palliative care in cancer treatment: rationale, evidence and clinical implications. Ther Adv Med Oncol. 2013;5(6):318-323. doi:10.1177/1758834013500375
3. Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, Dahlin CM, Blinderman CD, Jacobsen J, Pirl WF, Billings JA, Lynch TJ. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010 Aug 19;363(8):733-42. doi: 10.1056/NEJMoa1000678. PMID: 20818875.
4. Dosani, N., Bhargava, R., Arya, A. et al. Perceptions of palliative care in a South Asian community: findings from an observational study. BMC Palliat Care 19, 141 (2020). https://doi.org/10.1186/s12904-020-00646-6
5. Gaertner J, Boehlke C, Simone CB 2nd, Hui D. Early palliative care and the opioid crisis: ten pragmatic steps towards a more rational use of opioids. Ann Palliat Med. 2019 Sep;8(4):490-497. doi: 10.21037/apm.2019.08.01. Epub 2019 Aug 16. PMID: 31431028.