Welcome back. We hope that you've had a chance to review the content from our course essentials in palliative care. We provide here a brief review of the core topics covered in that course and we believe it will be helpful to you whether you've taken the course, or whether you're taking one of the other courses in our specialization. Palliative care, the best way for us to think about it is holistic care for patients and families who are facing life threatening illness. The World Health Organizations provides the following definition, and I believe it is true to the practice of palliative care as we do it today. Palliative care is an approach that improves the quality of life of patients and their families who are facing problems associated with life threatening illness. It prevents and relieves suffering through early identification, correct assessment, and treatment of pain and other problems, whether physical, psychosocial, or spiritual. What makes palliative care so unique is that the focus is not only on the medical components of illness, for example, the disease trajectory or the diagnosis, but really on how does illness impact a patient's whole self and their family. Thinking about their physical needs, whether it'll be a symptom such as pain, their emotional needs such as depression or anxiety that could be associated with a change in their help. Spiritual or existential needs which we know occur when patients and families are confronted with a life-altering diagnosis. Often people wonder, why me? Did God give up on me? Then of course, the social ramifications of all of the different changes that occur when patients have to have this very fundamental change in their Identity which could affect their work, their family, their interaction with their children, their church. When we think about palliative care, there are many ways to deliver this practice. There's often folks that you might encounter in your clinic. This could be your primary care doctor or a nurse practitioner that you see when you go get your blood pressure checked. Those folks may have skills in what we call primary palliative care where they can do some basic management for you. They might be able to check whether or not you need a pain medication or do an advanced directive with you if you're thinking about planning for the future. However, when things get complicated, there is a cohort of clinicians who have additional expertise in palliative care. These are folks who have additional training either through fellowship or certification that focus specifically on symptom management and assessment, conflict resolution and negotiation, thinking about futility and how we think about the ethics of different types of treatments for patients who are quite sick. These specialists can work alongside your primary clinician if they're struggling with a palliative care issue. An analogy that I often use is that you might see your doctor for hypertension and they're able to give you that first drug or maybe even the second drug, but if your blood pressure keeps going up and they can't get it under control, they may consult a cardiologist. In the same thing, on your primary care provider, if they need help with symptom management, if they're working through complex family issues and they need support, then they can consult a specialist palliative care provider. Palliative care is applicable across a variety of diseases. We know that using palliative care can improve outcomes in cancer and chronic obstructive pulmonary disease, cardiovascular disease, end-stage renal and liver disease, as well as HIV and AIDS. These are just some samples of where we can see palliative care working in a chronic disease management area. For example, in cancer and COPD, you may take care of patients who have shortness of breath and palliative care specialists can really help with what we call dyspnea management or shortness of breath management. For patients who have end-stage renal disease or liver disease, palliative care colleagues can be very helpful when thinking about transplant and whether or not those folks would be appropriate for renal or liver transplant. Then of course, in cardiovascular disease and in HIV and AIDS, we think about how those diseases are now quite chronic yet they're life altering. So palliative care can help with supportive care for the caregivers, thinking about medication management, thinking about self-care as you try to manage those illnesses. Palliative care not only is important for different diseases, but it's also important from the point of diagnosis of an illness through the end of life. Here we see this really lovely depiction of how you may integrate palliative care into your normal medical process for patients and families. For example, let's say you have a patient who was just diagnosed with an early stage breast cancer. The majority of her care at the very beginning right here, might be really focusing on thinking about a surgical plan, thinking about a radiation plan and maybe thinking about appropriate adjuvant treatments or medications that could help make sure that cancer doesn't come back. Alongside though, you would hope that you might have a symptom management approach. That would be the palliative care piece, where we were thinking about her symptoms, whether or not she had any pain at the wound site, whether or not she needed support for her children, whether or not her husband was overwhelmed with these changes, those would be all of the palliative care components. Imagine this patient over time, finds out that her cancer is no longer curable and it has recurred. We might see a step up at that point in terms of increased palliative care with a focus on symptom management and goals of care and the oncology care really focusing on disease modification to try to prolong her life, but maybe not cure her with appropriate medications such as chemotherapy. Then there could be another junction that we would imagine where we now know that all of the medications that are being given to prolong her life are no longer effective or the risk outweighs the benefit. In that situation, we're now thinking about moving from palliative care and curative care to hospice care, where the focus is really on full supportive management of the patient's needs and the family's needs with the goal of symptom management and improving quality of life when we are no longer able to prolong life. When someone passes away, we believe that palliative care should continue because we know loved ones continue to have needs, and we call this process the bereavement phase, where we know that families do better if they are given attention that is dedicated to understanding their grief and being able to help them to cope with that loss. This is not only true for parents and for couples, but also for children who are involved after a death. Many people ask, what makes palliative care work? How does palliative care really help folks? What's happening in those visits with the palliative care practitioner? There have been actually many studies that look at what the palliative care clinician is doing with patients and families and describing those interactions and categorizing what is happening and thinking about how it improves care. For one, we know that palliative care clinicians are spending a key amount of time doing rapport and relationship building. We're ensuring that these patients really trust us and want us to be a part of their care and are ready to really explore difficult things with us. That starts with just enjoying being in the same room and feeling like you're connected to the palliative care provider. The second component that we spend a lot of time on is really exploring a patient's understanding of their illness. A lot of times we provide a lot of data, but we don't really know if patients know what all of that data means. Medicine is really a whole another world and for many folks, it's like entering the twilight zone. They walk in, and they are trying to learn a whole new language. We give patients the time to really tell us back what they understand about their illness and what they need further information on so that we can fill those gaps and really understand what the patient needs to know in order to think about next steps. We also spend a great deal of time thinking about the effect of disease on a patient's quality of life. How does illness impact someone's daily function? How does pain impact someone's daily function? Our focus is really spent on thinking about those symptoms, thinking about psychosocial symptoms too, such as anxiety and depression and really coming up with a plan to improve quality of life at a symptom level and to create an actionable plan for each of those symptoms and provide psychosocial counseling so that patients feel better equipped to handle the treatments that they are asked to do. We also want to make sure that we understand what the patient is hoping for from these treatments. We often think that we're doing something to cure a patient or to give them more time. But what does that mean for the patient? Is the patient doing chemotherapy in order to attend a son's graduation or is the patient choosing to go through a kidney transplant so that they can make sure that they can take care of an aging parent? What we really want to know is, yes, we're putting them through a lot of different medical treatments. But what are their goals and what are their life goals? What are their goals for their family? What are their personal goals? How can we assist in making sure that our medical decisions really are in alignment with those goals? So that patients feel like they're receiving goal concordant care or care that is allowing them to live the best life possible. You have a good understanding now of what we do in our clinic visits. If we do this well, what happens? We have done a variety of studies from key researchers across the country and actually across the globe, looking to see what palliative care does to improve healthcare quality. There is a variety of different metrics that have been looked at in quality and that includes both at a patient level as well as at a caregiver level and then at a system level. For example, we know that if you integrate a solid palliative care intervention early in someone's chronic disease management, you improve a patient's quality of life, you improve their symptoms such as pain, shortness of breath, you also improve the caregivers quality of life, and that manifests as a feeling of decreased burden and feeling more empowered as a caregiver to take care of that person. We also find that anxiety and depression improve for patients. One of the things that we're really trying to change is thinking about how we look at end of life and allowing for patients to have a better quality of dying. What we see is that if you do palliative care well, patients have a better quality of life at the end of life, and what does that mean? It usually means that patients are able to die at home, patients are able to die with their goals met, patients are not dying in the intensive care unit or at a local emergency room, but rather with their needs being met in a place that's comfortable for them with their loved ones near them. What does that translate to at a system level, which is why people sometimes get excited, is that usually means that we're spending less money at the end of life and patients are getting better care at the end of life and that's improved quality. Additionally, there has been some indication that if you do all of this well, you also improve survival. So patients live not only better, but they live longer if they have an opportunity to have an integrated palliative care approach. Let's recap, palliative care is meant to improve the quality of life of patients with serious illness, as well as the quality of life for family and caregivers. Palliative care is a holistic approach, not just caring for the disease, but really thinking about the whole impact of disease on a patient's physical, psychosocial, and spiritual well-being. Palliative care is not relegated just to a specialist, but really can be practiced by all primary providers, whether it be your local cardiologist, your nurse practitioner in your PCP clinic, or maybe even a clergy person who's coming to visit you in the hospital. But sometimes we all need help and specialty palliative care is there for you and is a group of specialists who have extra training to provide that extra layer of support, not only for you as a patient but for your clinical team to assist with symptom management, as well as providing an extra layer of understanding around goals of care and complex decision-making.