All too often neglected, maximal quality improvement in the setting of life-limiting illness and noxious symptomatology is a worthy medical, public health, and humanitarian goal. The World Health Organization estimates that, globally, about 60% of all people who die would benefit from palliative care before death; however, palliative care is not exclusively reserved for patients at the end of life. Given the relative newcomer status of this field of medical care, some definition would be helpful. Palliative care is a multidisciplinary medical specialty—often involving social work and spiritual care—that is concerned with impeccable symptom management and supportive care for patients and their families facing life-limiting illness. It focuses on the amelioration of physical, emotional, psychological, and spiritual suffering. Palliative care is not strictly reserved for practice by palliative care specialists; non–palliative care treating specialists can and should be trained to provide what is called “primary palliative care” such as basic pain management and facilitation of clinical discussions with patients and families about disease prognosis and advance care planning. In the oncologic setting, the recommended timing for the integration of specialist palliative care in the management of cancer patients has steadily been moving upstream, closer to time of diagnosis, because outcomes research continues to demonstrate improved quality of life and, in some instances, improved survival with the earlier involvement of palliative care specialists. Such effects were seen in the widely publicized study by Temel et al., in which average survival time was increased by 2.7 months (11.6 months vs. 8.9 months, p = 0.02, n = 151) and health-related quality of life was improved for patients newly diagnosed with metastatic non-small-cell lung cancer and randomized for referral to palliative care compared with control patients not so randomized. In a similar vein, what oncologists mean by “palliation,” such as when palliative chemotherapy lines are routinely offered, might be changing as well, as stronger evidence emerges that such chemotherapy might not actually provide palliation—such as was seen in a recent prospective cohort study of 621 patients with progressive end-stage metastatic cancer who had a life expectancy of 6 months or less and who had already completed at least 1 chemotherapy regimen. In such patients, use of “palliative chemotherapy” was found to be associated with a reduction in the quality of life near death for patients who had a good baseline performance status (odds ratio: 0.35; 95% confidence interval: 0.17 to 0.75) and was not found to be associated with quality of life near death for patients with a moderate or poor baseline performance status.
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