Heather McLeod

Palliative Care

Definitions and Philosophy

The definition from the WPCA/WHO Global Atlas of Palliative Care at the End of Life begins with the WHO definition from 2002, then clarifies the definition in four key areas. The WHO 2002 definition is as follows:

For adults:

“Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual."

"Palliative care:

  • provides relief from pain and other distressing symptoms;
  • affirms life and regards dying as a normal process;
  • intends neither to hasten or postpone death;
  • integrates the psychological and spiritual aspects of patient care;
  • offers a support system to help patient’s live as actively as possible until death;
  • offers a support system to help the family cope during the patients illness and in their own bereavement;
  • uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated;
  • will enhance quality of life, and may also positively influence the course of illness;
  • is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.”
    • For Children:

      “Palliative care for children represents a special, albeit closely related field to adult palliative care. WHO’s definition of palliative care appropriate for children and their families is as follows; the principles apply to other paediatric chronic disorders.”

      "Palliative care for children is the active total care of the child’s body, mind and spirit, and also involves giving support to the family.

      • It begins when illness is diagnosed, and continues regardless of whether or not a child receives treatment directed at the disease.
      • Health providers must evaluate and alleviate a child’s physical, psychological, and social distress.
      • Effective palliative care requires a broad multidisciplinary approach that includes the family and makes use of available community resources; it can be successfully implemented even if resources are limited.
      • It can be provided in tertiary care facilities, in community health centres and even in children’s homes."

The WHO 2002 definition of palliative care is then clarified as follows:

“The Global Atlas adopts the current World Health Organization definition of palliative care. However, it has been recognised for some years that this definition requires further explanation to clarify the comprehensive nature of palliative care (WPCA Policy statement on defining palliative care). We elucidate this here, with supporting evidence, to ensure the definition is more explicit and transparent."

First, palliative care is needed in chronic as well as life-threatening/limiting-conditions.

  • Adults with a wide range of chronic conditions throughout the world have been recognised as benefiting from palliative care. Early intervention, well before the terminal stage, is recognised as optimal.
  • The WHO definition of palliative care for children states that palliative care should be provided to children with chronic and life-limiting illness, not only those who are dying. Paediatric palliative care begins when the illness is diagnosed, and continues regardless of whether or not a child receives treatment directed at the disease.
    • Second, there is no time or prognostic limit on the delivery of palliative care.

      • It has been widely advocated that palliative care should be delivered on the basis of need, not diagnosis or prognosis.
      • Although we have estimated numbers based on mortality data for consistency, palliative care should be provided ‘early in the course of the illness’ (WHO definition of palliative care) and at least as many people are estimated to have palliative care needs before the last year of life as during the last year of life.
        • Third, the Global Atlas describes the need for palliative care at all levels of care.

          • Palliative care is not limited to specialist palliative care services but includes primary and secondary level care.
          • Palliative care is provided at three different levels: i) through a ‘palliative care approach’ adopted by all healthcare professionals, provided they are educated and skilled through appropriate training. ii) ‘general palliative care’ provided by primary care professionals and those treating patients with life-threatening diseases, with a good basic knowledge of palliative care, and iii) ‘specialist palliative care’ provided by specialised teams for patients with complex problems.
          • The Global Atlas includes all three levels, and the requirement for provision at the three different levels will vary from country to country, depending on the proportion of deaths from palliative care diagnoses, according to models of healthcare, and the nature and extent of integration of palliative care within these models. In high income countries, it is estimated that between 30-45% of palliative care need may be met by specialist palliative care.
            • Fourth, palliative care is not limited to any one care setting.

              • Palliative care is provided wherever a person’s care takes place, whether this is the patient’s own home, a care facility, hospice inpatient unit, hospital, or outpatient or day care service."
                • The relationship between curative and palliative care

                  “The relationship between curative and palliative care plays out differently in different countries and societies, for a variety of reasons. However, we emphasise that palliative care should in no way become a substitute for appropriate curative care.

                  • Modern medical care has a strong bias towards curative medicine. In high income countries, death is frequently medicalised, and curative treatments may be prioritised ahead of palliative care. Better, and earlier, integration of palliative care alongside active treatment is needed.
                  • For low and middle income countries, however, curative care and active management may be very limited, or not available at all. Palliative care is needed, but not as a substitute for development of healthcare systems and provision of appropriate services.
                  • In some societies, the cultural context may mean that death and dying are often stigmatised, such that perceptions and taboos need to be challenged before palliative care provision can be addressed.
                    • The Worldwide Palliative Care Alliance recommends that all governments integrate palliative care into their country’s health system, alongside curative care. At a minimum, palliative care should be provided even when curative care is unavailable.”