October 10, 2017

Palliative Care

Palliative care is an approach that improves the quality of life of patients (adults and children) and their families who are facing problems associated with life-threatening illness. It prevents and relieves suffering through the early identification, correct assessment and treatment of pain and other problems, whether physical, psychosocial or spiritual.

Addressing suffering involves taking care of issues beyond physical symptoms. Palliative care uses a team approach to support patients and their caregivers. This includes addressing practical needs and providing bereavement counselling. It offers a support system to help patients live as actively as possible until death.

Palliative care is explicitly recognised under the human right to health. It should be provided through person-centred and integrated health services that pay special attention to the specific needs and preferences of individuals.

Palliative care is required for a wide range of diseases. The majority of adults in need of palliative care have chronic diseases such as cardiovascular diseases (38.5%), cancer (34%), chronic respiratory diseases (10.3%), AIDS (5.7%) and diabetes (4.6%). Many other conditions may require palliative care, including kidney failure, chronic liver disease, multiple sclerosis, Parkinson’s disease, rheumatoid arthritis, neurological disease, dementia, congenital anomalies and drug-resistant tuberculosis.

Pain is one of the most frequent and serious symptoms experienced by patients in need of palliative care. Opioid analgesics are essential for treating the pain associated with many advanced progressive conditions. For example, 80% of patients with AIDS or cancer, and 67% of patients with cardiovascular disease or chronic obstructive pulmonary disease will experience moderate to severe pain at the end of their lives.

Opioids can also alleviate other common distressing physical symptoms including breathlessness. Controlling such symptoms at an early stage is an ethical duty to relieve suffering and to respect the dignity of people.

Poor access to palliative care

Each year an estimated 40 million people are in need of palliative care, 78% of whom live in low- and middle-income countries. For children, 98% of those needing palliative care live in low- and middle-income countries with almost half of them living in Africa.

Worldwide, a number of significant barriers must be overcome to address the unmet need for palliative care:
  • national health policies and systems do not often include palliative care at all
  • training on palliative care for health professionals is often limited or non-existent
  • population access to opioid pain relief is inadequate and fails to meet international conventions on access to essential medicines.
A 2011 study1 of 234 countries, territories and areas found that palliative care services were only well integrated in 20 countries, while 42% had no palliative care services at all and a further 32% had only isolated palliative care services.

In 2010, the International Narcotics Control Board found that the levels of consumption of opioid pain relief in over 121 countries were “inadequate” or “very inadequate” to meet basic medical needs. In 2011, 83% of the world’s population lived in countries with low to non-existent access to opioid pain relief.

Other barriers to palliative care include:
  • lack of awareness among policy-makers, health professionals and the public about what palliative care is, and the benefits it can offer patients and health systems
  • cultural and social barriers, such as beliefs about death and dying
  • misconceptions about palliative care, such as that it is only for patients with cancer, or for the last weeks of life
  • misconceptions that improving access to opioid analgesia will lead to increased substance abuse.

What can countries do?

National health systems are responsible for including palliative care in the continuum of care for people with chronic and life-threatening conditions, linking it to prevention, early detection and treatment programmes. This includes, as a minimum, the following components:
  • Health system policies that integrate palliative care services into the structure and financing of national health-care systems at all levels of care.
  • Policies for strengthening and expanding human resources, including training of existing health professionals, embedding palliative care into the core curricula of all new health professionals, as well as educating volunteers and the public.
  • A medicines policy which ensures the availability of essential medicines for managing symptoms, in particular opioid analgesics for the relief of pain and respiratory distress.
Palliative care is most effective when considered early in the course of the illness. Early palliative care not only improves quality of life for patients but also reduces unnecessary hospitalizations and use of health-care services.

Palliative care needs to be provided in accordance with the principles of universal health coverage. All people, irrespective of income, disease type or age, should have access to a nationally determined set of basic health services, including palliative care. Financial and social protection systems need to take into account the human right to palliative care for poor and marginalized population groups.

Specialist palliative care is one component of palliative care service delivery. But a sustainable, quality and accessible palliative care system needs to be integrated into primary health care, community and home-based care, as well as supporting care providers such as family and community volunteers. Providing palliative care should be considered an ethical duty for health professionals.

Key facts

Palliative care improves the quality of life of patients and their families who are facing problems associated with life-threatening illness, whether physical, psychosocial or spiritual.

Each year, an estimated 40 million people are in need of palliative care, 78% of them people live in low- and middle-income countries.
Worldwide, only about 14% of people who need palliative care currently receive it.

Overly restrictive regulations for morphine and other essential controlled palliative medicines deny access to adequate pain relief and palliative care.

Lack of training and awareness of palliative care among health professionals is a major barrier to improving access.

The global need for palliative care will continue to grow as a result of the rising burden of noncommunicable diseases and ageing populations.
Early palliative care reduces unnecessary hospital admissions and the use of health services.

WHO response

Palliative care medicines, including those for pain relief, are included in WHO’s list of essential medicines for adults and children. Palliative care is recognised in key global mandates and strategies on universal health coverage, noncommunicable diseases, and people-centred and integrated health services.

In 2014, the first ever global resolution on palliative care, World Health Assembly resolution WHA67.19, called upon WHO and Member States to improve access to palliative care as a core component of health systems, with an emphasis on primary health care and community/home-based care. WHO’s work to strengthen palliative care will focus on the following areas:
  • integrating palliative care into all relevant global disease control and health system plans
  • developing guidelines and tools on integrated palliative care across disease groups and levels of care, addressing ethical issues related to the provision of comprehensive palliative care
  • supporting Member States in improving access to palliative care medicines through improved national regulations and delivery systems
  • promoting increased access to palliative care for children (in collaboration with UNICEF)
  • monitoring global palliative care access and evaluating progress made in palliative care programmes
  • encouraging adequate resources for palliative care programmes and research, especially in resource-limited countries
  • building evidence of models of palliative care that are effective in low- and middle-income settings.
1). World Health Organization: Palliative Care - WHO Fact Sheets. Accessed 08.10.17. Available here: http://www.who.int/mediacentre/factsheets/fs402/en/
2). Centers for Disease Control: Hospice Care. Accessed 10.10.17. Available here: https://www.cdc.gov/nchs/fastats/hospice-care.htm
3). NHS Choices: End of Life Care. Accessed 10.10.17. Available here: http://www.nhs.uk/Planners/end-of-life-care/Pages/what-it-involves-and-when-it-starts.aspx
4). Barbara Nelson, PhD: Why the CDC Needs to Recognize Palliative Care. Pain News Network; Mar 28,2017. Available here: https://www.painnewsnetwork.org/stories/2017/3/28/why-the-cdc-needs-to-recognize-palliative-care

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