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MAY / JUNE 2013 :: 74(3)
Chronic Pain

This issue focuses on the challenge of managing chronic pain. Commentaries present various treatment options, including opioids, nonopioid medications, surgery, and alternative therapies. Authors also address the problems of opioid misuse and abuse and discuss ways to lessen these risks. Original articles examine health professionals’ communication with adolescents about smoking, as well as children's immunization status as verified by practice records and by the North Carolina Immunization Registry.


Foundation Investments in Palliative Care

M. Tina Markanda

N C Med J. 2013;74(3):262-263.PDF | TABLE OF CONTENTS

Palliative care is a medical specialty that focuses on preventing and relieving the suffering of patients with life-limiting and life-threatening illnesses. It is an interdisciplinary practice that utilizes the complementary knowledge and skills of a deep bench of health care providers, including physicians, nurses, social workers, pastors, and other professionals. Palliative care focuses on the whole person, rather than viewing the patient as a disparate set of individual body systems, and the preferences of the patient and his or her family guide decision making. Palliative care programs may be hospital-based or community-based.

The need for palliative care services will likely be even greater in the future, due to the growing proportion of elderly individuals in the population and the increasing incidence of chronic diseases. Nationally, the number of individuals 65 years of age or older is expected to increase considerably over the next couple of decades. According to the US Census Bureau, approximately 39 million US residents were 65 years of age or older in 2011 [1]. By 2030, this segment of the population is expected to grow to 72 million people [2]. In North Carolina, 13% of the state’s population was 65 years of age or older in 2011 [3], and 18% of the state’s population will belong to this age group by 2030 [4]. Because health care resources are finite, we will need to make significant changes in the way that medicine is practiced and how care is provided to individuals and families.

Chronic diseases such as heart disease, diabetes, cancer, and stroke are affecting increasing numbers of individuals. These patients require extended periods of treatment and highly coordinated care. According to data from the Centers for Disease Control and Prevention, nearly half of all adults had at least 1 chronic disease in 2005 [5]. Among those 65 years of age or older, nearly 90% suffer from at least 1 chronic condition, and many patients have multiple chronic illnesses [6]. The incidence of multiple chronic illnesses increases with age.

Fortunately, the number of palliative care programs also continues to increase. According to the Center to Advance Palliative Care (CAPC), there were more than 1,500 hospital-based palliative care teams in the United States in 2009. In North Carolina, 75% of hospitals with 50 or more beds offer palliative care services. The number of community-based palliative care programs also continues to increase [7].

Between 2002 and 2012, the trustees of The Duke Endowment, a private foundation founded by James B. Duke in 1924, awarded grants of almost $3.9 million to support programs relating to palliative care. These grants have helped organizations to establish interdisciplinary palliative care teams, to improve the quality of palliative care, and to increase the palliative care workforce. Since the first grant was awarded, there has been much progress in this field, and many lessons have been learned.

The first of these lessons is that palliative care plays an important role in the full spectrum of health care services. Palliative care complements traditional specialty care by providing comprehensive services to support the patient and his or her family members. While other specialists focus on the patient’s specific illnesses, the palliative care team can provide additional support to manage symptoms and side effects of treatment. This concept and philosophy will become increasingly important as health care reform seeks to manage care comprehensively and accountably by aligning services.

Much has also been learned about the benefits of palliative care. Patients who receive palliative care services report better management of their pain and symptoms, and they and their family members are more engaged in making medical decisions [8]. Palliative care also focuses on meeting the patient’s psychosocial and spiritual needs and on helping individuals to establish advanced directives, when appropriate. Studies have shown that providing highly coordinated care and proactively meeting the patient’s needs can improve quality and reduce costs. A study published in The New England Journal of Medicine in 2010 showed that patients with advanced lung cancer who received early palliative care reported lower rates of depression and better quality of life compared with patients who did not receive such services. Patients who received palliative care also had a 2.7-month longer median duration of survival [9].

Finally, we have learned that more palliative care professionals are needed. Given the nascent nature of palliative care, there are limited numbers of physicians who are certified in this specialty. CAPC reported that 2,887 physicians were board-certified in palliative care in the United States in 2011; in North Carolina, 89 physicians were board-certified in palliative care, and 477 registered nurses were certified in palliative care [7].

Given the increased incidence of chronic diseases and changing demographics—in the United States as a whole and in the Carolinas—there will be a greater need for programs that provide holistic care for individuals and families. Investments by The Duke Endowment have been timely and have helped to increase capacity for palliative care services in the Carolinas. Organizations and professionals continue to learn more as this specialty becomes more integrated into the health care system.

Potential conflicts of interest. M.T.M. is an employee of The Duke Endowment.

1. US Census Bureau. The older population in the United States: 2011. US Census Bureau Web site. Last revised November 28, 2012. Accessed May 19, 2013.

2. US Census Bureau. The next four decades: the older population in the United States: 2010 to 2050. US Census Bureau Web site. Published May 2010. Accessed May 19, 2013.

3. US Census Bureau. State and County Quick Facts. North Carolina. Last revised March 14, 2013. Accessed May 19, 2013.

4. Quick Facts about Aging in NC. UNC Institute on Aging Web site. Last modified December 14, 2011. Accessed May 19, 2013.

5. Centers for Disease Control and Prevention (CDC). Chronic diseases and health promotion. CDC Web site. Last updated August 13, 2012. Accessed May 19, 2013.

6. Chronic conditions among older Americans. AARP Web site. Accessed May 19, 2013.

7. Morrison RS, Meier DE. America’s Care of Serious Illness: A State-by-State Report Card on Access to Palliative Care in Our Nation’s Hospitals. New York, NY: Center to Advance Palliative Care; 2011. Accessed May 19, 2013.

8. Rafinski K. A better way to manage pain. AARP Web site. Published June 1, 2011. Accessed June 3, 2013.

9. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non–small-cell lung cancer. N Engl J Med. 2010;363(8):733-742.

M. Tina Markanda program officer, The Duke Endowment, Charlotte, North Carolina.

Address correspondence to Ms. M. Tina Markanda, 100 N Tryon St, Ste 3500, Charlotte, NC 28226 (