Integrative palliative care provides new approach to end-of-life process

Photo Cred: National Cancer Institute/Unsplash

By Avery St. Onge

The focus of medicine in the United States has often been to keep terminally ill patients alive for as long as possible through aggressive interventions, sometimes forgoing comfort in the process. The emerging field of integrative palliative care aims to instead provide patients with as much relief and symptom management as possible through conventional treatments paired with complementary modalities.

“It’s an evolution of society to realize we can’t always stop death even with the most aggressive interventions,” said Delia Chiaramonte, MD, an integrative palliative care physician in Baltimore, Md. “Sometimes a person could choose that rather than ending their life sedated asleep on a ventilator. They want to be at home, surrounded by family, and things that are meaningful to them.”

In many ways, the novel coronavirus pandemic (COVID-19) has illuminated the issue of end-of-life care in the U.S. and around the world. Countless news stories have depicted people dying not just painful, but lonely deaths due to hospital visitation restrictions. However, the U.S. struggled with providing quality end-of-life care prior to the pandemic as well.  

A recent study, published in the Journal of Pain and Symptom Management compared the quality of end-of-life care in countries around the world in 2019. The U.S. ranked No. 43 out of the 81 countries observed, a relatively low ranking for a wealthy country with ample healthcare resources. The study’s researchers attributed the score to disparities in healthcare among the wealthy and poor, but also to the U.S. health system’s hyperfocus on prolonging life and treating and curing disease, which is sometimes a detriment to end-of-life care.

“Places like the U.S. are susceptible to overtreatment, where in the end people spend lots of money and die with regret because they spend the last months of their life getting care that wasn’t particularly helpful,” said Eric Finkelstein, PhD, lead author of the study and executive director of Lien Centre for Palliative Care at Duke‐NUS Medical School in Durham, N.C.

The study asked palliative care experts from around the world to rate their country’s end-of-life care quality. The survey included yes/no questions on 13 indictors of end-of-life care like religious needs, contact with friends and family, and non-medical concerns. The final sample included responses from 181 experts who represented a total of 81 countries. The countries were graded on a letter scale, from A to F.

The five countries that ranked highest and received A grades were all considered high-income countries including, the United Kingdom, Ireland, Taiwan, Australia, and the Republic of Korea. Costa Rica also received an A and was the first middle-income country to appear on the list. The first low-income country ranked was Uganda at No. 31. At No. 43, the U.S. received a C grade.

For Finkelstein, the U.S ranking was not entirely surprising. He said the questions the study asked about end-of-life care surrounding topics like preferred place of death and spiritual needs are not always top priority in U.S. healthcare.

“Death with dignity and compassion and place of choice, even pain management, and mental health, these things are not that expensive but tend not to be the focus of our health system,” he said. “The incentives for the system are to treat, and that’s where the money is as well.”

Chiaramonte, who is division chief at the Integrative and Palliative Care Gilchrist/Greater Baltimore Medical Center (GBMC), had a mixed reaction to the study’s results. She said although the American healthcare system is overly focused on aggressive treatments, she believes end-of-life care has improved over the years due to a growing appreciation and acceptance of palliative medicine.

Leading an integrative palliative care program focused primarily on cancer patients, Chiaramonte defines integrative palliative medicine as a relatively new field that works to alleviate symptoms of chronic illness with a combination of conventional and complementary medicine. To her, increasing the number of integrative palliative care specialists in the U.S. is an obvious solution to improve end-of-life care quality.

“Complementary modalities are so helpful,” Chiaramonte said. “To be a palliative doctor who doesn’t use those tools is just a shame.”

William Zvarick, LAc, is a Traditional Chinese Medicine (TCM) physician who works under Chiaramonte in the palliative care program at GBMC. Zvarick said his modalities are specifically beneficial in the hospital setting where doctors often don’t have the time or resources to address patient discomfort. He said TCM addresses problems like abdominal pain that’s difficult to solve through pharmaceuticals.

“Manual therapy and needles add a whole extra dimension that Western medicine, for all of its power and all of its usefulness, just can’t go near,” Zvarick said.

His position is unique. TCM physicians typically do not treat palliative care patients in hospitals. To work at GBMC, he’s paid through a grant that was provided to the palliative care program.

For Zvarick, what’s preventing complementary care from being incorporated into palliative care in hospitals isn’t an issue of cultural background or unfamiliarity. He believes that once physicians are exposed to the practice, it sells itself. He said the real obstacle is that TCM is not yet a billable service.

“That’s a systemic problem in our healthcare system that may be preventing this from becoming embraced: the sheer dollar incentive,” he said.

The for-profit healthcare model in the U.S. makes it difficult for services like manual therapy, which alleviates but doesn’t always cure symptoms, to make money and therefore survive in a hospital setting. For that reason, according to Zvarick, employing more TCM physicians in hospitals will be a significant challenge.

Despite the hardship of incorporating holistic approaches into palliative care, Chiaramonte is hopeful that society is beginning to understand the limits of Western medicine and become more accepting to the concept of integrative palliative care.

Just as she advocates for holistic remedies in mainstream palliative care, Chiaramonte encourages those in integrative health not to shy away from end-of-life discussions with their patients. She said integrative healthcare focuses mainly on disease prevention when the approach is equally helpful for those already diagnosed with progressive and advanced diseases.

“People want to be seen as a whole person,” she said. “They don’t want to be seen as a disease or a stage of a disease. They don’t want to be seen as someone who is at end-of-life because as long as you’re on this earth, you’re as valuable and full of a person as anyone else on their journey.”