Palliative care clinicians seek to understand and treat the physical, psychological, spiritual, and social components of the patient's and family's distress, within a model that views the patient and family as a single unit. The focus of care is on alleviation of suffering and restoring the patient to a sense of "wholeness" (30). Care is provided across the entire age spectrum (31). Outstanding communication competencies are integral to the practice of palliative medicine (32). Whereas the traditional focus of medicine is cure and life prolongation, palliative care complements these goals with the focus on optimizing quality of life for the patient and family. Palliative care clinicians provide expert symptom assessment and meticulous treatment of pain, often using medications, nonpharmacologic treatments (e.g., meditation or hypnosis), and interventional approaches; similar intensive strategies are used to treat other common symptoms at the end of life, including nausea, fatigue, insomnia, and constipation. Palliative care clinicians also seek to evaluate and treat psychiatric disorders (e.g., depression, anxiety, and delirium) as well as to help patients explore feelings of grief, loneliness, fear and uncertainty about the future, and concerns about loved ones. Spiritual/religious and existential issues are also a focus of assessment and treatment. Anger at or isolation from God, guilt about past behavior, and uncertainty and fear about the afterlife are among the common issues that arise in this domain; in addition, existential concerns about the meaning, purpose, and value of one's life arise frequently and are the subject of attention. The impact of the patient' s illness on family members, the toll of caregiving, preparation for death, bereavement, and exploring concerns about key relationships are commonly a focus of palliative care. Because of the breadth and intensity of issues, as well as the shortened time frame for addressing them, an interdisciplinary team involving physicians, nurses, social workers, a chaplain, pharmacist, and, ideally, a psychiatrist works together to provide personalized treatment. Care can be provided in the inpatient, outpatient, nursing home, and home settings; inpatient palliative care programs may provide consultative services or have specialized units for care of patients with palliative care needs. Hospice is an invaluable resource for the provision of care in the community; more than 90% of hospice services are provided in patients' homes, whereas a small proportion are provided in nursing homes and inpatient hospice facilities.
Over the past 10 years, clinical guidelines for the provision of palliative care have been developed by a variety of organizations. The National Consensus Standards for Quality Palliative Care (33) and the National Comprehensive Cancer Network (34) have promulgated recommendations for patients with advanced disease. Whereas past practice has incorporated hospice or palliative care only when curative or disease-modifying treatments have failed, contemporary palliative care practice integrates palliative care principles and approaches from the time of diagnosis with a life-threatening illness as demonstrated in Figure 1.