Understanding the Full Scope of Palliative Care Services

Date Submitted: 3/3/2025 

Date Published: 4/22/2025

According to the World Health Organization, global demand for care will increase for people with life-threatening illnesses as they get older, and by 2060, the need for palliative care could double (1). First started by Dame Cicely Saunders, palliative care is a specialized medical care that supports patients with life-threatening illnesses. A common misunderstanding is that palliative care is only meant for terminally ill patients. However, palliative care has evolved since the original 1960s model of hospice care, which focuses on end-of-life care. Palliative care helps anyone with a serious illness at any stage of life by helping manage pain, stress, and symptoms (2). It also provides emotional support for patients and their families through understanding the illness and coping with challenges (2). Some institutions have even rebranded their programs to address the stigma associated with palliative care, like the MD Anderson Cancer Center, which renamed its Palliative Care Unit to “Supportive Care.” This helps show its role beyond just end-of-life treatment. Palliative care is also closely related to oncology, which is the study and treatment of cancer. 

A study done in 2019 titled “Models of Palliative Care Delivery for Patients With Cancer” focused on cancer-related palliative care by analyzing five major models of service delivery: outpatient palliative care clinics, inpatient palliative care consultation teams, Acute Palliative Care Units (APCUs), community-based palliative care, and hospice care (Figure 1)(3). The study reviews where we are today in the field of palliative care and how these models support cancer patients, particularly through new approaches like nurse-led models, telehealth services, primary palliative care, and embedded clinics, which are all different methods that reshape how patients receive support. 

Let’s break down each of the five major models of palliative care delivery. 

Figure 1: Five major models of palliative care delivery from Hui et al.(3). 

Outpatient Palliative Care Clinic

Outpatient palliative care provides specialized medical care for people with serious illnesses outside of hospitals. It aims to improve quality of life through symptom management, psychosocial support (through chaplains, social workers, and/or psychologists), and advanced care planning. It consists of standalone clinics, embedded clinics (which are clinics located near workplaces), telehealth-based services, and enhanced primary palliative care, often delivered by a multidisciplinary team of physicians, advanced practice providers, nurses, and psychosocial professionals.                          

Outpatient palliative care offers several key benefits, especially in improving patient outcomes while using relatively fewer resources compared to inpatient models​. One significant advantage is its ability to serve patients earlier in their illness, with studies showing substantial benefits at four months after starting palliative care, including improved quality of life, reduced depression, better illness understanding, and even increased survival (3)​. Early referrals to outpatient palliative care have been linked to better end-of-life care outcomes, such as lower rates of aggressive treatments like chemotherapy initiation near death and higher hospice enrollment (4-5). Outpatient palliative care reduces healthcare costs by decreasing the need for prolonged hospitalizations and intensive care unit (ICU) admissions, contributing to overall cost savings​ (6). Additionally, with these benefits, telehealth-based palliative care is especially helpful in enhancing quality of life in rural areas, though it may not significantly reduce symptoms or improve end-of-life care​ (7).                                         

The structure of outpatient clinics can vary, with some having only physicians, advanced practice providers, or a combination, which affects how many patients can be treated​. Studying outpatient palliative care can be challenging because teams are arranged differently, patients in control groups often receive late palliative care, and it is hard to measure outcomes accurately​ (3).

Inpatient Consultation Services

Inpatient palliative care is medical care provided inside a hospital setting, usually for patients in the later stages of disease. Inpatient care is regarded as the backbone of palliative care medicine in the United States, as approximately 90% of “National Cancer Institute”-designated cancer centers have inpatient care teams. The palliative care team, which usually consists of a doctor, a nurse practitioner, a social worker, and a chaplain, is focused on managing patient symptoms and care planning while the patients are in the hospital. The service model for inpatient palliative care typically involves this group having daily rounds with hospitalized patients. They also support decision-making for patients and families (3).

In a study conducted by Grudzen et al., it was found that the group with the dedicated palliative care team had a much better quality of life than the group with usual care at 12 weeks. However, there were only slightly better results in secondary outcomes, such as depression, ICU admissions, discharge, and survival (8). Inpatient palliative care can also be beneficial for caretakers, as studies show that inpatient palliative care referrals can save upwards of $4,000 per admission for patients with cancer (9). In a study examining patients admitted for hematopoietic stem-cell transplantation, it was found that caregivers had lower rates of post-traumatic stress disorder (PTSD) and depression at six months post-transplantation (10). Unfortunately, the current palliative care infrastructure is not built to accommodate all hospitalized cancer patients, which is an issue to address as the need will continue to grow.

Acute Palliative Care Units (APCUs)

APCUs are specialized inpatient facilities designed for patients with severe and/or complex symptoms that require intensive management (3). Unlike general palliative care teams, APCUs take full responsibility for a patient's care. They focus on physical, emotional, and spiritual well-being. They handle complex cases, including severe pain, sedation for agitated behavior, and difficult end-of-life decisions. These units are especially helpful for patients with advanced cancer who need urgent symptom relief. However, APCUs require the most staff compared to all other models and are generally found in larger hospitals, making them less common. Only 20-30% of United States cancer centers have them, compared to 70% in Europe (10). Patients in APCUs typically have a short life expectancy, measured in days to weeks, and 30-50% pass away while still in the hospital (11). While these units provide essential, high-quality care, they are not widely available, making it necessary to improve access and find ways to expand palliative care services beyond the hospital setting​.

Community-Based Palliative Care

Community-based palliative care programs provide essential support for patients that receive care at home or in long-term care facilities, like nursing homes or skilled nursing facilities. These programs offer in-person visits, equipment, supplies, and telephone support for patients at home or in community-based facilities. Unlike traditional home care, community-based palliative care is led by specialized teams with expertise in end-of-life support, so they would be better equipped to manage serious symptoms and provide emotional support. 

This model has several key benefits, including increasing the likelihood of home death, which would allow one to pass with more respect to their preferences (2). It also provides support for caregivers, and reduces excessive hospital visits. Patients that receive community-based palliative care often experience better control of their symptoms and more satisfaction with their care (2). This approach is more common in Europe, where palliative day-care centers provide social and medical support in a community setting, which offers an alternative to full-time home-based care (2).

Hospice Care

              Hospice care is a specialized type of palliative care designed specifically for patients with a life expectancy of six months or less (3). Hospice care focuses entirely on comfort and quality of life rather than trying to extend it or find curative treatments. A common misconception is that palliative care and hospice care are the same, but hospice is reserved for the final stage of illness. Hospice offers pain relief, as well as emotional, psychological, and spiritual support. Hospice allows patients to remain in their community, whether at home or in a specialized facility surrounded by loved ones. Studies have shown that patients in hospice experience less depression and higher satisfaction with their care compared to those who do not receive it (12-14). Additionally, hospice care has been linked to fewer hospitalizations, emergency room visits, and ICU admissions, leading to lower healthcare costs in patients' final months (15). However, despite its benefits, many patients enroll in hospice too late, even just days before passing. Expanding awareness and encouraging earlier referrals to hospice could help more patients and families receive the full benefits of this compassionate care model​.

Conclusion 

From outpatient clinics to hospice care, palliative care has become a professional specialty with multiple service models that meet different needs. Each model serves a different purpose along the disease journey, and together, they provide complete support for cancer patients and their families. The evidence strongly shows that early referral to palliative care teams improves patient and caregiver outcomes. By matching the correct type of care to each patient's needs at the right time, palliative care can significantly enhance the quality of life and may even extend survival in some cases.

Future 

Palliative care could still improve in several ways. First, clear standards should be developed so all programs deliver consistent, quality care. More research could also focus on finding the right time to start palliative care for different types of cancer, helping patients earlier in their disease journey. Telehealth services can be expanded to reach patients in rural areas who can't easily travel to specialty centers. Finally, including primary palliative care into routine oncology and primary care practices will help address essential patient needs, reserving specialist involvement for complex cases. These improvements would ensure that all cancer patients receive the proper support at the right time, regardless of where they live or what stage of illness they face.

Authors

• Suraj Murugarajan: smurugarajan@ucsd.edu, University of California, San Diego

• Narek Manukyan: nmanuky1@uci.edu University of California, Irvine

• Junain Ahmed junain@umich.edu, University of Michigan, Ann Arbor

• Zahraa Alfatlawi: zahraalf@umich.edu University of Michigan, Ann Arbor 

References:

1.          WHO takes steps to address glaring shortage of quality palliative care services [Internet]. www.who.int. 2021. Available from: https://www.who.int/news/item/05-10-2021-who-takes-steps-to-address-glaring-shortage-of-quality-palliative-care-services 

‌2.          Saunders C. The evolution of palliative care. Patient Education and Counseling. 2000 Aug;41(1):7–13.

3.          Hui D, Bruera E. Models of Palliative Care Delivery for Patients With Cancer. Journal of Clinical Oncology [Internet]. 2020 Mar 20;38(9):852–65. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7082156/ 

‌

4.          Hui D, Kim SH, Roquemore J, Dev R, Chisholm G, Bruera E. Impact of timing and setting of palliative care referral on quality of end-of-life care in cancer patients. Cancer [Internet]. 2014;120(11):1743–9. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4073257/

5.          Jang RW, Krzyzanowska MK, Zimmermann C, Taback N, Alibhai SMH. Palliative Care and the Aggressiveness of End-of-Life Care in Patients With Advanced Pancreatic Cancer. JNCI: Journal of the National Cancer Institute. 2015 Jan 20;107(3).

6.          Europe PMC. Europe PMC [Internet]. Europepmc.org. 2016 [cited 2025 Mar 2]. Available from: https://europepmc.org/article/pmc/pmc4560956 

7.          Bakitas M, Lyons KD, Hegel MT, Balan S, Brokaw FC, Seville J, et al. Effects of a Palliative Care Intervention on Clinical Outcomes in Patients With Advanced Cancer. JAMA [Internet]. 2009 Aug 19;302(7):741. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3657724/

8.          Grudzen CR, Richardson LD, Johnson PN, Hu M, Wang B, Ortiz JM, et al. Emergency Department–Initiated Palliative Care in Advanced Cancer. JAMA Oncology. 2016 May 1;2(5):591.

‌

9.          May P, Normand C, Cassel JB, Del Fabbro E, Fine RL, Menz R, et al. Economics of Palliative Care for Hospitalized Adults With Serious Illness. JAMA Internal Medicine. 2018 Jun 1;178(6):820.

‌

10.        Hui D. Availability and Integration of Palliative Care at US Cancer Centers. JAMA. 2010 Mar 17;303(11):1054.

‌

11.        Hui D, Cherny N, Latino N, Strasser F. The “critical mass” survey of the palliative care program at ESMO-designated centers of integrated oncology and palliative care. Annals of Oncology. 2017 Sep;28(9):2057–66.

12.        Kane RL, Berstein L, Wales J, Rothenberg R. Hospice effectiveness in controlling pain. JAMA [Internet]. 1985 Oct;253(18):2683–6. Available from: https://pubmed.ncbi.nlm.nih.gov/3886943/

13.        Kane RL, Klein SJ, Bernstein L, Rothenberg R, Wales J. Hospice Role in Alleviating the Emotional Stress of Terminal Patients and Their Families. Medical Care. 1985 Mar;23(3):189–97.

14.        Kane Robert, Bernstein L, Wales J, Leibowitz A, Kaplan S. A Randomised Controlled Trial of Hospice Care. The Lancet [Internet]. 1984 Apr 21 [cited 2020 Dec 21];323(8382):890–4. Available from: https://www.sciencedirect.com/science/article/abs/pii/S0140673684913497

15.        Obermeyer Z, Makar M, Abujaber S, Dominici F, Block S, Cutler DM. Association Between the Medicare Hospice Benefit and Health Care Utilization and Costs for Patients With Poor-Prognosis Cancer. JAMA [Internet]. 2014 Nov 12 [cited 2019 Oct 3];312(18):1888. Available from: https://jamanetwork.com/journals/jama/fullarticle/1930818