**2.3 Philosophy of palliative care**

According to the philosophy of palliative care, the patients are provided with care and support in various institutions; death is part of ordinary life; physical, social, and spiritual aspects of care all are integrated; and the main targets are to enhanced life quality of the patients and to ensure that the patient quickly returns to his/her social life [10, 16].

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*Palliative Care Services from Past to Present DOI: http://dx.doi.org/10.5772/intechopen.88990*

**2.4 Palliative care team**

the patient [17, 18].

period [6, 17].

These components are listed as follows:

vidual and his/her family and to alleviate pain [4, 17].

Cancer patients in need of palliative care are a group of patients with high psychosocial, spiritual, and physical needs who experience many different symptoms, especially pain [6, 8]. In addition, the level of distress experienced by the family and its members increases in this period, and this situation affects the family order intensively. The most common problems experienced by cancer patients include physical symptoms such as pain, nausea, vomiting, fatigue, constipation, and loss of appetite. However, psychological problems such as anxiety, fear, helplessness, hopelessness, exhaustion, and depression are also common in patients. Economic and social problems are other important problems for cancer patients [6, 8, 10, 13]. Patients' need for palliative care to cope with all these problems is increasing. Palliative care includes a holistic approach to cancer treatment that can improve or optimize the quality of life of cancer patients and their relatives in the best possible way, meeting the needs [4, 6, 9]. Palliative care is one of the most critical building blocks of the war against cancer. Palliative care is a significant health service, responsibility, medical requirement, and need from the diagnosis of cancer to the end of life and is an indispensable element of national health policies. Therefore, it is imperative that the palliative care service for cancer patients has basic dimensions such as symptom control; psychological, spiritual, and emotional support; support for the families and relatives of cancer patients; and support during the mourning period [4, 7, 13]. The World Health Organization envisages the development of palliative care services in all countries. The WHO also envisions the establishment of a palliative care service network, which can serve the whole country, in underdeveloped countries with low-income levels even if they can do nothing about cancer [7]. The WHO recommends the completion of shortcomings in palliative care, rather than the investments that could bring considerable burdens on the country's economy, such as expensive treatments, radiotherapy devices, or screening programs [1, 5].

Palliative care is provided by a team of experienced and trained medical staff

*Patient population*: palliative care is for patients in all age groups who are affected

*Patient- and family-oriented care*: in palliative care, the patient and his family should be given tailored care, and the care plan should be applied and evaluated individually taking into account the patient's and family's preferences and objectives [8, 17].

*The continuity of palliative care*: palliative care should start with the diagnosis of a life-threatening disease and should continue throughout the treatment period, after treatment, and until the death of the individual and during the mourning

*Comprehensive care*: in palliative care, multidimensional diagnosis is required to eliminate the psychological, spiritual, social, and physical problems of the indi-

*Interdisciplinary team*: a palliative care team should primarily include medical, nursing, and social work professionals. Palliative care may also require a broad

by chronic illness or trauma and whose life quality is adversely affected [12, 17].

who serve for a common purpose and volunteer. This service needs multidisciplinary healthcare services, including an algologist, oncologist, neurologist, surgeon, palliative care nurse, cleric, social volunteers, and psychologist [10, 17]. Besides what is mentioned, it also needs an interdisciplinary approach; the palliative care team provides care to the patient and his/her family and plans the care plan to include the various components according to the current and future needs of

#### *Palliative Care Services from Past to Present DOI: http://dx.doi.org/10.5772/intechopen.88990*

*Palliative Care*

the mourning period [9, 10].

**2.1 The purpose of palliative care**

disease characteristics [1, 4, 7, 9, 13].

**2.2 Basic principles of palliative care**

• To neither expedite nor delay death

therapy and chemotherapy [7, 9, 14, 15]

normal process

mourning period

his/her social life [10, 16].

**2.3 Philosophy of palliative care**

illness

[7, 8]. In palliative care, patient-specific care, family support, multidisciplinary teamwork, and effective communication are essential [6]. In short, palliative care is a philosophy of care and is based on holistic care and support for families including

The goal of palliative care is to restore the functional capacity of a patient by being sensitive to the cultural and local values, beliefs, and practices of the individual, to alleviate pain, and to improve the life quality by controlling the symptoms [6, 11, 12]. In other words, the purpose is to reduce or eliminate the symptoms of the disease without any further examinations when the cure is no longer possible in the disease. Indeed, what the WHO expected from palliative care team is to respect patients and their relatives and to consider their wishes. This expectation should be interpreted as providing health care to the patient and his/her relatives that will ensure their well-being regardless of their age, economic or social status, and

The basic principles of palliative care can be summarized as follows:

• To integrate the psychosocial and spiritual aspects of patient care

• To ensure that the patient and the relatives of the patient accept death as a

• To provide support to patients' relatives to cope with problems during the

• To identify and meet the needs of the patient and his/her family including the

• To manage the clinical complications resulting from treatments such as radio-

According to the philosophy of palliative care, the patients are provided with care and support in various institutions; death is part of ordinary life; physical, social, and spiritual aspects of care all are integrated; and the main targets are to enhanced life quality of the patients and to ensure that the patient quickly returns to

• To reduce other symptoms, pain in the first place

• To make the patient as active as possible until death

**2. Purpose, philosophy, and components of palliative care**

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Cancer patients in need of palliative care are a group of patients with high psychosocial, spiritual, and physical needs who experience many different symptoms, especially pain [6, 8]. In addition, the level of distress experienced by the family and its members increases in this period, and this situation affects the family order intensively. The most common problems experienced by cancer patients include physical symptoms such as pain, nausea, vomiting, fatigue, constipation, and loss of appetite. However, psychological problems such as anxiety, fear, helplessness, hopelessness, exhaustion, and depression are also common in patients. Economic and social problems are other important problems for cancer patients [6, 8, 10, 13]. Patients' need for palliative care to cope with all these problems is increasing. Palliative care includes a holistic approach to cancer treatment that can improve or optimize the quality of life of cancer patients and their relatives in the best possible way, meeting the needs [4, 6, 9].

Palliative care is one of the most critical building blocks of the war against cancer. Palliative care is a significant health service, responsibility, medical requirement, and need from the diagnosis of cancer to the end of life and is an indispensable element of national health policies. Therefore, it is imperative that the palliative care service for cancer patients has basic dimensions such as symptom control; psychological, spiritual, and emotional support; support for the families and relatives of cancer patients; and support during the mourning period [4, 7, 13]. The World Health Organization envisages the development of palliative care services in all countries. The WHO also envisions the establishment of a palliative care service network, which can serve the whole country, in underdeveloped countries with low-income levels even if they can do nothing about cancer [7]. The WHO recommends the completion of shortcomings in palliative care, rather than the investments that could bring considerable burdens on the country's economy, such as expensive treatments, radiotherapy devices, or screening programs [1, 5].

#### **2.4 Palliative care team**

Palliative care is provided by a team of experienced and trained medical staff who serve for a common purpose and volunteer. This service needs multidisciplinary healthcare services, including an algologist, oncologist, neurologist, surgeon, palliative care nurse, cleric, social volunteers, and psychologist [10, 17].

Besides what is mentioned, it also needs an interdisciplinary approach; the palliative care team provides care to the patient and his/her family and plans the care plan to include the various components according to the current and future needs of the patient [17, 18].

These components are listed as follows:

*Patient population*: palliative care is for patients in all age groups who are affected by chronic illness or trauma and whose life quality is adversely affected [12, 17].

*Patient- and family-oriented care*: in palliative care, the patient and his family should be given tailored care, and the care plan should be applied and evaluated individually taking into account the patient's and family's preferences and objectives [8, 17].

*The continuity of palliative care*: palliative care should start with the diagnosis of a life-threatening disease and should continue throughout the treatment period, after treatment, and until the death of the individual and during the mourning period [6, 17].

*Comprehensive care*: in palliative care, multidimensional diagnosis is required to eliminate the psychological, spiritual, social, and physical problems of the individual and his/her family and to alleviate pain [4, 17].

*Interdisciplinary team*: a palliative care team should primarily include medical, nursing, and social work professionals. Palliative care may also require a broad

team of collaborators, such as psychologists, pharmacologists, religious officials, mourning consultants, dietitian, physics/vocational/art/game and music therapists, case managers, trained volunteers, home care assistants, and voluntary organizations [7, 17].

*Alleviation of the pain*: the primary objective of palliative care is to take measures to prevent the pain and other symptoms, as well as the many problems caused by the disease and treatment, and to eliminate these problems [6, 17].

*Communication skills*: effective communication in palliative care is crucial for helping to make medical decisions, determining goals and preferences, active listening, and sharing of useful information.

*The skill of care during death and mourning period*: in the process of mourning and loss, the palliative care team must be aware of the age-related physical and psychosocial symptoms, the care and support needs of the patient and his family, the early signs and symptoms of death, and the prognosis of death [8, 17].

*Ensuring continuity of care between institutions*: palliative care should work in conjunction with all systems involved in health care (such as hospitals, emergency services, hospices, home care, community, and school). The palliative care team should cooperate with professional and nongovernmental organizations in these specified healthcare settings to ensure the continuity and coordination of palliative care [17, 18].

*Equality in accessing palliative care*: the palliative care team is responsible for providing a service that is accessible to all, regardless of race, ethnicity, gender, socioeconomic status, place of residence, and cultural attitudes [12, 17].

*Quality service delivery*: palliative care services should be of high quality and outstanding. It is vital to regularly determine the requirements for a quality service, to measure the care process using appropriate measurement tools, and to ensure continuity [4, 8, 10, 17].

#### **2.5 Palliative care needs**

Palliative care provides a cost-effective service by reducing unnecessary diagnostic and therapeutic interventions, ineffective intensive care, and emergency department admissions [14, 19]. It has been reported that the integration of palliative care from the early stages of the disease increases the quality of care and prolongs the life span [18, 20].

Patients, who are bedbound, do not have curative treatment and have difficulty in controlling physical and emotional symptoms evaluated by the palliative care team. If the palliative care team thinks that it will improve the life quality of the patient and his/her family, the patient is admitted to the palliative care unit [19, 21].

Criteria for admission to palliative care unit:


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[8, 22].

**3. Palliative care levels**

**3.1 Basic palliative care approach**

*Palliative Care Services from Past to Present DOI: http://dx.doi.org/10.5772/intechopen.88990*

**2.6 Target groups in palliative care**

Parkinson's disease, and rheumatoid [19, 22].

rhosis, AIDS, kidney diseases, and neurological disorders.

needs of these patients who need palliative care [4, 22, 23].

uncertain

4.Patients who are diagnosed with delirium and whose etiology is multiple or

7.Patients with worsening clinical symptoms and laboratory symptoms (dyspnea, hemoptysis, uncontrolled pain, etc.) despite treatment; patients with a Karnofsky Performance Scale score of <70%; patients with oncological emergencies such as vertebra metastasis and hypercalcemia; patients who had pneumonia more than two times in the last 3 months; oncology patients with high comorbidity, shorter life expectancy than 6 months, and progressive disease despite treatments such as surgery, radiotherapy, and chemotherapy

5.Geriatric syndromes: falls, incontinence, neglect, and abuse

6.Fragile patients with treatment-resistant stage IV heart failure

8.Patients with treatment-resistant end-stage chronic lung disease

Assessment Staging of Alzheimer's disease (FAST) [19, 20]

9.Dementia patients with acute changes in the clinical picture: Functional

The World Health Organization (WHO) Worldwide *Palliative Care* Alliance (WPCA) states the medical conditions that require palliative care as follows:

*Diseases requiring palliative care in adults*: cancers, Alzheimer's, dementia, cardiovascular diseases, cirrhosis, chronic obstructive pulmonary disease, diabetes, acquired immune deficiency syndrome (AIDS), renal failure, multiple sclerosis,

*Diseases requiring palliative care in children*: cancers, neonatal diseases, congenital anomalies, cardiovascular diseases, blood and immune disorders, meningitis, cir-

Persons who will provide palliative care to children should receive specialized training, and palliative care should be family oriented. Parents' comments on palliative care, taking part in the care of the child and being in a decisive position on legal issues, may cause disagreement with the team. Therefore, cooperation with the family is required. Families generally prefer home care after the acute period. In developed countries, this system is more suitable in terms of cost and compliance of the child. The palliative care team should cooperate with the family through home visits, educate the family on care, and provide psychosocial support to the family

It is a system where palliative care principles are applied by all health professionals and clinicians [4, 22]. Most patients with severe and progressive diseases are cared for by these clinicians in the hospital. Thus, this system focuses on the principle that all clinicians should have good knowledge and skills about the palliative care approach [23]. Therefore, these clinicians should be able to meet the healthcare *Palliative Care*

organizations [7, 17].

continuity [4, 8, 10, 17].

**2.5 Palliative care needs**

prolongs the life span [18, 20].

effects

feed orally

Criteria for admission to palliative care unit:

(according to Norton/Braden) decubitus ulcer

ing, and sharing of useful information.

team of collaborators, such as psychologists, pharmacologists, religious officials, mourning consultants, dietitian, physics/vocational/art/game and music therapists, case managers, trained volunteers, home care assistants, and voluntary

the disease and treatment, and to eliminate these problems [6, 17].

*Alleviation of the pain*: the primary objective of palliative care is to take measures to prevent the pain and other symptoms, as well as the many problems caused by

*Communication skills*: effective communication in palliative care is crucial for helping to make medical decisions, determining goals and preferences, active listen-

*The skill of care during death and mourning period*: in the process of mourning and loss, the palliative care team must be aware of the age-related physical and psychosocial symptoms, the care and support needs of the patient and his family,

the early signs and symptoms of death, and the prognosis of death [8, 17]. *Ensuring continuity of care between institutions*: palliative care should work in conjunction with all systems involved in health care (such as hospitals, emergency services, hospices, home care, community, and school). The palliative care team should cooperate with professional and nongovernmental organizations in these specified healthcare settings to ensure the continuity and coordination of palliative care [17, 18]. *Equality in accessing palliative care*: the palliative care team is responsible for providing a service that is accessible to all, regardless of race, ethnicity, gender,

socioeconomic status, place of residence, and cultural attitudes [12, 17].

*Quality service delivery*: palliative care services should be of high quality and outstanding. It is vital to regularly determine the requirements for a quality service, to measure the care process using appropriate measurement tools, and to ensure

Palliative care provides a cost-effective service by reducing unnecessary diagnostic and therapeutic interventions, ineffective intensive care, and emergency department admissions [14, 19]. It has been reported that the integration of palliative care from the early stages of the disease increases the quality of care and

Patients, who are bedbound, do not have curative treatment and have difficulty in controlling physical and emotional symptoms evaluated by the palliative care team. If the palliative care team thinks that it will improve the life quality of the patient and his/her family, the patient is admitted to the palliative care unit [19, 21].

1.Patients with a visual analogue scale (VAS) pain score of ≥5 despite medical treatment, impaired sleep patterns due to pain, and persistent pain even at rest and patients that cannot be administered with medical treatment due to side

2.Malnutrition patients whose oral intake is impaired, who have a nutritional risk screening 2002 score of ≥3, have a weight loss over 10% in the last 6 months, and who need enteral or parenteral nutrition because they cannot

3.Patients who is infected and treatment-resistant and who has stage III–IV

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### **2.6 Target groups in palliative care**

The World Health Organization (WHO) Worldwide *Palliative Care* Alliance (WPCA) states the medical conditions that require palliative care as follows:

*Diseases requiring palliative care in adults*: cancers, Alzheimer's, dementia, cardiovascular diseases, cirrhosis, chronic obstructive pulmonary disease, diabetes, acquired immune deficiency syndrome (AIDS), renal failure, multiple sclerosis, Parkinson's disease, and rheumatoid [19, 22].

*Diseases requiring palliative care in children*: cancers, neonatal diseases, congenital anomalies, cardiovascular diseases, blood and immune disorders, meningitis, cirrhosis, AIDS, kidney diseases, and neurological disorders.

Persons who will provide palliative care to children should receive specialized training, and palliative care should be family oriented. Parents' comments on palliative care, taking part in the care of the child and being in a decisive position on legal issues, may cause disagreement with the team. Therefore, cooperation with the family is required. Families generally prefer home care after the acute period. In developed countries, this system is more suitable in terms of cost and compliance of the child. The palliative care team should cooperate with the family through home visits, educate the family on care, and provide psychosocial support to the family [8, 22].
