Abstract
Shelley R. Adler, PhD
Lucille R. Marchand, MD, BSN, FAAHPM
Nancy Heap, LCSW
The current biomedical health care system in the United States clearly is challenged by a host of pressing concerns. The complexity of the opioid crisis, the unmet needs of the aging population, and physician burnout are just a few examples of complicated problems that can only be solved with innovative, multifaceted strategies. As one model of an interprofessional approach that builds on existing discrete efforts, the authors propose an amplification of integrative palliative care—a hybrid of integrative health and palliative care—to enhance healing and reduce suffering.
At first glance, some may view integrative health, which focuses on wellness, as disparate from palliative care, which focuses on quality of life in serious illness. In fact, the two fields share core values and goals. Overlooking the synergy between the two health care disciplines misses a critical opportunity to provide truly transformative care for people with serious illness. The authors advocate here for a holistic, hybrid approach to living well across the life course; one that builds on the strengths and shared philosophies of integrative medicine and palliative care.
Serious illness, whether life-threatening or chronic, threatens the whole person—physically, psychologically, socially, and spiritually. Suffering encompasses more than just physical distress. 1 As Frankl notably observed, an individual may have pain or other debilitating symptoms, but not suffer from them; conversely, a person may be free of physical symptoms, yet suffer enormously. 2 Dame Cicely Saunders, the founder of the modern hospice movement, introduced the concept of “total pain,” which includes the physical, emotional, social, and spiritual dimensions of distress. 3 Put another way, suffering is experienced by whole persons, not bodies. 4 This central concept of holism—the recognition of the primacy of body/mind/spirit—is foundational to both integrative medicine and palliative care.
Mutual Core Values
Integrative health emphasizes healing and well-being for people of all ages, across the entire life span; focuses on patient-centered care; addresses the “whole person” (mind, body, and spirit); prioritizes relationship-based care; and makes use of multiple approaches and health professions. 5 Palliative care emphasizes quality of life and the reduction of suffering for people of all ages, from the time of diagnosis of a serious or life-threatening illness until death; focuses on patient and family support; addresses medical, psychologic, and spiritual needs; prioritizes relationship-based care; and uses a multidisciplinary, interprofessional, team approach. 6 Both disciplines highlight quality of life; optimize well-being, regardless of illness status; emphasize interprofessional and team-based collaboration; provide personalized/individualized care; and strive for contextualized health care. Although many people associate the use of palliative care with terminal disease, mistaking palliative care for hospice care (which is only a subset of the field), palliative care is best provided early in the trajectory of serious or chronic illness, increasing as illness progresses toward end of life. 7
Building on Complementary Strengths
Both palliative care and integrative medicine stand to benefit greatly from closer collaboration. The field of palliative care Presents integrative medicine with more models for care across the life course, including meaningful engagement in anticipation of and at patients' end of life.
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Integrative medicine is predicated on the importance of patient-centered care, but there is still much to be done to fulfill the promise of a truly holistic approach to life-threatening illness and the end-of-life phase. Palliative care endorses exploring patient choices early and often. Integrative medicine should be more explicit and consistent in establishing and revisiting the goals of care—and advance directives—of seriously ill patients. Although the authors typically hear of misaligned, heroic, end-of-life health care efforts in biomedical contexts, integrative medicine practitioners are also susceptible to well-intentioned but misplaced attempts at continuing difficult interventions (e.g., challenging diets or herbal regimens) well past the time that they can be truly beneficial.
Provides a prototype for the integration of spirituality into health care.
In palliative care, spirituality is defined as “the way individuals seek and express meaning and purpose and the way they experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred.” 9 Often, people with life-threatening illness have spiritual needs that are not adequately addressed by their health care providers. 10,11 The U.S. National Consensus Conference developed a model of implementation of spiritual care that recognizes the obligation of all clinicians to attend to all dimensions of the suffering of a patient and family and to elicit the patient's spiritual needs and then respect those beliefs and struggles. 9 The model has two main components: the clinician/patient relationship and clinical assessment and treatment of spiritual distress. The best palliative care displays a nuanced understanding of spirituality and provides an opportunity to include beliefs and practices that have been revered in diverse societies for millennia—and is also respectful when patients and families decline to discuss their beliefs or accept spiritual support. 12 Health care provided in this way is deeply personal to the individual, culturally relevant, and healing.
Offers proven models of integrated, team-based care.
Despite the discipline's name, integrative medicine too often misses (or is denied) opportunities to collaborate meaningfully with biomedical specialists as team members, with the result that integrative medicine remains an adjunctive practice. More strikingly, in too many settings, integrative health care practitioners, themselves, do not practice together as members of an interprofessional team, instead delivering “parallel” care.
Similarly, the field of integrative medicine offers best practices to inform and optimize palliative care. Integrative medicine Presents nonpharmacologic strategies, such as acupuncture or mindfulness meditation, that can be easily incorporated into standard palliative care for pain management, as well as techniques for reducing other symptoms commonly experienced by patients receiving palliative care (e.g., nausea, depression). Incorporating these strategies may facilitate the reduction of medications for symptoms such as anxiety, which are often more effectively treated with nonpharmacologic modalities. Fewer medications mean fewer adverse drug effects and fewer side effects (problems that are often treated with additional pharmaceuticals). Offers a set of tools and human interactions that often lead to a sense of serenity and tranquility. As Steinhorn et al. note, integrative medicine can create avenues for seriously ill people to achieve a peaceful and calm inner state: the serenity and tranquility “often experienced during integrative medicine treatments is similar to that seen during deep prayer or meditation. In such a transcendent or nonordinary state of consciousness, many people experience new insights or understanding of their lives and choices they must make.”
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Provides proven mind/body techniques that are helpful, not only for suffering patients but also for practitioner resilience and well-being. Burnout, a work-related syndrome involving emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment,
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is a major issue facing the palliative care clinician workforce. The burnout rate for physicians in palliative care is more than 62%—higher than the rate reported in medical oncology (45%).
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As clinicians interact with patients to promote healing and well-being, growth and meaning can develop for the practitioners, as well.
Working Together to Heal
With such a strong foundation of shared values and complementary strengths, clinicians, educators, and researchers in the fields of integrative medicine and palliative care are poised to make significant contributions in the emerging realm of integrative palliative care. With serious and chronic illness, cure is often not possible, but integrative palliative care can reduce suffering, enhance well-being, and support meaning making for patients, as well as practitioners.