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Editorials

Primary palliative care needs urgent attention

BMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l1827 (Published 18 April 2019) Cite this as: BMJ 2019;365:l1827

Re: Primary palliative care needs urgent attention

Primary palliative care needs attention in the US also

The authors point out the international need for primary level palliative care and emphasize the role of primary care clinicians and teams in delivering this service. They also rightly point out the pressures that exist in the primary care setting and potential barriers to systematic implementation of the delivery of primary palliative services from such settings.
In the United States there are about 7000 palliative medicine specialists. Estimates are that another 10 thousand at least are needed to meet the population needs, and our current training programs are not producing enough to make up this difference. As for so many other healthcare issues, primary care practice has been identified as an important setting from which to begin to address basic palliative needs of patients with serious illness, and their loved ones. The barriers to systematically delivering primary palliative services from primary care practice that are cited by these authors are also similar in the United States1; we may have even more to overcome as our healthcare delivery system does not have a robust primary care base.
The authors of this editorial emphasize supportive frameworks to systematically deliver primary palliative services. Advanced models of structuring and delivering primary care provide higher quality care, produce better patient outcomes, and at lower overall costs to the healthcare system – they meet the triple aim. Such practices have been proposed as particularly well suited for the systematic delivery of primary palliative services. Patients from practices with more features of the advanced primary practice engage in advance care planning, a key component of palliative services, more often than those from other practices.2 The successful integration of behavioral health services is a prime example of how specialty services might be integrated with primary care and enhance coordination between primary and specialty level palliative care.
However, challenges in the US exist in educational and policy arenas, as they do elsewhere. There has been some emphasis on teaching medical students the basics of palliative care, but there are no models reinforcing these concepts or systematically demonstrating the delivery of primary palliative services in primary care outpatient residency training settings.
Multiple policy challenges exist in the US too. Among the most important are identification of quality measures relevant for patients with multimorbidity or serious illness, and GME reform encouraging healthcare that shares similar features whether primary or palliative care: care that is patient-centered and relationally-based throughout the illness trajectory and across illnesses.
1. https://doi.org/10.3122/jabfm.2016.06.160054
2. https://doi.org/10.1093/fampra/cmx113

Competing interests: No competing interests

20 April 2019
David E. Nowels
Academic Physician
University of Colorado School of Medicine
Department of Family Medicine, University of Colorado School of Medicine, 12631 E. 17th. Ave., Rm. 3501, Aurora, CO 80045–0508