The quality of life of at least 100 million people would have improved--if today's knowledge of palliative care was accessible to everyone. A Public Health Strategy (PHS) offers the best approach for translating new knowledge and skills into evidence-based, cost-effective interventions that can reach everyone in the population. For PHSs to be effective, they must be incorporated by governments into all levels of their health care systems and owned by the community. This strategy will be most effective if it involves the society through collective and social action. The World Health Organization (WHO) pioneered a PHS for integrating palliative care into a country's health care system. It included advice and guidelines to governments on priorities and how to implement both national palliative care programs and national cancer control programs where palliative care will be one of the four key pillars of comprehensive cancer control. The WHO PHS addresses 1) appropriate policies; 2) adequate drug availability; 3) education of policy makers, health care workers, and the public; and 4) implementation of palliative care services at all levels throughout the society. This approach has demonstrated that it provides an effective strategy for integrating/establishing palliative care into a country.

The need for palliative cancer care is greater than ever notwithstanding the strides made over the last decade. Further efforts are needed to realize the integration of palliative care in the model and vision of comprehensive cancer care by 2020.

PurposeThe purpose of this new resource-stratified guideline is to provide expert guidance to clinicians and policymakers on implementing palliative care of patients with cancer and their caregivers in resource-constrained settings and is intended to complement the Integration of Palliative Care Into Standard Oncology Care: American Society of Clinical Oncology Clinical Practice Guideline Update of 2016.MethodsASCO convened a multidisciplinary, multinational panel of experts in medical oncology, family medicine, radiation oncology, hematology/oncology, palliative and/or hospice care, pain and/or symptom management, patient advocacy, public health, and health economics. Guideline development involved a systematic literature review, a modified ADAPTE process, and a formal consensus-based process with the Expert Panel and additional experts (consensus ratings group).ResultsThe systematic review included 48 full-text publications regarding palliative care in resource-constrained settings, along with cost-effectiveness analyses; the evidence for many clinical questions was limited. These provided indirect evidence to inform the formal consensus process, which resulted in agreement of ≥ 75% (by consensus ratings group including Expert Panel).RecommendationsThe recommendations help define the models of care, staffing requirements, and roles and training needs of team members in a variety of resource settings for palliative care. Recommendations also outline the standards for provision of psychosocial support, spiritual care, and opioid analgesics, which can be particularly challenging and often overlooked in resource-constrained settings. Additional information is available at www.asco.org/resource-stratified-guidelines.It is the view of ASCO that health care providers and health care system decision makers should be guided by the recommendations for the highest stratum of resources available. The guideline is intended to complement but not replace local guidelines.

A model for pain relief and palliative care for the Middle East has been established in Jordan. King Hussein Cancer Centre (KHCC) in Amman is now a truly comprehensive cancer center as it includes palliative care for inpatients, outpatients, and patients at home. This is especially important in a country and a region where over 75% of the cancer patients are incurable when diagnosed. To support effective palliative care delivery, there have been many significant changes in Jordan between 2001 and 2006. Regulations governing opioid prescribing have been changed to facilitate effective pain management. The national opioid quota has been increased. Cost-effective, generic, immediate-release morphine tablets are being produced in Jordan. Intensive, interactive bedside training courses for doctors, nurses, and clinical pharmacologists have started to overcome opiophobia and motivate health care professionals to take up palliative care as a profession. "Champions" for palliative care have emerged who are leading the development of palliative care in Jordan's health care systems and starting to support neighboring countries to develop pain relief and palliative care. While before 2003, fewer than 250 patients per year received palliative care, by 2006 more than 800 patients per year were receiving pain relief and palliative care through the KHCC and Al Basheer Hospital. The achieved changes and the unusually rapid and effective institutionalization of palliative care serve as a model for other countries in the Middle East region as to what should be done and how.

The need for psychiatrists to work with patients and families living with chronic life-threatening illnesses has never been greater. Further, psychiatrists may find exciting work within the relatively new field of palliative care, which is devoted to the prevention and relief of all suffering. Increasingly, individuals are living longer with multiple issues that cause suffering, interfere with their lives, and often lead to psychosocial sequelae. To ensure state-of-the-art care for patients and families throughout an illness and any ensuing bereavement period, many experienced psychiatrists are needed as consultants to, and as members of, interdisciplinary palliative care teams. This need presents limitless opportunities for psychiatrists to care for patients, provide education, and engage in research. The potential to make a difference is great.

There is evidence that physicians selected to be EPEC Trainers judge the EPEC Curriculum to be high in quality, respected, and most importantly, usable. They use the EPEC Curriculum as part of a train-the-trainer dissemination strategy. The interpretation of this enthusiastic assessment is tempered by the study's limitations including respondent bias and possible acquiescence. Nevertheless, it appears that the EPEC Curriculum has set a standard of knowledge in the field and is an example of disseminating new information to physicians in practice. We conclude that the EPEC Curriculum is an effective vehicle to transmit palliative care information to physicians in practice.

Major depression is prevalent, difficult to assess, underrecognized, and undertreated in hospice settings. Furthermore, it is associated with significant morbidity and mortality. A retrospective chart review of 2716 patients receiving hospice care was conducted in order to determine the baseline rate of recognition of depression in patients with advanced, life-threatening illnesses by frontline hospice clinicians. Documentation of "depression" as either a diagnosis or problem was used as an estimate of how often these disorders were considered significant issues by the treating interdisciplinary team. Of the patients receiving home/long-term care, 10.8% (234/2168) had depression documented as a diagnosis or significant problem. The presence of recognized depression in this setting was associated with significant differences in gender, marital status, and terminal diagnoses. Total length of hospice care was also significantly longer. Of patients receiving inpatient care, 13.7% (75/548) had depression documented as a diagnosis or significant problem. Recognized depression in this setting was associated with significant differences in marital status, length of inpatient stay, and total time in hospice care. If documentation is representative of the care that the interdisciplinary teams provide, depression of any kind appears to be underrecognized in this population. In fact, it is on the low end of prevalence estimates in the literature. Improved depression assessment is needed in order to minimize the impact of depression on patients living with advanced, life-threatening illnesses.

Delirium is highly prevalent in those with serious or advanced medical illnesses. It is associated with many adverse consequences, including significant patient, family, and health care provider distress. This article suggests a novel approach to delirium assessment and management and provides useful, practical guidance for clinicians based on a complete review of the existing literature and the expert clinical opinion of the authors and their colleagues, derived from over a decade of collective bedside experience. Comprehensive assessment includes careful description of observed symptoms, signs, and behaviors; and an understanding of the patient's situation, including primary diagnosis, associated comorbidities, functional status, and prognosis. The importance of incorporating goals of care for the patient and family is discussed. The concepts of potential reversibility versus irreversible delirium and delirium subtype are proffered, with a description of how diagnostic and management strategies follow from these concepts. Pharmacological interventions that provide rapid, effective, and safe relief are presented. Employing both pharmacological and nonpharmacological interventions, including patient and family education, improves symptoms and relieves patient and family distress, whether the delirium is reversible or irreversible, hyperactive or hypoactive. All interventions can be provided in any setting of care, including patients' homes.