Palliative medicine grew out of a counterculture to perceptions in the 1950s and 1960s that the major causes of death and disability were all but addressed [1]. As such, death and dying were not areas that were receiving serious attention both academically and clinically. Palliative care was a reaction in many ways to the perception that death was a clinical “failure”. Although much of our health system spends time concerned that death may be a consequence of poor care or iatrogenic, the vast majority of deaths are, or should now be, expected in clinical care, since mortality patterns have changed rapidly in the last century.

In resource-rich countries, chronic complex diseases have largely replaced acute causes of disability and death. This has meant that life expectancy has increased but, at the same time, the causes of death have shifted from maternal and child health, trauma, infection and acute cardiovascular diseases to chronic, progressive illnesses such as cancer, organ failure and neurodegenerative diseases. For example, rarely are young healthy people dying of community-acquired pneumonia and the rates of death from acute myocardial infarction in the fifth and sixth decade continue to decline. Such changes in the causes of death and disability have required a significant paradigm shift in the clinical care of people across the community. There is now a need for every clinician to be able to take a palliative approach. This is defined as the ability to deal with key elements of clinical care for someone who has a life-limiting illness as well as supporting their caregivers. A palliative approach is not limited by the physical setting in which care is delivered. Whether the person with the life-limiting illness is based at home, or in an institutional setting, quality palliative care can and should be delivered.

How does one define a patient where the intent should be palliative? Essentially, if a person has a progressive illness that is likely to lead to death, then a palliative approach should be taken. This in no way precludes the use of disease-modifying therapies. Indeed, a palliative approach should be taken in tandem with disease-modifying therapies, using both approaches to ensure that care is optimised for patients. Lynn et al. use the question “Would you be surprised to hear that this person had died in the next 12 months?” [2]. This question does not limit supportive and palliative care to the last 12 months of life, but does help to frame clinical thinking on the matter.

This chapter provides an overview of outcomes from quality research into the net effects of engaging palliative care, the palliative care needs of surgical patients and their caregivers, the models of care configured to address patients’ palliative care needs and the key elements that clinicians need to consider when providing a palliative approach.

Evidence from good quality health services research has been evolving over the last 30 years. This has been complemented by increasingly sophisticated population-based studies that help to identify key associations between the uptake of specialist palliative care services and outcomes for patients, for their caregivers and for the health system in which they are treated. This creates two levels of evidence – rigorous randomised trials and other interventional studies from which causality can be derived – and observational studies where only associations can be drawn. Data are available at patient, caregiver, service and health systems levels.

For patients, there is evidence of improved symptom control, better met needs, better satisfaction with care and better quality of dying and improved comfort in the last 2 weeks of life [3]. Both a randomised controlled trial (RCT) and a high-quality observational study have suggested that there may be survival benefit in late-stage disease with referral to palliative care [4, 5], although this may be that premature mortality was avoided in the hospice/palliative care group [6]. There appears to be benefit in better maintaining function in people with a multidisciplinary approach that includes specialists and primary clinical staff joining the patient and caregiver in at least one case conference [7]. Having controlled for major factors known to be associated with poor health in general, being a caregiver is a risk factor for poor health outcomes [8]. Having relinquished their roles, caregivers for people at the end of life who have used specialist palliative care services had better long-term survival and were better able to adjust to their changed circumstances [9, 10]. Specialist palliative care services are also associated with better met caregiver needs, improved satisfaction with care and less caregiver anxiety [3]. For health systems, benefits include reduced inpatient stays, fewer presentations to the emergency department and reduced overall costs [7, 11–13].

The World Health Organization has not only sought to define “palliative care” in ways that it has not done for other areas of clinical care but also set out the framework for service delivery [14]. The basic framework includes that:

Patient-defined areas of importance include the ability to carry out one’s affairs as the end-of-life approaches, resolving relationship issues and being involved in decision-making [15–17]. Without excellent physical symptom control, it is almost impossible to carry out these important end-of-life tasks [17]. Planning for one’s death includes being part of discussing what is important at that time, ensuring that legacy issues are actively addressed (How does one want to be remembered? Are there unfinished projects?) and ensuring that one’s wishes are known and are going to be respected while dying and once dead.

Being alert throughout the life-limiting illness is incredibly important to patients who are facing death. By contrast health professionals would often regard physical symptom control as more important than being cognitively intact [17]. Although a great deal of health policy is now advocating for home death, the place of care is actually far less important to patients if their family and friends are able to freely spend time with them and to support them. “Home death” as an outcome measure per se fails to reflect the complexities of care and the demands made of family and friends as they provide the bulk of that care.

The speciality of supportive and palliative care has grown up charged with the responsibility of providing team-based clinical care to the people at the end of life with the most complex needs and their families and consultative support for colleagues providing care where the patient or family have less complex needs; ensuring that there is adequate education at an undergraduate, postgraduate and post-registration level; and ensuring that high-quality research is continuing to refine the evidence-base for clinical care that is offered and the way that health services are structured to deliver optimally these services.

In the developed world, the majority of deaths occur in acute care, and this trend is expected to increase in line with population ageing and changing patterns of caregiver availability. These secular trends in where care is provided, especially in the terminal phases of a life-limiting illness, vary widely from country to country depending on health and social system drivers. A small proportion of all acute care deaths will be managed by the patients’ surgical team, with support from a specialist palliative care team, as required.

Despite the increase in the number of palliative care services within the acute care sector over the past two decades, in the USA these services are more likely to be based in larger hospitals, academic medical centres, not-for-profit hospitals and VA hospitals compared to other hospitals [18]. These consultative palliative care services are most frequently called upon to support the treating team with discussions about prognosis and goals of care, pursuing documentation of advance directives, discussion about foregoing specific treatments and/or diagnostic interventions, family and patient support, discharge planning and symptom management [19]. The input of hospital-based palliative care teams to patient’s care has been shown to improve symptom control and quality of life, alleviate emotional burden and improve caregiver and patient satisfaction [3, 20, 21]. In the USA, palliative care provided to hospitalised patients with advanced disease has resulted in lower costs of care and less utilisation of intensive care compared to similar patients receiving usual care [22].

Following the high-profile randomised controlled trial (RCT) in the USA by Temel et al. [4] for people with advanced lung cancer where participants were randomised to either early referral to palliative care or to routine care, there is now increasing interest in encouraging earlier referral to specialist palliative care services [23], which is appropriate for people with more complex needs [24]. Simultaneously, the timely initiation of a palliative approach is appropriate for people whose care needs can be managed by their existing care team.

The key elements of a palliative approach are access; collaborative interdisciplinary team-based care; defining the goals of care; evaluating the “net effect” of any treatments or interventions addressing, where relevant, issues of withholding and withdrawing treatment; determining preferred place of care and, separately, the preferred place at the time of death; and managing care transitions.