The April 21, 2005, cover story from USA Today touted that the “U.S. is getting old fast, seniors will out number school-age children in many states by 2030, the Census Bureau says in a report out today. That promises to intensify the political tug-of-war between young and old for scarce resources” (El Nasser, 2005). This article reviewed the recent population predictions by the U.S. Census Bureau that identified which states will have the largest elderly population growth over the next 25 years. “As you reach the end of life the last year or last two years—the use of medical care is very intense” (Cauchi, 2005, p. 3A). Most states are worried about access and utilization of state Medicaid funding as the Baby Boomers age and place more healthcare demands upon limited resources. Another front page article printed in the February 24, 2005 USA Today reported, “Health care tab ready to explode, costs could be 19% of total economy by 2014” (Appleby, 2005). Growth in healthcare spending will outpace economic growth through the next decade. By 2014, the nation’s spending for healthcare will equal $11,045 per person, up from $6,423 per person in 2005 (Appleby, 2005).

Yet another news release from June 15, 2005, reports that older Americans are less willing to sacrifice physician/hospital choice to save costs (Cassil, 2005). Elderly Americans are much less willing than are working-age Americans to limit their choice of physicians and hospitals to save on out-of-pocket medical costs (Cassil, 2005). The U.S. Department of Health and Human Services (DHHS) has projected that, by 2013, the enrollment share of Medicare managed care plans will increase by 30% from the current level of 12% (Cassil, 2005).

These newsworthy reports parallel the issues that will affect the care of patients living with chronic disease over the next several decades. By 2030, for the first time in history the old will outnumber the young; by 2010, the oldest of the Baby Boomers will reach the age of 65. Not only will there be an increase in older people, but also more people will be living longer with chronic disease (DHHS, 2002; Lynn & Adamson, 2003). Currently, the leading causes of death in the United States are cancer, heart disease, stroke, chronic obstructive pulmonary disease, and dementia (DHHS, 2002; Lynn & Adamson, 2003). Chronic diseases are symptomatic, are progressive, and can interfere with the patient’s functional ability and quality of life.

It is here where palliative care can help to support the care of symptomatic patients, improve quality of life, and provide care options that focus on comfort versus cure in a disease that is no longer curable. Palliative care clinicians understand the importance of partnering with traditional care and offering to serve as the conduit between all providers while maintaining patient and family goals of care and providing the coordination, continuity, and cost-effective care that is often lacking in this patient population.

Because the majority of the palliative care programs have been initiated in the oncology setting, this has restricted palliative interventions into the management of chronic debilitating nonmalignant diseases (Kuebler, Lynn, & Von Rohen, 2005). Patients with other diseases such as heart failure and emphysema can also benefit by the knowledge and skills of the palliative care clinician and the comprehensiveness and reliability of palliative care programs (Kuebler et al., 2005). This chapter provides a historical overview of the field of palliative care. It briefly touches on the definitions associated with supportive, palliative, end-of-life, and hospice care. The advanced practice nurse (APN) providing services to the patient and family who are facing a limited prognosis is in an ideal position to apply the philosophy of palliative care to the care of the patient from diagnosis until death and to recognize when to consider supportive services such as hospice care.

Preceding World War II, the specialty of oncology was divided into surgery, immunology, and endocrinology (Seymour, Clark, & Winslow, 2005). The majority of patients, however, often presented with advanced malignancy; the availability of palliative treatments within the traditional care system were rare, and prescribed opioids were limited for fear of hastening death, precipitating addiction, and producing euphoria (Seymour et al., 2005).

During this era, suffering at the end of life was perceived as a test of spiritual and psychological character. There were a few community-based studies during this time, highlighting the degree of suffering in individual patients. Despite patient suffering, the investigators did not recommend a change in policy or an evaluation of or change in practice patterns (Seymour et al., 2005). Some studies recommended that prescribers consider earlier use of opioids but do so with trepidation (Seymour et al., 2005). Peer reviewed papers found in medical publications during this time that documented the physical, mental, and emotional distress associated with dying generated limited, if any, medical interest in the care of the dying patient (Hinton, 1963).

In 1958, Cicely Saunders from the United Kingdom and John Bonica from the United States simultaneously participated in separate prospective observational studies of patients living with and dying from advanced disease and their medical management. These investigators identified two common myths held by healthcare providers caring for this patient population regarding the management of cancer-related pain (Meldrum, 2005; Wall, 1997):

Saunders and Bonica, however, regarded pain and suffering as an integral part of the daily responsibilities of the physician and nurses providing patient care. These pain management leaders took the initial and controversial stance that opioids were essential in the successful management of cancer-related pain (Meldrum, 2005; Seymour et al., 2005). Saunders’ first publication in 1958 outlined a philosophy of care that highlighted a holistic, multidimensional, patient-centered approach to pain and symptom management. This philosophy of care continues to provide the framework on which the hospice and palliative care movement is built. This care model includes the following key concepts (Seymour et al., 2005):

The ongoing reductionism and subspecialization that originates from Western medicine in the twenty-first century will challenge the ability to maintain the “whole person” concept of care. The explosion of HIV/AIDS in developing countries will prompt an urgent need to shorten the gap in basic palliative care between developed and developing countries (Saunders, 2001). There is a need to standardize palliative practices, and the routine utilization of psychometrically valid and reliable symptom assessment and quality of life instruments can help to identify outcomes for patients who receive palliative interventions. Palliative care clinicians could learn from Saunders’ original methods of listening, recording, observing, and measuring specific interventions. Palliative care clinicians should develop the skills and knowledge that are associated with appreciating and understanding the spiritual, social, and psychologic stress that patients experience with a life-limiting disease—and the impact that this has on the family or loved ones.

Palliative care, supportive care, end-of-life, and hospice care are terms that are frequently used interchangeably. Yet, hospice and end-of-life care are distinctly different from the others. While hospice and end-of-life care are always a part of palliative care and/or supportive care, the reverse is not always true (Kuebler et al., 2005). The following discussion identifies the differences and similarities associated with these terms.