Palliative Care Is Proven.

Palliative care was officially recognized by the World Health Organization in 1990 as a distinct specialty dedicated to relieving suffering and improving quality of life for patients with serious illnesses. Journal of Palliative Medicine (JPM) was founded in 1997 in response to the need for a scientifically rigorous peer-reviewed journal to advance the field. In our first quarter of the century, JPM has become a leading global peer-reviewed scientific journal. What is the way forward? We engaged with this question in two ways. First, we utilized artificial intelligence techniques to analyze the trends of the articles published in JPM for the past two decades to discern key topic themes. Second, we applied human intelligence by convening seven panels of experts to discuss current topics of interest to the field as a separate strategy for discerning the future. Taken together, the way forward is clear. The field of palliative care has become broader and more subspecialized than anyone ever imagined at the beginning. The expansion of new knowledge has accelerated in all directions from its origins in the end-of-life care of patients with cancer. Although implementation science is of paramount importance, the barriers to implementation of this growing body of specialized knowledge lie not just with the need for more science. Some of the barriers lie within our field. The way forward requires confidence in what we know and the establishment of new collaborations outside of our field, including with people outside of traditional health care.

Accountable and Transparent Palliative Quality Measures Will Improve Care.

How do we build on the proven successes of hospice and palliative care and build clinical programs to serve those who need it in the context of real-world health care? Experiences with glide pathways have clearly shown that changes in financial incentives must always be implemented with counterbalancing measures that ensure that seriously ill patients are getting high-quality care consistent with their goals and values. There are quality measures for quality improvement and there are quality measures for accountability or transparency. We must balance any financial incentives with concrete quality measures that act as a check and balance to the care that is being provided. This area of investigation is rich in opportunity. Much research is needed to advance the craft of hospice and palliative care if the field is to move forward at scale in a timely manner. We need to democratize research and engage both "small r" and a "big R" researchers in the manner of other subspecialties such as oncology and cardiology. Future research should focus on building innovative systems and models of care to uncover needs of seriously ill patients and their caregivers and effectively cater to those needs.

Caught in a Loop with Advance Care Planning and Advance Directives: How to Move Forward?

Completion of an advance care planning (ACP) process and/or an advance directive should result in patients receiving the care they desire at the end of life. However, three decades of research have shown that is just not the case. ACP has been a front runner in developing the science within palliative care. Some positive outcomes such as lowering levels of surrogate grief may be associated with ACP. Yet, it does not appear that further ACP research will ensure that seriously ill patients will get goal-concordant care. An unfortunate consequence of palliative care research and advocacy so far is the misguided notion of many hospital systems trying to solve their palliative care problems by only implementing an ACP initiative. At best, ACP is but one tool in the collective palliative care toolbox. New tools are needed. Given that we have finite resources, future research should focus more on tools to improve symptom management, better models of care, and systems that will ensure goal-concordant care that meet the needs of the population that the health care system is designed to meet.

Generalist versus Specialist Palliative Medicine.

The issue of generalist versus specialist palliative care is on the minds of healthcare leaders everywhere. We are amid changing demographics of physicians. The industrialization of medicine is well underway in the US and around the developing world. Is it important to identify patients who benefit the most from specialist palliative care, given that it is currently a limited resource? Should we step out of standard practice and redesign palliative care using principles of population management? The COVID pandemic rapidly introduced virtual palliative care consults. Is it a better way to promote wide access to specialty palliative care? Looking forward, should we promote ways to advance primary palliative care and reserve specialty palliative care to patients who will benefit most from this level of care? These questions, and others, are considered in this transcribed discussion between leading physicians in the field.