title: Education, implementation, and policy barriers to greater integration of palliative care: A literature review.
abstract: BACKGROUND
  Early integration of palliative care into the management of patients with serious disease has the potential to both improve quality of life of patients and families and reduce healthcare costs. Despite these benefits, significant barriers exist in the United States to the early integration of palliative care in the disease trajectory of individuals with serious illness.
  
  
  OBJECTIVE
  To provide an overview of the barriers to more widespread palliative care integration in the United States.
  
  
  METHODS
  A literature review using PubMed from 2005 to March 2015 augmented by primary data collected from 405 hospitals included in the Center to Advance Palliative Care's National Palliative Care Registry for years 2012 and 2013. We use the World Health Organization's Public Health Strategy for Palliative Care as a framework for analyzing barriers to palliative care integration.
  
  
  RESULTS
  We identified key barriers to palliative care integration across three World Health Organization domains: (1) education domain: lack of adequate education/training and perception of palliative care as end-of-life care; (2) implementation domain: inadequate size of palliative medicine-trained workforce, challenge of identifying patients appropriate for palliative care referral, and need for culture change across settings; (3) policy domain: fragmented healthcare system, need for greater funding for research, lack of adequate reimbursement for palliative care, and regulatory barriers.
  
  
  CONCLUSIONS
  We describe the key policy and educational opportunities in the United States to address and potentially overcome the barriers to greater integration of palliative care into the healthcare of Americans with serious illness.
authors.affiliation: Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA Melissa.Aldridge@mssm.edu.
authors.forename: Melissa D
authors.initials: MD
authors.lastname: Aldridge
authors.affiliation: Radboud University Medical Center, Nijmegen, The Netherlands.
authors.forename: Jeroen
authors.initials: J
authors.lastname: Hasselaar
authors.affiliation: ATLANTES Research Programme, Institute for Culture and Society, University of Navarra, Pamplona, Spain and Palliative Medicine Group, Area of Oncology and Haematology, Navarra's Health Research Institute (IDISNA), Pamplona, Spain.
authors.forename: Eduardo
authors.initials: E
authors.lastname: Garralda
authors.affiliation: Radboud University Medical Center, Nijmegen, The Netherlands.
authors.forename: Marlieke
authors.initials: M
authors.lastname: van der Eerden
authors.affiliation: Vanderbilt University School of Medicine, Nashville, TN, USA.
authors.forename: David
authors.initials: D
authors.lastname: Stevenson
authors.affiliation: Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
authors.forename: Karen
authors.initials: K
authors.lastname: McKendrick
authors.affiliation: ATLANTES Research Programme, Institute for Culture and Society, University of Navarra, Pamplona, Spain and Palliative Medicine Group, Area of Oncology and Haematology, Navarra's Health Research Institute (IDISNA), Pamplona, Spain.
authors.forename: Carlos
authors.initials: C
authors.lastname: Centeno
authors.affiliation: Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA Center to Advance Palliative Care, New York, NY, USA.
authors.forename: Diane E
authors.initials: DE
authors.lastname: Meier
mesh_terms: D019033:Delivery of Health Care, Integrated / Q000458:organization & administration* / Q000592:standards; D004502:Education, Medical, Continuing / Q000592:standards; D006291:Health Policy; D006297:Health Services Accessibility / Q000458:organization & administration; D006801:Humans; D015279:Organizational Culture; D010166:Palliative Care / Q000458:organization & administration*; D013727:Terminal Care / Q000458:organization & administration; D014481:United States; D000078329:Workforce
keywords: Palliative care; barriers; integrated palliative care