HOUSTON--Recent studies suggest that the key to improving end-of-life
care is ensuring that the medical staff, including physicians, is properly
trained to support patients physically, emotionally, and spiritually during
their final days.
"It is the responsibility of the caregiver to ensure the highest
possible level of well-being until death," Richard Payne, MD, said
at a symposium on cancer and the central nervous system, sponsored by The
M.D. Anderson Cancer Center, where Dr. Payne is chief of the Section of
Pain and Symptom Management.
Cancer care has historically focused on delivering state-of-the-art
therapies with a curative intent, Dr. Payne noted. "We are realizing
now that we need to place the same emphasis on palliative care, which is
care designed to minimize suffering through pain and symptom control, rehabilitation,
and other critical areas of end-of-life needs."
In the current society, the medical staff is ill prepared to provide
an effective level of palliative care. "There is a lack of formal
training, a lack of role definition, and a lack of empathy," Dr. Payne
In addition, he noted, end-of-life care is generally not considered
the doctor's job and is usually delegated to a nurse or other staff member.
This goes against the findings of recent studies indicating that end-of-life
care should be directed by a team of professionals including physicians,
nurses, psychiatrists, clergy, and others as appropriate.
In addition to their medical expertise, Dr. Payne said, these individuals
need core competency in the key areas of palliative care: interviewing/counseling,
pain and symptom control, rehabilitation, empathy, and ethics.
Training Programs Lacking
The AMA recently reported that only 1,851 (16%) of 7,048 residency programs
offered a course in the medical and legal aspects of end-of-life care.
A national survey of residency programs found that 15% of 1,168 accredited
programs in primary care offered no formal training in palliative care,
and that most residents and fellows in these programs coordinated end-of-life
care for 10 or fewer patients annually.
The Study to Understand Prognosis and Preferences for Outcomes and Risks
of Treatment (SUPPORT) found substantial shortcomings in the care being
given to seriously ill patients, and the investigators suggested that more
education for physicians and the public is needed to improve care for the
In response to these and other reports, the American College of Physicians
and the Academy of Hospice Physicians have outlined the skills deemed necessary
to ensure competency in end-of-life care and symptom control.
Also, the Committee on Care at the End-of-Life, established by the Institute
of Medicine, is evaluating current knowledge about end-of-life care and
making recommendations to policy makers for improving care of terminally
ill patients. Input from oncologists and other practitioners who care for
patients with chronic medical illnesses, especially cancer, has been critical
to the process.
Dr. Payne described palliative care as care that affirms life, regards
death as a natural process, provides relief from pain and other distressing
symptoms, ensures respect for the patient's preferences, and provides rehabilitation
to restore some level of independence.
"Our patients do not want to die, but they appear less fearful
of death than of the suffering and indignities associated with death,"
he said. "They do not want to be in pain; they want to be alert and
able to talk with loved ones, and have some control over 'how' they die."