Drs. Choi and Billings provide an excellent summary of the historical developments, clinical issues, and ethical dilemmas associated with palliative care. As they recount, the British hospice movement of the 1960s began as a fringe movement away from the main academic centers and organized medicine. This separation provided a safe environment in which palliative-care practitioners could deliver clinical care while establishing a new body of knowledge. On the other hand, because of this lack of connection, palliative care is still not recognized as a specialized area of medical practice in many countries, including the United States. This perception persists despite the fact that palliative care developed earlier than other fully recognized subspecialties such as emergency medicine and critical care.
Although all tertiary-care hospitals have a fully organized emergency room as well as intensive care and coronary care units, only a few have an established palliative-care unit. And yet hundreds of patients die each year of progressive chronic illness in every major tertiary hospital. Moreover, there is solid economic and financial justification for establishing palliative-care units.[1-3] These units provide sophisticated clinical care to cancer patients suffering from severe physical and psychosocial distress (and their families), and are also the most effective settings for education and research.
Choi and Billings appropriately describe the use of palliative care in the prevention of suffering. Proposed by MacDonald as the fourth phase of his comprehensive cancer control program, this model led to the endorsement of palliative care by the World Health Organization in its cancer control policies.
A Helpful Bridge
The area of artificial nutrition and hydration is one in which palliative care can act as a bridge between the traditional hospital-based practice (universal hydration) and the traditional hospice practice (universal nonhydration). Outcomes such as hunger and thirst are of limited informational value in these patients because their correlation with nutritional and hydration status is poor. On the other hand, progressive dehydration can result in delirium, increased fatigue, accumulation of neurotoxic metabolites of opioids and other drugs, and numerous other symptoms. Subcutaneous hydration can be administered safely by patients and their relatives and can offer an alternative to dehydration or the maintenance of a complex and expensive intravenous route at home.[7,8]
Choi and Billings discuss the importance of palliative care as an aid to communication with patients and families. Research has shown that simple aids to communication such as audiocassettes and prompt sheets can improve communication among physicians, patients, and their families.[9,10]
Care at the End of Life
The issues surrounding care at the end of life are particularly complex and require better characterization. For example, the term "intractable suffering" needs to be better defined. Should it refer to physical and psychological symptoms or should it also include existential suffering? What efforts should be made to rule out delirium or depression in patients who present with intractable suffering? What efforts to control these symptoms should be made before intractable suffering is diagnosed? Prospective research must be conducted to better characterize this syndrome and to define the most appropriate treatment.
Choi and Billings appropriately discuss the enormous attention paid to the issues of physician-assisted suicide and euthanasia. In North America, however, this issue is relevant to only a minority of patients and their families. Perhaps the most pressing issue is that of improving access to palliative care for patients and families. Most North American cancer patients die in acute-care facilities where there are no designated palliative-care teams or units. One of the greatest challenges for our health-care system is to ensure that these patients have access to appropriate palliative care. A great challenge for academic medicine, too, is to ensure that we improve the body of knowledge in all the areas outlined by Choi and Billings.