Introduction
For the past 25 years, there has been an intense research effort to discover the cure for cancer. That research effort has led to a mature appreciation of this challenge. Although there may have been an unrealistic expectation for a single "breakthrough" when the American research effort was expanded in the 1960s, it is now apparent that progress in the "war on cancer" will be incremental. For example, the critical insights into molecular and cell biology spawned by this effort are tremendous. However, the fact remains that many patients who are diagnosed with cancer today will predictably die of the disease [1]. This sober fact has led to a revision in the organization of the research efforts on cancer and to a renaissance of interest about how best to care for patients who are terminally ill.
Historical Perspective
The following quotation from an article on controlling pain in 1941 [2] illustrates the prevailing view of appropriate medical management of patients with advanced malignancy at that time:
"While the patient is able to care for himself fairly well he may be managed at home, but when he has reached the stage where his is a bed and chair existence or where frequent attention is necessary he is best cared for in some institution...the use of narcotics in the terminal cancer [patient] is to be condemned if it can possibly be avoided."
Patients tell us that their two biggest fears about advanced incurable cancer are isolation from their families and severe pain. This quotation poignantly illustrates that standard management of terminal cancer during the first half of this century often fulfilled the fears of patients with cancer. Sadly, this predilection for sequestering seriously ill persons from their families in hospitals and for avoiding the appropriate use of opioids remains widely prevalent.
A very different approach was described by Cicely Saunders [3],
after observing the care of some patients with terminal cancer
in England. She noted that when pain was treated with oral morphine(Drug information on morphine)
on a regular schedule, patients were much more comfortable than
when morphine was given "as needed." Furthermore, after
listening to what patients themselves said they needed, she founded
the first modern hospice--a place to care for terminally ill patients.
She learned that a team approach, involving members of multiple
disciplines working together, focusing on both patients and their
families, was better than the traditional approach. This approach
has been variably termed palliative care, palliative medicine,
hospice medicine, and hospice care. The choice of terminology
is less important than an understanding of the underlying
principles.
Goals of Palliative Care
Palliative care seeks to relieve human suffering, which is uniquely subjective. To provide palliative care, practitioners must shift their focus to the patient's point of view. The patient becomes the expert on suffering, and the physician becomes the consultant. Often, health-care professionals find this to be a striking contrast to providing therapy with curative or remissive intent; in that paradigm, practitioners' knowledge of the science of medicine and the management of disease is paramount.
Dr. Saunders' insight from listening and responding to the description of suffering by terminally ill patients has been amplified by Dr. Eric Cassel. In a seminal article, Dr. Cassel described the inherently subjective nature of suffering and its relationship to the goals of medicine [4]. According to Dr. Cassel, suffering occurs when any of the many facets of a person's life is threatened. The threat can come from any of the following aspects: physical pain, damaged self-image, destroyed social roles, inhibited secret life, disrupted connections with other people, activities that can no longer be pursued, a future that cannot be lived, and a challenge to the sense of meaning in life or the spiritual dimension. To relieve the suffering of patients with advanced, incurable cancer, we must use a model that addresses all these aspects of suffering. In essence, the objective methods of diagnosis and treatment with which we characterize cancer rarely reveal the most significant features of patients' illness [5].
It should be apparent that suffering can be physical, psychological, social, and spiritual. It is experienced not only by patients, but by their families as well. Again, the goal of palliative care is to relieve suffering. No single health-care provider could ever hope to address all these issues for a given patient and family. Hence, a disciplinary team approach is required. Each member of the team, be it physician, nurse, social worker, chaplain, pharmacist, physical and/or occupational therapist, dietitian, or volunteer, has a unique role to play in the palliative care of a particular patient and his family. Suffering is best relieved when all team members communicate and work together as an interdisciplinary team.
Some aspects of good palliative care are broadly applicable to all phases of cancer treatment. It is important to manage symptoms and optimize quality of life throughout treatment. However, the proportion of attention given to the relief of suffering will vary during the course of cancer treatment. For example, the symptoms associated with bone marrow transplantation protocols can be profound. Although careful treatment of those symptoms is important, the protocol would not be altered or abandoned to spare patients from experiencing the symptoms. The primary goal is to prevent death from cancer, not to prevent suffering. Patients should be made aware of this goal before they enter into such cancer treatment.
Primary emphasis is given to the prevention of suffering when efforts to control the cancer itself are no longer possible or desired. When optimizing quality of life is the primary goal of medical care, patients should be treated using the principles and treatment approaches of palliative medicine. Patient referral to a hospice program can be the optimal way to provide palliative care to patients with cancer.
A 52-year-old man presented with an erythematous lesion in the axilla of unknown duration. Surgical excision was performed. What is your diagnosis?
