Changing Perspectives on Palliative Care
Changing Perspectives on Palliative Care
In the 1950s, a group of clinicians, who later would be the forerunners of the discipline to be known as oncology, completed the first clinical trial in acute lymphoblastic leukemia. This beginning led to the formation of a learned society in oncology. In the mid-1980s, the American Board of Internal Medicine recognized the field of oncology by providing a qualifying examination to establish its importance in the development and treatment of cancer. The impressive growth in this field over the past decade evolved through a variety of basic research advances and the introduction of clinical trials.
As well as we have performed in oncology, however, we have not performed well when faced with caring for cancer patients for whom cure is no longer possible. It is estimated that over 60% of individuals initially diagnosed with cancer can be classified as having disease that is no longer curable.
A Lack of Training
As a group, oncologists remain poorly trained in palliative care (derived from the Latin for "to cover over"), although this failing is not unique to this specialty. With the rise in public demand for complementary and alternative medical care, we are faced with the need to develop a better approach to palliative care for the person with cancer. Indeed, optimum palliative care seems to play a positive role in preventing the need for physician-assisted suicide. This care must begin at diagnosis and continue through to the end of life.
The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT) clearly delineates the scope of this problem. Prior to this sentinel work, the modern hospice movement begun by Dame Cicely Saunders in the late 1960s brought the need for better care at this period of life to our attention.
The article by Drs. Choi and Billings clearly delineates advances in palliative care, highlighting a new area of concerngood communication skills. How many of us have been trained in how to break bad news, or how to obtain informed consent, or for that matter, how to present the family with choices when introducing our approach to the care of their loved one?
What then is the role of this new discipline in patient care? An illness that will eventually shorten the patient’s life (eg, cancer, obstructive pulmonary disease, dementia) calls for good symptom managementie, palliationas the foundation of total care. However, medical attention is only one aspect of palliative care. The nursing profession, social services, spiritual leaders, and other health-care professionals comprise the interdisciplinary team that would manage such a case.
The problems encountered by such a team are exemplified in the following case report: A 75-year-old man, a retired crane operator, lives with his wife of 52 years in a private home. He receives a pension from his job, social security, and Medicare. He was diagnosed with Duke’s D colon cancer following an evaluation of blood in his stool. His other major illnesses include coronary artery disease, chronic obstructive pulmonary disease, and a long history of osteoarthritis. He refused chemotherapy or radiation. Who should care for this person? His primary physician, the oncologist, the geriatrician, the assigned nurse, or the palliative-care specialist? Until he is eligible for hospice care, the palliative-care team would best meet his medical and psychosocial needs. Hospice can be considered when he becomes eligible for such care, based on the guidelines put forth by the Medicare Hospice Benefit.
With the rise of the discipline known as hospice/palliative care, the oncologist is now in a position to become an active participant in this emerging area of health care. It is imperative that oncology training programs incorporate palliative care into their curricula for the 21st century.
Dr. Ira Byock notes three factors that are critical to the incorporation of these concepts into standard health care (I. Byock, personal communication, 2001):
(1) CompetenceIn addition to curriculum development, standards of care must be established and evaluated through certification and accreditation mechanisms. Moreover, research and continuous quality improvement must be part of our daily activities in palliative care. Only then can we hope to rally public support for our efforts.
(2) Centers of excellence to teach and provide exemplary palliative careWe currently have National Cancer Institute-designated cancer centers. With a similar set of requirements, we could establish palliative-care training at these centers and foster its introduction to all cancer treatment protocols.
(3) Universal access to this type of careWe must ensure that all people receive palliative care as part of their treatment. We cannot consider our efforts complete until we have reached this objective.
Physicians need to be made aware of this growing new discipline. The American Board of Hospice/Palliative Medicine and the American Academy of Hospice/Palliative Medicine are leading the way for physicians in the development of this field. There are now over 500 physicians certified in palliative medicine. We can only hope that, like oncology, this area of care will continue to expand until physicians around the world recognize it as an important discipline in the war on cancer.
1. Portenoy RK, Coyle N, Kash KM, et al: Determinants of the willingness to endorse assisted suicide: A survey of physicians, nurses, and social workers. Psychosomatics 38:277-287, 1997.
2. Phillips RS, Hamel MB, Covinsky KE, et al: Findings from SUPPORT and HELP. J Am Geriatr Soc 48:S1-S6, 2001.
3. Clark D: An annotated bibliography of the publications of Cicely Saunders. 1:1958-1967. Palliat Med 12:181-183, 1998.
4. Standards and Accreditation Comm Medical Guidelines Task Force (eds): Medical Guidelines for Determining Prognosis in Selected Non-Cancer Diseases, 2nd ed. NHO, Arlington, Va.