The Emerging Field of Palliative Medicine
by Neil MacDonald, MD
Chairman, Department of Palliative Medicine
McGill University School of Medicine, Montreal

Palliative Medicine, Pain Control and Symptom Assessment
American Board of Internal Medicine

Palliative care is the active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social, and spiritual problems is paramount. The goal of palliative care is achievement of the best possible quality of life for patients and their families. Many aspects of palliative care are also applicable earlier in the course of the illness, in conjunction with anticancer treatment.

Palliative care:

    - Affirms life and regards dying as a normal process
    - neither hastens nor postpones death
    - provides relief from pain and other distressing symptoms
    - integrates the psychological and spiritual aspects of patient care
    - offers a support system to help patients live as actively as possible until death
    - offers a support system to help the family cope during the patient's illness and in their own bereavement

Radiotherapy, chemotherapy, and surgery have a place in palliative care, provided that the symptomatic benefits of treatment clearly outweigh the disadvantages.

The above definition of palliative care is extracted from Cancer Pain Relief and Palliative Care, the 1994 Report from the World Health Organization, Geneva, Switzerland.

While the goals put forward in this definition are entirely logical, evidence suggests that patients dying from cancer and other disorders often do not receive the care appropriate for their situation. Reasons for this relate to both medical school and postgraduate training priorities and possibly an over-estimation of the life-lengthening capabilities of certain aggressive therapies received by patients in their last days of life.

The palliative care movement developed because of the perception than an unacceptable contrast existed between the reality of care at the end of life and the ideal care which patients and families should receive.

With its wellspring in the United Kingdom, the movement is now established throughout the English-speaking developed world, Scandinavia, and selected countries in Europe. The Cancer and Palliative Care Unit of the World Health Organization has also urged that palliative care form an essential component of cancer programs in developing countries.

In two countries, Britain and Australia, palliative medicine has emerged as a formal specialty, and the introduction of specialty status for palliative medicine has been advocated in Canada.

In the United States, there is currently no specialty in palliative care and palliative medicine, and those practicing in this area are from a wide number of disciplines. The focus in the United Stares, as in Britain, has been predominantly on the care of cancer patients. More recently, programs assisting AIDS patients have evolved, and other programs are beginning to enroll patients with neurodegenerative diseases.

At the current time in this country, palliative care services are available in some major institutions; however, these are few and far between. In addition, there are even fewer academic training programs for individuals interested in pursuing palliative medicine as a career.

The rationale for specialty development derives in part from the thesis that excellent palliative care is simply applied; with a change in health priorities, it can be readily made available for the increasing number of patients and families suffering from the impact of cancer and other chronic diseases associated with severe symptomatology and ultimate death. The problems of these patients are regarded as a fertile field for both educational development and research. Formal specialty designation will provide a focal point for these activities.

In a number of countries, societal acceptance and/or legalization of euthanasia and physician-assisted suicide is either in place or under consideration. Regardless of one's moral views, informed discussion on this topic cannot proceed without acceptance of the fundamental understanding that all patients and families must have access to excellent care in the last days of life.

In summary, there are imperative biological, moral, and ethical factors which dictate that a guarantee of access to good palliative care by dying patients and their families must be regarded as a priority in our global society. The organizational arrangements through which this goal is realized will vary from country to country.

© Copyright Neil MacDonald, 1996. All Rights Reserved. No portion of this work may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage or retrieval system now or hereafter invented, without permission in writing from the Publisher.