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