Six years ago, I was attending a Pain and Palliative Care Symposium when I heard a medical oncologist say, “We treat disease. We do not treat emotion.” She was an outspoken advocate for palliation in all aspects of care, be they spiritual, mental, or corporeal, and during all stages of illness ranging from curative treatment to terminal care. Initially, her words struck me as false, almost antithetical to the entire profession of medicine. Today, they resonate as precise if not true.
In understanding what palliative medicine is, it is imperative to know what it is not, and what it could be. Coincidentally, the recent death of our former first lady, Barbara Bush, known to be receiving “comfort care” in her final days, prompted the National Hospice and Palliative Care Organization (NHPCO) to release a statement clarifying the nomenclature and respective roles of palliative care, comfort care, and hospice. According to the NCPCO’s April 16 statement, comfort care refers to “care plan for the patient that is focused on symptom control, pain relief, and quality of life.” NHPCO further clarifies the terms “hospice” and “palliative care” as two forms of comfort care, respectively defined below:
“Under hospice care, a person receives medical care as well as emotional, psychosocial, and spiritual care delivered by an interdisciplinary team of professionals that includes a physician, nurse, social worker, allied therapists, counselors, home health aides, spiritual and grief support and trained volunteers.
“Palliative care means patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice.”
Palliative medicine, more specifically, specializes in minimizing symptoms, like pain, intractable nausea, or difficulty breathing, and in reducing stress, which can take place at with any type of illness at any time. The goal is to ease a patient’s suffering and provide them with the best quality of life possible throughout the course of their illness. Palliative care is neither synonymous with end-of-life care nor is it the last-ditch effort we meekly resort to when treatment fails. We should consider a palliative care consult or evaluation when the health care team seeks further measures to assist a patient in coping with his or her illness, whether there is a short-lived active problem or a terminal prognosis, thereby assisting the primary care team with optimal symptom relief for the patient. Treatment continues as per standard of care for patients seeking palliation. These consults enhance, rather than substitute, the interdisciplinary and patient-centered treatment plan, and often lead to a dialogue on life goals and advance care planning, conversations that are never too premature to initiate with a patient and their family.
Patients who desire to forgo treatment for a terminal illness altogether may also benefit from palliation of their stress, pain, and other physical symptoms brought on by the illness, prior treatment, or even treatment withdrawal. Those who are additionally burdened with a prognosis estimated to be fewer than six months receive hospice, or end-of-life, care. According the NHPCO, the focus of hospice is providing the terminally ill patient with “high-quality” psychological and spiritual support while tending to symptomatic management “to the whole person and to family caregivers”. Curing the life-limiting illness is not the goal of hospice care, which concentrates in providing as much comfort and as best of quality of life as possible. Delivered by a multidisciplinary team of healthcare providers, social workers, volunteers, and religious figures, hospice can take place at a dedicated inpatient ward, outpatient facility, and, most often, takes place at home. Patients who later are in remission of a terminal illness may discontinue hospice care and proceed with management as clinically warranted.
As providers, we are expected to be empathetic, if not sympathetic, to the pain, suffering, and anxiety alongside our patients. In addition to the support provided to patients and their families, palliative care specialists are skilled at supporting the providers themselves, who too often face these challenges rife with emotions but without mental relief or understanding from their care team colleagues. Medical students planning their fourth-year are encouraged to spend time or rotate with a palliative care team to learn about what can be offered to patients as well as strategies to help cope as an aspiring health care provider facing serious illness and death regularly.
Ask about Palliative Care and Hospice at your hospitals, and visit the National Hospice and Palliative Care Organization (NHPCO) for more information. Check out NHPCO’s public awareness campaign Moments of Life: Made Possible by Hospice.
Fatima Elgammal is a fourth-year medical student from St. George’s University School of Medicine. She spent four years at Rutgers New Jersey Medical School in the Department of Neuroscience, Pharmacology and Physiology studying neuronal changes in traumatic brain injury models of epilepsy, and developed an interest in critical care and trauma during her surgery clerkship at Hackensack University Medical Center. A native of New Jersey, Fatima will begin General Surgery Residency July 2018 at Rutgers.
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