August 23, 2015

Palliative Care Comes of Age

Last week, the New England Journal of Medicine published a short review article entitled “Palliative Care for the Seriously Ill.” Eleven years ago, the NEJM also published a review of “Palliative Care,” at that time putting it in the section of the journal called “Clinical Practice.” What has changed over the decade? What has remained the same?

Comparing and contrasting the two short articles, both of which emanate from the Mount Sinai School of Medicine, reveals some interesting changes. Perhaps the first change worth noting is that the Mount Sinai School of Medicine is now the Icahn School of Medicine at Mount Sinai. That a venerable school of medicine should now be named after a business magnate known as a ruthless corporate raider instead of after the alleged birthplace of the Ten Commandments says worlds about developments in the field of medicine. Palliative care itself has been affected by the widespread corporatization of medicine, with 2/3 of all hospice providers for-profit in 2013, compared to 5% in 1990. But the article rightly concentrates on describing the field of palliative care rather than one specific program, hospice care. The authors carefully distinguish between the population who stand to benefit from palliative care--those with serious illness--and those who may benefit from hospice care--those who are in the last months of life.

What stood out reading the new and older articles side by side is that in 2004, Morrison and Meier were at pains to explain the rationale for the very existence of palliative care. They emphasized the under-treatment of symptoms such as pain, delirium, and nausea in very sick patients. They discussed the fixation of American medicine on cure, even when cure was not possible, and the false dichotomy between cure and comfort. In 2015, Morrison, writing this time with Kelley, a young colleague (also a marker of change as a new generation of physicians rises to prominence in palliative medicine), do not feel the same need to justify palliative care. To the extent that they do feel obligated to explain why palliative care should exist, they provide data, itself a welcome development over the past decade, offering a graph showing the prevalence of ten specific symptoms in advanced illness, broken down by disease category (cancer, congestive heart failure, chronic obstructive pulmonary disease, advanced kidney disease, dementia, and AIDS).

Another area discussed in some detail in the new article but scarcely mentioned in 2004 is the various delivery models for palliative care. Ten years ago, palliative care consisted principally of in-hospital consultation and of home-based hospice. Today, it is both of those but it is also increasingly provided in the outpatient arena and in the nursing home.

The discipline of palliative care is much the same today as it was a decade ago: it is based on the three-legged stool of communication (which includes establishing the goals of care and planning for the future), symptom management (which addresses symptoms from pain to constipation), and psychosocial and spiritual support (which is targeted to families along with patients). But it has grown into a mature field with a small but robust and burgeoning research base. It is an interdisciplinary form of care that offers an “added layer of support” to conventional care (words chosen from market research done by the Center for the Advancement of Palliative Care); it is for the “seriously ill,” (as the authors quietly insert into the title of their article), not just for the dying; and it is for people of “any age,” not just for older people (who seemed to be the primary target in the earlier article that emphasized the graying of the population).

The field has made remarkable strides. I have just one nagging concern. In its eagerness to view palliative care as a supplement to rather than a replacement for conventional care, the field has a tendency to ignore the important truth that when palliative care clinicians review the prognosis and the options with patients, the conclusion may well be that less is more. And in its excitement over the surprising finding in one important study that patients with palliative care may actually live longer than those receiving usual cancer care, the field glosses over the importance of making trade-offs between life-prolongation, comfort, and maximizing function. Sometimes, to be sure, there are no life-prolonging options: the aggressive chemotherapy that oncologists offer and patients seize upon simply won't work and may paradoxically shorten life. But sometimes--and I would argue more often--there is a potentially life-prolonging option. That course of treatment, however, is typically very risky. Its likelihood of succeeding may be extremely small and its probability of causing misery extremely high. What palliative care does in this scenario is to lay out the alternatives and figure out which makes most sense for a patient and family in light of their goals of care. What palliative care does not do, however, is deny the importance of making trade-offs. 

Perhaps when the New England Journal publishes a review article about palliative care in another ten years, the authors will not feel the need to view the field as an add-on, but rather as the more realistic and comprehensive approach to the management of advanced illness. The truth is that most of the diseases that kill people today--heart disease, many cancers, and dementia, for example--are chronic diseases. They cannot be cured. All treatment for these conditions is inherently palliative. Cardiologists, oncologists, and neurologists all practice palliative care all the time; they just don't do as good a job as they might. Here's to Palliative Care 3.0!

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