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Vital Signs

Spring 2011

Palliative Care: Helping Patients and Families Through Difficult Times


VS-Spring2011-Palliative CarePalliative care — which aims to optimize quality of life for patients and families dealing with a life-threatening illness by anticipating, preventing and treating mental and physical suffering — is among the fastest-growing subspecialties in medicine. Once largely confined to providing comfort for patients at the end of life, it is increasingly provided in conjunction with treatment aimed at a cure. Thomas Strouse, M.D., medical director of the Stewart and Lynda Resnick Neuropsychiatric Hospital at UCLA and holder of the Maddie Katz Chair in Palliative Care Research and Education, discusses this increasingly emphasized aspect of patient care.

Has medicine’s view of palliative care changed over the years, and if so, how?
Clearly it has. Historically, palliative care was seen as only what you do when you can’t do anything else. Now there is growing recognition that we need to embrace the most basic humanitarian values in medicine and in the Hippocratic oath — that when people are at a high risk of having physical, psychological or spiritual suffering, treatment focused on reducing that suffering is inherently valuable.

When, and for whom, is it offered?
Ideally, palliative care is available to people from the first days or weeks of a catastrophic illness, whether the treatment for that illness is likely to yield a cure or long-term remission, or whether that illness is going to have a rapid and potentially even fatal outcome.

So palliative-care treatments and efforts to cure the patient’s disease aren’t mutually exclusive? One doesn’t interfere with the other?
Indeed not. The New England Journal of Medicine published a study last August in which patients with non-small-cell lung cancer, which is almost always a fatal lung cancer, were randomized into two groups. One got standard chemotherapy treatment, and the other group received standard chemotherapy treatment and an early palliative-care consultation that focused on pain and symptom management. The group that got standard chemotherapy plus palliative care, not surprisingly, experienced less pain and better quality of life than the group not receiving the palliative care. The surprising finding, though, was that they also lived about 30 percent longer.

VS-Spring2011-Thomas Strouse, MD Who is on a palliative-care team and what types of services are they providing?
Teams typically include physicians and nurses as well as chaplains, social workers and other allied professionals on an asneeded basis. In terms of what they address, certainly pain is a very common symptom and an important part of palliative care, but not everyone, even at the end stage of a disease, has pain. From the physical perspective, palliative-care teams also manage fatigue, nausea, constipation, dehydration, non-healing skin sores, shortness of breath and dry mouth, to name a few. It’s not just physical symptoms, though. There is also anxiety, depression and confusion. We manage psychological distress, which can simply mean providing assistance in coping with the stresses and demands of the situation. And palliative care also addresses existential or spiritual distress — whatever for the individual it means to be facing off with his or her mortality.

What role does the palliative-care team play in helping the patient and family with end-of-life treatment issues?
In the ideal situation, a palliative-care team has worked with a patient and family over time, which makes it much easier to enhance patients’ self-determination and autonomy by helping them identify their goals of care, as well as assisting them in thinking about advance directives. Palliative-care teams can help patients and their physicians understand and articulate their values in this area.

How are these teams received by patients and families?
Much depends on the way the introduction is made. In my career, I’ve been met by families as if I were the leader of the death squad because of the way I was introduced by the primary or treating physician. But I’ve also been greeted by many families who said they were so glad to see us. If patients know our presence doesn’t mean their doctor has given up but that the palliative-care clinicians are just part of the treatment team with expertise in symptom management, we are very well received.

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