ANESTHESIOLOGY AND PALLIATIVE CARE

"The movement for palliative care has arisen around the world as a protest against the pain, isolation and neglect of dying people.DAME CICELY SAUNDERS 20 Palliative care has its roots in London, England, where Dame Cicely Saunders established St. Christopher's Hospice in 1967. Three decades later, still in its relative infancy in most of North America, there is a special need for expansion of palliative care resources in medicine. Pushed in part by the debate on physician-assisted dying and the general aging of the population, aided by the electronic communication explosion, there has been a dramatic increase in public awareness and discussion about end-of-life options. 16 In an increasingly information-driven environment, much of the lay public is ahead of the medical community in its knowledge of issues surrounding death; academic institutions have been slow to react. Although there are palliative care services available at some teaching institutions, there are few well-organized programs and training opportunities are nearly nonexistent. Fortunately, several organizations outside academia are making vigorous efforts to promote public discourse, disseminate knowledge to health care providers, further research into end-of-life issues, and advocate for "healthy deaths." 33 These organizations are readily accessed electronically through the World Wide Web (Table 1). End-of-life care frequently is haphazard and suboptimal, even in the presence of the most well-meaning health care providers. Poor assessment skills, lack of specific knowledge in palliative techniques, scarcity of practitioners skilled in pain relief therapies, inadequate hospital support for multidisciplinary teams, and uncertain reimbursement are major obstacles to establishment of adequate comfort care for every dying person. Relief from pain, though not the only issue at the end of life, is an ever-present concern. If not treated properly, persistent pain syndromes can lead to severe psychologic distress, 5,30 and preventable suffering. 9 Anesthesiologists have been at the forefront of pain management since the mid-1940s, when John J. Bonica introduced multidisciplinary pain management. A similar multidisciplinary approach is integral to quality palliative care. 31 At a minimum, anesthesiologists are called upon to perform diagnostic or therapeutic nerve blocks. At one extreme, we may be asked to give advice about "terminal sedation," a form of comfort care that is hotly debated as an alternative to physician-assisted dying. 28 Alternatively, some anesthesiologists have seized the opportunity to play an extensive role in palliative care, moving outside the operating room, using their general expertise in comfort care to help dying patients. This article will: (1) define palliative care; (2) suggest ways in which anesthesiologists can positively influence both psychologic and somatic distress; (3) describe the nature and prevalence of palliative care programs in the United States and Canada; (4) illustrate some of the financial concerns associated with palliative care; and (5) argue for increased involvement by anesthesiologists in end-of-life care.