"Palliative Care" Means "Active Care"
Authors: Lynne Lamberg
Journal: JAMA (2002)

PHILADELPHIA—After her best friend died, a woman in her 80s who lived in a nursing home developed anxiety and shortness of breath. She was admitted to a hospital where physicians discovered she had lung cancer. The woman, a long-time smoker, chose not to have aggressive care, and returned to the nursing home. The staff gave her a bible that had belonged to her friend, which comforted her. The nursing home social worker and nurses spent more time with her. She had no family, and chose not to see a member of the clergy. Palliativecare, sometimescalledcomfort care, goes beyond pain relief to embrace emotional, social, and spiritual needs of seriously ill patients, said geriatric psychiatrist Judith Crossett, MD, PhD, who treated the woman just described at the University of Iowa Hospitals and Clinics in Iowa City. Palliative care is appropriate, she added, whenever an illness causes pain and suffering and its underlying cause cannot be treated. Palliative care can meet patient needs even if patients can’t state them, she said, citing a quarry truck driver, known to have back pain, who developed endstage dementia and began to strike out at people. Responding to his body language, Crossett stepped up pain treatment, ultimately administering morphine. The man calmed down, appeared more comfortable, and ate better. He lived another 2 months, awake often enough for family members to visit and feel that he recognized them. Palliative care extends to a patient’s family as well, and can help reconcile differences between the wishes of a patient and the family on matters such as aggressiveness of treatment, Crossett said. She chaired a workshop on the role of the geriatric psychiatrist in palliative care at the annual meeting of the American Psychiatric Association (APA). Few medical schools or residency programs provide training in palliative care, and few general clinical textbooks cover the topic, Crossett said, even though primary care physicians, internists, oncologists, and other specialists often see patients who need such services. Many physicians are not comfortable discussing death and dying with patients, Crossett said, and resist “do not resuscitate” orders. Palliative care, she said, does not preclude active treatment of illnesses such as bronchitis or depression in a person with cancer. Indeed, according to Diane Meier, MD, director of the Center to Advance Palliative Care (CAPC) and a professor of medical ethics at Mount Sinai School of Medicine, New York City, people need palliative care from the day of diagnosis of any serious illness—perhaps for years, not just for a few months at the end of life. Palliative care embraces much more than hospice care, she stressed in an interview. It aims not only to relieve pain and suffering, but to improve quality of life for patients and their families throughout the illness. Palliative care services draw on multidisciplinary teams including physicians, nurses, social workers, chaplains, and others. Only about 700 of the nation’s 7000 hospitals have formal palliative care programs, Meier said, even though the sickest patients may be hospitalized numerous times in the course of their illness, and need ongoing support services. Assessment of home needs, advance care planning, and other palliative care services, she said, lower costs by reducing length of hospital stay, pharmacy costs, and rehospitalizations. The CAPC serves as a resource for hospitals and health care systems interested in developing such programs (http://www.capc.org).