Published: May 3, 2007
Updated: July 2, 2007
Doctors may become supporters instead of healers when no cure is available.
Many patients that I see in the clinic or on the hospital ward have diseases I cannot cure.
Either they will get better on their own or with some supportive care; or I can help them understand what they have and why we cannot cure it.
I am helping them to cope with a situation that may seem mysterious. This moves me from the category of “healer” to “supporter” or “palliator.”
Dr. Dean S. Miner describes below the field of palliation and what it means to the patient and the care giver.
-- Dennis Clements MD, PhD, MPH
Webster’s Dictionary defines palliation as “easing the severity of a pain or a disease without removing the cause.”
Reflecting on the history of the delivery of health care, almost all of the care delivered by physicians and other healers until the early 1900s was palliative in nature.
Lacking knowledge of the underlying cause of disease and lacking the science to provide appropriate diagnostic tools, most of what those in the healing professions had to offer their patients was directed at the relief of suffering.
Indeed, until more modern times, healers had to focus on improving the quality of their patients lives by helping to better manage the symptoms of disease processes that were often poorly understood and very rarely “curable.”
By contrast, modern medicine, with all of its associated advances in science, has allowed physicians and other health care providers to dramatically improve their ability to accurately identify and treat the underlying causes of countless medical conditions.
Most modern health care providers and consumers are increasingly focused on finding the “cure” without much deliberative thought about the emotional, physical, and financial cost of that cure.
In spite of the increased focus on cure, it is certainly true that every modern health care provider practices some degree of palliative care medicine, in the sense that we all face conditions like asthma or allergies that can be controlled with medication even if they are not truly “cured.”
When we tell parents to use saline nose drops and a bulb suction to treat the symptoms of nasal congestion caused by an upper respiratory virus in their child, we are offering palliative care advice.
We have no cure for upper respiratory viruses, but we know how to ease the severity of the illness. We palliate the symptoms of the illness by suggesting to treat with the saline, even though we know this will not stop the illness.
As health care providers and health care consumers, we are often so focused on finding the appropriate diagnosis and treatment for the condition at hand that we fail to ask ourselves or our patients what the goal of our care is.
Most of the time the goal of care is obvious and assumed. Although it is often only tacitly understood, both the health care provider and the consumer usually want to identify the best course of treatment that will lead to both a longer life as well as an improved quality of life.
Often we do not overtly discuss how our treatments for medical conditions may affect quality of life as a trade-off for extended duration of life. Clearly, if the medical condition you are evaluating is a non-life threatening condition like a cold or allergies, and the treatment associated with it carries little or no risk, elaborate discussions about the goals of care are not necessary.
However, when the condition is potentially life threatening or the treatment for it may compromise the quality of the life that remains, the importance of overtly discussing the goals of care and outlining the potential risks and benefits of treatment options becomes obvious, even if it is difficult at times. What we define as palliative care changes with the severity and prognosis of the condition that is affecting the patient.
An otherwise healthy five-year-old child who comes in to see a pediatric oncologist with a new diagnosis of acute lymphocytic leukemia will often have a very good prognosis despite having to go through a treatment with chemotherapy that will decrease the quality of his life in the short term, in exchange for the potential benefit of a long and healthy life in the future.
Palliative care for this five-year-old with a new diagnosis of leukemia may simply be the aggressive administration of medications to control the side effects of nausea associated with his chemotherapy. Under the circumstances, we can not stop (or remove the cause of) his nausea, if the goal of our care is to “cure” the leukemia. All we can do is “palliate” the symptom.
If the same five-year-old returned to us three years later after a failed attempt at cure following three years of chemotherapy, a failed bone marrow transplant, and complications of heart and kidney failure, as health care providers we likely would be facing a situation where despite our best hopes, we might not be able to “remove the cause” of this child’s illness and cure his leukemia.
At this point in the child’s life, having a detailed discussion between the patient, his family, and the health care providers is essential to move forward.
If all parties involved felt that the goal of care should be improving the quality of the patient’s remaining life, rather than attempting to treat every complication of his illness that might shorten the duration of his life, palliative care for this patient at this point might include decisions to keep the child at home with his family with medicines to treat his symptoms aggressively, rather than hospitalizing the child for more invasive treatments that might only prolong his life slightly while decreasing its quality.
The modern day “palliative care” medicine movement is in many ways an effort to re-educate both the public and health care providers about the roots of the healing professions, by reminding us all that good, compassionate health care is truly focused on the relief of suffering, and that it is guided by an informed, and joint decision made between the patient and the provider about what the goals of care should be.
-- Dean S. Miner, MD, is a physician with Duke Children’s Primary Care.
-- Dennis Clements, MD, PhD, MPH, is the chief of primary care pediatrics at Duke Children's Hospital.