Breast Matters - Making Palliative Care a Priority
Issue No. 4
Making Palliative Care a Priority
Ask Thomas J. Smith, M.D. how long he’s been practicing and promoting palliative care, and he responds without hesitation: “Probably since dinosaurs ruled the earth.”
Jokes aside, Smith was first introduced to and intrigued by palliative care when, as an oncologist-in-training in 1984, the attending physician with whom he trained suggested that the clinicians pay attention to the patients’ pain and distress while treating their lung cancer. “That was not standard practice,” says Smith, director of Palliative Medicine for Johns Hopkins Medicine.
Oftentimes, it still isn’t.
Palliative care, defined by the Center to Advance Palliative Care as “specialized medical care for people with serious illnesses focused on providing patients with relief from the symptoms, pain and stress—whatever the diagnosis—with an explicit goal to improve quality of life for both the patient and the family,” became a board-certified specialty only recently, in 2006. Despite its emerging status, palliative care has the potential to greatly improve the quality of life for patients experiencing pain and distress, either during an acute medical condition or a terminal illness.
Palliative care can be administered by physicians, nurses or other specialists. But as trusted medical professionals who deliver a diagnosis of cancer and explain treatment options to patients, oncologists make a natural choice. However, as Smith points out, many oncologists are uncomfortable with discussing issues related to palliative care. Statistics bear this out.
“Most oncologists think they do a good job of palliative care. But our patients and families often have a different perspective,” Smith says. Take communication, for example. Ninety percent of our patients say they want open communication, including information about their prognosis, but about two-thirds to three-quarters of patients with incurable, metastatic disease report that they could be cured of their illness.” He notes that patients who maintain unrealistic prognosis goals don’t live any longer, die worse deaths and miss out on opportunities to transition peacefully.
It’s a disconnect that Smith is working hard to change—for several reasons. Palliative care has been proven to result in better quality of life, better quality of care, improved symptom management and equal or better survival, all at a cost that’s affordable. While it doesn’t involve expensive state-of-the-art technology, palliative care does require those who deliver it to be adequately trained. As director of palliative medicine for Johns Hopkins Medicine, Smith has made this his mission.
“I want to see us as one of the international leaders in palliative care, both from the medicine and nursing points of view. Hopkins is such a leader in so many things. We really have an opportunity to create an academically-based program, and to be one of the leaders in this new field,” Smith says.
Five Signs that strong Palliative Care is Being Delivered:?A medical provider/oncologist…
1. Conducts a spiritualassessment and is prepared to refer patients to a religious leader if they indicate that religion/spirituality is important to them.
2. Has repeated conversations with patients about how they are coping and asks, “What is important to you?”
3. Provides a symptom assessment that goes beyond pain to address questions about depression and delirium.
4. Asks patients “sensitive” questions about the future, such as whether they have a living will, who will make medical decisions if they are unable and what, if any, resuscitation directives they choose.
5. Introduces the concept of hospice care when patients have three to six months to live, not a few weeks or days.