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Rapid Responses: Rapid Responses published:
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The Palliative Spectrum
- Peter H S Cox (18 March 2005)
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Palliative care and chronic illness in the elderly
- Angel J. Romero, Francisco Olascoaga (23 March 2005)
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Palliative care of chronic illness: end of life is more than death
- Patrick T White (29 March 2005)
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Peter H S Cox, Management consultant and sarcoma patient Systems 4, 4 Squirrels Heath Avenue, Gidea Park, Essex. RM2 6AH
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Palliative care should not begin the moment a patient is determined to be terminally ill. There is a whole spectrum of palliation that starts at the moment of diagnosis. From the day one is told one has a potentially terminal disease, such as soft tissue sarcoma, the prognosis of a premature death is an all too apparent option both to the medical practitioner and to the patient. Palliation, in the sense of needing to absorb and respond to the meaning of that option for the patient, becomes even then a medical imperative. GPs and oncologists need whatever empathetic skills they may possess to understand and to support the person who is suddenly and unexpectedly facing the prospect of their demise. The "How long have I got Doc?" question may not be articulated, but it will be there and it needs a response. Curative treatments are sought and sometimes found, but - in the case of sarcoma - metastatic spread to the lungs signals the end of that phase and the beginning of a palliative treatment phase. Wherever the disease manifests itself the oncologists will seek to excise, nuke or poison the damaged tissue, but both the physicians and the patients will be aware that the many-headed Hydra can be disabled but never slain. There is palliation in the physicians and the patients working together to make a - putting it crudely - "cost/benefit" analysis of what may be gained at what cost. (Such a determination may also apply within the curative treatment phase: should one take neo-adjuvant chemotherapy now "just in case", or should one keep in on the shelf as a backup later if needed?) The duration of that palliative treatment phase can be long (in sarcoma up to twenty years or more) or it can be brief. The ending of that phase is not solely a medical determination to make. Physicians may decide they can do no more, but the patient may disagree. Particularly with the rare sarcomas the active patient will seek out information through on-line support groups about developing treatment options across the world, some that may offer new hope and some merely a false dawn. Contrariwise, it may be the patient who signals the end of palliative treatment. They have grown weary of endless bouts of chemotherapy, with all the attendant pain and perhaps diminishing returns, and may opt for a shorter but higher quality of life. Again, the skills of the medical profession in working alongside the patient in making that choice is an aspect of palliation. When the disease has such momentum that death is predictable or imminent, then palliative care in the sense of minimising suffering and maximising the opportunity for a 'good death' (howsoever defined that difficult phrase) enters its final phase. If throughout this journey both the medical professionals and the patients have been aligned in their knowledge and understanding of the disease, have co-operated in taking decisions jointly, have taken the time to explore the holistic meaning of life, disease and death, then palliation as a spectrum can offer healing if not cure. If, however, being palliative only begins when the patient is in clear 'periculo mortis' then it would perhaps be of little surprise that the medical profession cannot then meet the patient, where they are needed, in the ground of their being and their not-being. Competing interests: None declared |
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Angel J. Romero, Professor of Internal Medicine "Dr. Gustavo Aldereguía" Hospital. Ave 5 de septiembre, esq. 51A. Cienfuegos, Cuba. CP: 55 100, Francisco Olascoaga
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Dear Sir, We agree with Murray et al (1) that we must broaden the spectrum of palliative care to patients in the advanced stages of chronic illness, in whom we can establish in a relatively short time a drastic finale. In geriatric medicine terminal illness care is an important aspect, maintaining us busy and worried day by day.The elderly frequently suffer from chronic illness that requieres palliative care, which can be accompanied by the "geriatric syndromes", also known in Anglosaxon literature as "The Four Giants" (inmobility, falls, incontinence and mental failure)(2). These syndromes, in one form or another, and frequently in combination, are present in terminal elderly, thus complicating further the medical assistance of these patients (3). Usually, in the case of geriatric patients with these syndromes we can identify with precision the presence of a terminal illness and establish an approximate prognosis. However, this is not quite effortless in frailty elderly with chronic illness such heart failure, in which palliative care can be applied (4), but also some beneficial therapeutic actions which can further prolong their lives. Therefore, in concurrence with Murray et al, we find it neccessary to overcome therapeutic negligence in geriatric patients with chronic illness to destroy the paralytic prognosis, for there is always an elegible care plan. In ultimate instance, we can comply with the saying "caring is best when there´s no curing" which closely approach us to the humanity of Medicine. Yours faithfully, AJ Romero, F Olascoaga References: (1)Murray SA, Boyd K, Sheikh A. Palliative care in chronic illness. BMJ 2005; 330:611-612. (2)Romero AJ, Nieto R. Theorical frame from terminal care in the elderly. Geriátrika 2004; 20(5): 198-205. (3) Romero AJ. Síndromes geriátricos en el paciente anciano terminal. Geriatrianet.com 2005; 7(1): 2-10. http://www.geriatrianet.com. (4)Stewart S, Mc Murray JJV. Palliative care for heart failure. BMJ 2002; 325: 915-916. Competing interests: None declared |
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Patrick T White, Senior Lecturer in General Practice and Primary Care Department of General Practice and Primary Care, King's College London, SE11 6SP
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Murray et al draw welcome attention to the need to address the end of life in the care of people with advanced non-malignant chronic illness.(1) In advanced non-malignant chronic illness the proximity of death and the likely inadequacy of treatment to prevent it change the circumstances of the illness significantly. However accurate prognosis may be impossible and that also changes the circumstances. Although the doctor may know that death is approaching (and the patient may know so too) the circumstances demand planning for a stage of life that may continue for a year or more. In heart failure for example, even with a high B-type natriuretic peptide result (see report in the same issue of the BMJ), patients cannot be given a prognosis of less than two years with adequate reliability.(2) Two year survival in COPD patients with severe disease is between 50 and 64%.(3;4) Murray et al are right to warn against a paralysis of clinical decision making, but the inaccuracy of prognosis in these diseases presents complex challenges. Planning specifically for death in advanced chronic disease may seem rather a rather limited approach when rich possibilities still remain for the patient. Murray and colleagues appear to be using the term end of life as a euphemism for death, as it is widely used throughout medicine. But the context of their editorial demands a broader and deeper understanding of this term. Approaching the end of life has implications that may be distinct from the implications of imminent death. These include the need to consider symptom management in preference to disease control, information about the advanced stage of the disease, advance directives, and choice about place of care. These subjects are the business of palliative care but they need to be extended back into the care of advanced disease without entailing for the patient and the patient’s family the perceived finality of palliative and hospice care. Much has been learnt about the attributes of a good death and this learning should be extended to that stage in advanced disease that precedes dying.(5) Lynn and colleagaues in Washington have proposed seven promises that should characterise care at the end of life.(6) These promises provide a suitable template for the end of life at the stage before death becomes imminent. In the research and development of our understanding about the end of life in advanced chronic disease it is now essential to learn from patients what their needs are and how they should be met. These needs are likely to including talking about the end of life without necessarily preparing for imminent death. Yours faithfully Patrick White patrick.white@kcl.ac.uk References (1) Murray SA, Boyd K, Sheikh A. Palliative care in chronic illness. BMJ 2005 Mar 19;330(7492):611-2. (2) Doust JA, Pietrzak E, Dobson A, Glasziou P. How well does B-type natriuretic peptide predict death and cardiac events in patients with heart failure: systematic review. BMJ 2005 Mar 19;330(7492):625. (3) Connors-AF J, Dawson NV, Thomas C, Harrell-FE J, Desbiens N, Fulkerson WJ, et al. Outcomes following acute exacerbation of severe chronic obstructive lung disease. The SUPPORT investigators (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments). Am J Respir Crit Care Med 1996 Oct;154(4 Pt 1):959-67. (4) Almagro P, Calbo E, Ochoa de EA, Barreiro B, Quintana S, Heredia JL, et al. Mortality after hospitalization for COPD. Chest 2002 May;121(5):1441-8. (5) Steinhauser KE, Clipp EC, McNeilly M, Christakis NA, McIntyre LM, Tulsky JA. In search of a Good Death: Observations of Patients, Families, and Providers. Annals of Internal Medicine 2002;132(10):825-32. (6) Lynn J, Schuster JL, Kabcenell A. Improving Care for the End of Life; A Sourcebook for Health Care Managers and Clinicians. 1-408. 2000. Oxford, Oxford University Press. Competing interests: None declared |
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