Clinical Review Recent advances

Palliative care

BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7260.555 (Published 02 September 2000) Cite this as: BMJ 2000;321:555
  1. J Andrew Billings, director (JBillings@partners.org)
  1. Palliative Care Service, Founders 600, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114-2698, USA

    Palliative care is defined as comprehensive, interdisciplinary care of patients and families facing a terminal illness, focusing primarily on comfort and support.1 Key aspects include meticulous symptom control; psychosocial and spiritual care; a personalised management plan that maximises patient-determined quality of life; family oriented care that extends through the time of bereavement; and delivery of coordinated services, especially in the home but also in hospital, extended care facilities, day care centres, and specialised units. In this article I introduce current concepts about palliative care and review advances in this subject over the past five years, highlighting developments of particular interest to generalists.

    Methods

    My choice of topics derives from my familiarity with patterns of medical practice, particularly in the United States;presentations at meetings; review of current textbooks; and monitoring of general medical journals, selected specialty journals on pain and cancer, and nine palliative care journals (see extra box on the BMJ ‘s website).

    Why the need for palliative care?

    Numerous recent studies confirm earlier observations that dying people and their families experience a wide range of unmet needs, while receiving very costly care.2 One large US study, SUPPORT, underscores many of these problems.3 This investigation enrolled patients who were admitted to an academic hospital with common, severe medical conditions and who had a median survival of six months. Considerable suffering and inappropriate use of resources were observed. Many patients died in pain or with high “symptom burdens.”4 Doctors proved no better than chance in judging whether their patients wanted cardiopulmonary resuscitation. Family members often experienced social and financial devastation—having to quit a job or suffering major losses of income or savings—because of the illness.

    Recent advances

    Better management of chronic cancer pain through thoughtful use of common analgesics, including opioids, and recognition that neuropathic pain requires additional treatment with anticonvulsants or tricyclic antidepressants

    Improved management …

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