For healthcare professionals only

Letters

Cancer isn't the only malignant disease

BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7344.1035 (Published 27 April 2002) Cite this as: BMJ 2002;324:1035

Palliative care can be useful in cardiovascular disease

  1. Richard H Sloan (medical{at}weld-hospice.org.uk), medical director
  1. Joseph Weld Hospice, Dorchester, Dorset DT1 2SL
  2. Brook House, Huntscott, Wootton Courtenay, Minehead TA24 8RR
  3. Accident and Emergency Department, Royal Lancaster Hospital, Lancaster, Lancashire LA1 4RP

    EDITOR—Moulder graphically illustrates the anguish of patients, professionals, and families when medical treatments have failed in end stage cardiovascular disease.1 In many respects, the same scenario existed with cancer until about 30 years ago. Doctors felt guilty that they didn't have anything else to offer. Patients and their families often sensed that they might be dying but suffered in silence. What changed to improve the lot for patients with cancer, and how could we learn from it?

    The modern palliative care movement, started in the late 1960s, highlighted the suffering of (mainly) patients with cancer and developed holistic strategies. Its success meant that it gradually became accepted as mainstream practice for patients in hospital or at home. No longer was cancer the taboo subject it was best not to talk about. Most patients eventually appreciated the opportunity to talk realistically about the likely course of their illness. Doctors realised that talk of specialist palliative care (hospice) services didn't necessarily frighten patients and often benefited them well before the final few days.

    Transferring this to end stage non-malignant disease has raised concerns. How do we know when the end stage has been reached? How do we detect the minority of patients who really would be frightened? Once the floodgates are opened to non-malignant disease how could hospice services possibly cope?

    I have worked in a hospice that has freely accepted patients with diseases other than cancer since opening eight years ago, and I do not believe that these patients' difficulties are particularly different from those successfully overcome in cancer. Prognosis is often difficult to gauge in malignant disease. Inoffensive questions can be posed to patients to find out how much or how little they want to know at any point. More resources for specialist palliative care would be required, but not necessarily beds: much can be achieved within existing healthcare structures by mainstream professionals with specialist palliative care support.

    Despite the continued advertising of the hospice's policy, relatively few patients with end stage cardiovascular disease are referred for assessment or advice. Only when mainstream healthcare professionals realise the similarities to cancer and feel confident in discussing things with patients will much of the mutual suffering be alleviated.

    References

    1. 1.

    Competent, compassionate terminal care should be given to everyone

    1. Lesley A M Evans, retired consultant physician in care of the elderly, Taunton.
    1. Joseph Weld Hospice, Dorchester, Dorset DT1 2SL
    2. Brook House, Huntscott, Wootton Courtenay, Minehead TA24 8RR
    3. Accident and Emergency Department, Royal Lancaster Hospital, Lancaster, Lancashire LA1 4RP

      EDITOR—With reference to the personal view by Moulder, I had hoped that those of us with a particular interest in terminal care in non-malignant conditions had succeeded in changing the attitude of our colleagues towards their management.1

      As a consultant in care of elderly people, I tried to adapt the principles of palliative care that I had learnt in hospices to the effective control of symptoms in end stage cardiac failure, peripheral vascular disease, chronic obstructive airways disease, degenerative neurological and rheumatological diseases, and the other conditions from which my patients were slowly dying. Such deaths are often far more unpleasant and distressing for the patient, the family, and the professional attendants than death from cancer. Yet we are not taught how to manage them.

      The same principles of management should apply, however, and the uncertain length of prognosis should never preclude the giving of appropriate and adequate medication to control distressing symptoms. End stage cardiac and respiratory failure usually respond well to very small doses of opiates, starting at 1 mg or 2 mg of oral morphine every four hours. I have had several patients referred by other physicians for terminal care who were soon established on a tiny dose of morphine and were symptomatically and functionally so greatly improved that they were able to be discharged home, where they continued to enjoy a reasonable quality of life for some considerable time.

      Patients with chronic non-malignant diseases should be treated with opiates if they need them, even for many years. They do not become addicted if the dose is titrated properly. The dose for very old and frail people will often need to be much smaller than the doses needed by patients with cancer, especially younger ones. The dose needs adjusting often and meticulously at first and any side effects such as constipation treated properly. This all takes time and requires frequent supervision, ideally by a consultant or general practitioner rather than an inexperienced junior who may err on the side of caution. Control of symptoms and a dignified death are just as important to the thousands of patients dying of degenerative and other so called non-malignant conditions in general hospital wards, or in nursing homes, or at home, as they are to the minority who receive hospice care.

      More of us are likely to die of cardiovascular, pulmonary, or neurological disease rather than cancer, and the teaching of students should take this into account. We need more teams in hospitals and the community that are dedicated to all palliative care, not just cancer.

      References

      1. 1.

      Terminal care should be discussed well in advance

      1. Marten C Howes (martenhowes{at}doctors.org.uk), specialist registrar in emergency medicine
      1. Joseph Weld Hospice, Dorchester, Dorset DT1 2SL
      2. Brook House, Huntscott, Wootton Courtenay, Minehead TA24 8RR
      3. Accident and Emergency Department, Royal Lancaster Hospital, Lancaster, Lancashire LA1 4RP

        EDITOR—Moulder's personal view discussed the management of patients with terminal vascular disease.1 agree that the terminal care of non-neoplastic conditions in Britain is often lacking, although respiratory physicians have to some extent addressed this matter in the management of end stage chronic obstructive pulmonary disease.2 3 disagree with the comment that unclear prognostic indicators mean that clinicians do not address death and dying. The prognosis for heart failure can be just as clear as that with patients with cancer (as referred to in the article), and an informed discussion is possible on the terminal care of patients with various other conditions—for example, AIDS, dementia, or liver disease3

        It is a source of great frustration to me and many of my colleagues in emergency specialties that proper discussion of interventions planned in the event of life threatening deterioration of end stage conditions has not occurred between patient, consultant, and near family, and recorded in the medical notes. The presentation of such patients to accident and emergency departments puts a considerable burden on emergency physicians, on call teams, and intensivists, to make decisions regarding the most appropriate treatment for these patients. These decisions are often hampered by unavailable case records, disagreement between family members, and disagreements among medical staff, none of whom is likely to be the patient's regular doctor. There are the problems of locating a suitable bed, discussing and documenting orders not to resuscitate, and caring for the distraught family, whose expectations of survival can be poorly informed and unrealistic. These issues should be addressed in a setting other than the busy, pressured atmosphere of accident and emergency or acute wards.

        Once such a discussion has taken place, a letter outlining the management plan in the event of deterioration to the point of near death should be copied to all involved in that patient's care, including general practitioners, local cooperative services covering general practices out of hours, accident and emergency, intensive treatment units, admissions wards, and a copy for the patient themselves, which could serve as a background to an advance directive. Timely planning of this sort is best for all concerned.

        Terminal care can be delivered in an accident and emergency department, but proper provision of community or hospice care, or hospital care in an appropriate setting, should be the aim for all patients according to their wishes and needs, not emergency admissions, diagnostic work ups, and aggressive treatments that are unlikely to change prognosis.

        References

        1. 1.
        2. 2.
        3. 3.
        4. 4.
        5. 5.
        View Abstract