Recent advances: Palliative care

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Abstract
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 of other symptoms—gastrointestinal symptoms, dyspnoea, confusional states, and depression Increasing use of advance care planning to preserve patient autonomy and choice around the time of death, when the capacity to make decisions may be impaired Improved understanding of the role of artificial feeding and hydration for dying people, especially those with neurological impairments. General consensus on the acceptability of withholding or withdrawing life sustaining supports and of the rule of double effect, which permits use of opioids and sedatives to relieve suffering even if death may ensue Doctors' prognostic estimates are important to both patients and clinicians in making good decisions about appropriate terminal care. Recent studies indicate not only that doctors seem reluctant to speak to patients about death, but also that they are inaccurate and systematically optimistic about the future, thus delaying timely sharing of information and referral to appropriate palliative care services.5 Compared with conventional care, palliative care seems to improve patient and family satisfaction and the identification of their needs while reducing overall costs through decreased use of acute hospital care.6 Studies of medical school curriculums, postgraduate physician training programmes,7 and standard medical textbooks8 reveal disappointingly little attention to end of life issues. However, numerous palliative care journals, textbooks, courses, and websites are now available to help clinicians in providing good terminal care (see extra box on the BMJ ‘s website for details). Increasing evidence confirms that “bedside manner” (communication and psychosocial skills) for terminal care can be taught.9