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Palliative Care (Hospice Care)

by Dr Gordon Coates

I've been thinking quite a bit lately about the care of dying patients, and I decided to have a look at an article that I wrote on the subject nearly thirty years ago. Its title was "Palliative care: The modern concept".

Before reading further, I suggest that you display the earlier article by clicking on the link below (which is now the only address for reprints, the original supply having been exhausted some years ago).

Palliative care
The modern concept
Dr Gordon Coates. Palliative care. The modern concept. MJA 1982; 2(11): 503-504.
© Copyright 1982. The Medical Journal of Australia - reproduced with permission.

On reading this article again after so many years, I found a number of things about it rather interesting – but also somewhat disturbing...

Although it had gradually become clear, over the few decades prior to 1982, that the life of terminally ill patients could be enormously improved by following a model of care which had then recently become known as the Hospice / Palliative Care model, very few of the principles which underpinned that model of care were less than two thousand years old! Indeed, most of them were considerably older than that, having their roots firmly planted in the Hippocratic School of medicine, which grew up around the famous Greek physician, Hippocrates of Cos, during the late fifth and early fourth centuries BC.

Despite the age of those principles, and the general acceptance of their value in providing optimal terminal care, such care was by no means universally available in 1982. Indeed, many patients, during their final months (or sometimes years) of life, experienced very considerable pain most or all of the time.

In addition, such patients frequently suffered many other distresses, such as severe nausea; frequent vomiting; extreme constipation; decubitus ulcers; intractible cough; severe itch; very distressing breathlessness... and a variety of other eminently controllable, but nevertheless uncontrolled, discomforts.

Their distress was not limited to physical discomforts, either. The preparatory grief experienced by patients and their loved ones alike, and the terrible grief of bereavement, experienced by those left behind after the death of the patient, were not given much attention by most health care professionals in those days.

My colleagues and I were very hopeful, in the early 1980s, that things would improve greatly when the wonderful results being achieved, documented and disseminated by the pioneers of the Hospice / Palliative Care Movement – people like Dame Cicely Saunders, Dr Derek Doyle, Dr Robert Twycross, Dr Elisabeth Kübler-Ross, Dr Colin Murray Parkes, Dr Richard Lamerton and Dr Balfour Mount – became more widely known. However, I now wonder whether perhaps we were overly optimistic...

There have certainly been many improvements in the care of terminally ill patients, but I have also come across many cases in which terrible suffering has been greatly neglected. Even as I type these words – almost three decades after the article referred to above was published – many dying patients are suffering pain and other symptoms which really would not be at all difficult or expensive to relieve, as discussed in my series of articles about cancer pain written in 2011 (also available as a free ebook, entitled How Cancer Pain is Treated). In addition, many patients and their loved ones still receive relatively little support as they pass through the greatest grief most of us ever experience.

I would therefore like to suggest that, as you read the article, you ask yourself whether there is anything in it which could not reasonably be provided as a normal part of health care; and, for those things which you feel could be provided – whether they are, or are not, routinely being provided, to most or all of those people who need them, most or all of the time; and, if not – why not?

Of course, there have been many helpful developments in recent decades, and the dissemination of the principles of modern hospice / palliative care has continued. For example, in 1984, Dr Josefina Magno founded an organisation called the International Hospice Institute, which later became the International Association for Hospice and Palliative Care (IAHPC).

The IAHPC encourages all countries to develop their own palliative care models, based on their existing resources and environment, adapting concepts developed in other countries to their own situation. Dr Derek Doyle, a founding member of IAHPC, estimated in 2003 that Dr Magno had been instrumental in encouraging the establishment of "more than 8000 hospice and palliative services in more than 100 countries." [1]

Perhaps, therefore, it is no longer necessary to question whether more could be done to provide optimal care for dying patients and their loved ones. Or is it? You can probably guess what I think about that. But what do you think?


If you have any comments about the article referred to, or my thoughts upon re-reading it, please address them to hospice@wanterfall.com


For more free articles and ebooks by the same author, on a wide range of topics, visit http://www.wanterfall.com

[1] Newman, L. 2003, 'Josefina Bautista Magno', BMJ September 27, 2003; 327(7417): 753, Online (retrieved on 15 August 2010 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC200824/)

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