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Integrating palliative medicine into an oncology practice

Palliative care is the total care of patients whose illnesses are not responsive to curative treatment and whose health is deteriorating progressively and rapidly toward death. The aim of palliative care is the relief of symptoms, the maintenance of the best possible quality of life (QOL) for the patient, and support for the family before and after the patient’s death.1 A part of palliative care is end-of-life care; however, palliative care is much broader, including collaborative care for patients receiving active antitumor therapy. Palliative medicine is the medical component of palliative care1,2— essentially, the science of symptom management. Oncology is the study of the biology and management of malignancies, and since its inception, it has had a disease-oriented approach to care. The evolution of modern oncology has been breathtaking. These developments have been the fruit of extensive research in human pathophysiology and tumor biology. The concept of disease as an “experience” has been altered to disease as a “lesion” causing illness or disability. The language of oncology is, by necessity, cancer-oriented. Tumors regress or progress, and responses are seen in terms of relative tumor burden. In addition, death is seen as the ultimate defeat and dying the result of less than optimal management rather than as a natural part of life. The first hospice (from the Latin hospitium, meaning welcoming inn or guest chambers) occurred in the 4th century and was established by Era Fabiola, a Roman matron.3 During the crusades and through the Middle Ages, monasteries carried the burden of caring for the sick and dying. At the time, hospitals were frequently unwilling to admit the dying. In the 17th century, a hospice specifically for care of the dying was developed in Lyon, France, under the direction of Mme. Jeanne Garnier. Her influence led to the foundation of six other establishments for the care of the dying between 1874, in Paris, and 1899, in New York. The Kaiserswerth, the first Protestant hospice, was founded in Germany in 1863, and St Joseph’s of Dublin was established in 1879.3 Cicely Saunders, the founder of St. Christopher’s Hospice in London, ushered in the modern era of palliative care by combining compassionate care, astute clinical observation, and research. She and Robert Twycross accomplished the first trial in palliative medicine, a double-blind controlled study comparing morphine and diamorphine for cancer pain.3 Clinical studies in a vast array of symptoms have expanded the discipline to include psychosocial, spiritual, and QOL research. Palliative medicine and hospice developed as a protest against the neglect of the experience of disease.3 It was a reaction to positivist, reductionist, technologically centered care—i.e., tumor management rather than patient management. In the United States, the movement evolved