4 ideas for better integration of palliative care in medicine

Medicine as practiced today has lost its acceptance of the finite nature of human life and this is leading to negative consequences for elderly patients with multiple health problems, argues physician and nurse palliative care experts a Health Affairs commentary.

With the Institutes of Medicine (IOM) set to publish as new report on end-of-life care at the end of June, Charles F. von Gunten, M.D., an NIH investigator, professor and provost at The Institute for Palliative Medicine at San Diego Hospice, an affiliate of the University of California, San Diego, University of San Diego and San Diego State University, as well as the editor-in-chief of the Journal of Palliative Medicine, teamed with Betty Ferrell, Ph.D., M.A.,FAAN, FPCN, director of Nursing Research & Education and a Professor at the City of Hope Medical Center in Duarte, California, to offer their joint perspective on the harm caused by a lack of integration of palliative care in medicine.

According to Dr. von Gunten and Ferrell, in the past half of the century, the approach to treating the elderly changed as doctors began “applying the scientific method to human illness, in the hope of deconstructing the process of getting old and dying into component parts that could be addressed.” Moving away from the recognition that aging and eventually dying is inevitable, has meant that we now aggressively try to cure each and every medical problem of advanced old age without looking at the larger picture of whether what is being done makes sense for the individual patient and his or her family.

The solution, they argue, will not be achieved by simply trying to insert elements of palliative care into the current approach to delivering healthcare. Rather, the system for how new physicians and nurses are trained needs to fundamentally change.

“Clinicians are developed by apprenticeship; they learn by doing,” they write. “Consequently, meaningful changes in clinician behavior with regard to palliative care will not be achieved unless such clinicians observe the desired approaches modeled by others that they respect, then practice under supervision, and are rewarded when they so practice.”

In the article, Dr. von Gunten and Ferrell highlight several steps that could be taken to change the current standard approach to care for the elderly to a more sensible one that incorporates palliative care at all points in the healthcare continuum for elderly patients with multiple serious and chronic conditiosn. Four are especially relevant for healthcare system leaders and hospitals. They are:

1. Provide structured mentoring of nurses new to palliative care.
2. Make palliative care the responsibility of all physicians, not just specialists.
3. Make extensive continuing education in palliative care required for physician and nurses already in practice.
4. At teaching hospitals, provide opportunities for medical students to gain immediate clinical experience in applying what some medical schools now teach about death and dying in courses during the preclinical years.