PALLIATIVE medicine is one of the fastest growing segments of medicine in the world today. It was accorded specialty status in the United Kingdom in 1987.
Long before doctors ever dreamed of being able to cure any patient, they saw their task as the relief of suffering. A 16th century aphorism comes to mind: “To cure sometimes, To relieve often, To comfort always.”
The word “palliative” is derived from the Latin word pallium, meaning cloak or cover. The Oxford English Dictionary defines the word “palliate” as “to mitigate, to alleviate, to lessen pain, to give temporary relief”. Thus, in palliative care, symptoms are “cloaked” with treatments whose primary aim is to promote patient care.
Hospice and palliative care is defined as a concept of care that provides coordinated medical, nursing and allied services for people who are terminally ill; delivered where possible in the environment of the patient’s choice, providing physical, psychological, emotional and spiritual support for patients and their kin.
The provision of hospice and palliative care includes grief and bereavement support for the family and other carers during the life of the patient, and continuing after death.
The World Health Organisation (WHO) defines palliative care as “the active total care of patients whose disease is not responsive to curative treatment.
Control of pain, of other symptoms, and of psychological, social, and spiritual problems is paramount. The goal of palliative care is achievement of the best possible quality of life for patients and families. Many aspects of palliative care are also applicable earlier in the course of the illness in conjunction with anti-cancer treatment.”
Essence of palliative care
Palliative care is planned, total and holistic care that:
·Provides relief from pain and other distressing symptoms
·Affirms life and regards dying as a normal process
·Intends neither to hasten nor to postpone death
·Integrates the psychological and spiritual aspects of patients care
·Offers a support system to help patients to live as actively as possible until death
·Offers a support system to help the family cope during the patient’s illness and in their own bereavement
Most physicians consider hospice care and palliative care to be synonymous.
The concept of palliative care arose out of the hospice movement in the 1960s when Dame Cicely Saunders opened St Christopher’s Hospice in London. Palliative care usually begins when a patient is diagnosed as in the terminal stages of a disease, which could generally mean a three- to six-month life expectancy.
The recent recognition that cancer patients and others (such as those with Motor Neuron Disease, Multiple Sclerosis, AIDS patients, etc) need symptom management throughout the course of their disease and not just in its terminal stages has changed the definition of palliative care.
Need for palliative care
It is required for many patients early in the course of the disease, sometimes from the time of diagnosis. It should not be associated only with terminal care. Palliative care should thus be integrated in a seamless way, with all other treatment modalities and services, to provide the best possible quality of life for the patient and their family.
WHO has been instrumental in introducing the principles and philosophy of palliative care into developing countries. It has served as a catalyst to develop policies and advance treatment strategies to benefit cancer patients and patients debilitated with pain.
Governments, NGOs, institutions and a strong network of individuals are pledging, starting or actively implementing cancer pain relief and palliative care according to established WHO principles.
The main reason for concentrating on palliative care rather than curative measures is the overwhelming need to alleviate suffering in an affordable way. Many developing nations cannot afford high tech cancer treatments. Also, practically 90% of the population in some countries do not seek medical help or health care until it is too late or the problem has reached epidemic proportions.
Although palliative care services began in the early 1990s in Malaysia, the service is mainly available in major towns. Hospices are now found in many states in the country, and the formation of palliative care units and teams by the Health Ministry has increased the services here.
The demand for hospice care is slowly but surely growing as Malaysians become increasingly aware of this service and welcome it gratefully. Palliative care services that are available today include:
·Palliative Care Units (in-patient) within hospitals
·Palliative Care home teams (run by government hospitals and private centers)
·Hospices (offer home care/day care/inpatient care or a combination of services)
Doctors have a dual responsibility to preserve life and to relieve suffering. The primary aim of palliative care is to minister and impart as much meaning and comfort as possible for the remainder of a patient’s life.
Although the primary strategy is symptom control and relief of the distress caused by the progression of disease, care is planned so that patients maintain control of decisions regarding their care, comfort and preparation for death. The ethics of palliative care are those of medicine in general, namely:
·Patient autonomy (respect for the patient as a person)
· Beneficence (do good)
·Non-malfeasance (minimise harm)
·Justice (fair use of available resources)
These cardinal principles need to be applied against the background of respect for life and acceptance of the ultimate inevitability of death.
In Dame Cicely Saunders’ eloquent words “The care of the dying demands all that we can do to enable patients to live until they die? includes the care of the family, the mind, and the spirit as well as the care of the body?
‘You matter because you are you. You matter to the last moment of your life, and we will do all we can, not only to help you die peacefully, but to live until you die.”
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