MULTIDISCIPLINARY CARE OF THE TERMINALLY ILL PATIENT - 06/09/11

As defined by the World Health Organization (WHO), palliative care involves the “active, total” care of patients with attention to their physical, emotional, and spiritual needs.<sup>41 World Health Organization Cancer Pain—Past, Present, Future J Pain Symptom Management 1996 ; 65-72

Haga clic aquí para ir a la sección de Referencias</sup> Palliative care affirms life and regards dying as a normal process, neither hastening nor postponing death. Traditionally, palliative care was conceived as being synonymous with end-of-life or hospice care. It is now recognized that the concepts of palliative care are compatible with providing curative treatments. In particular, the assessment and treatment of pain and other symptoms and care to optimize physical and emotional functioning are critical to improving overall well being and medical outcomes of patients, in any stage of illness.

Advances in technology and medical care have changed the trajectory of dying. In the past, death tended to be quick, often sudden, and not a long drawn-out affair. Today, death frequently is associated with a progressive debilitating terminal phase. A typical hospital death often occurs when the patient is at the most ill point of his or her disease trajectory and is dying from multiple organ failure, metabolic abnormalities, blood dyscrasias, and exhaustion. Pain may be one among many distressing symptoms for the individual to cope with, making assessment, management, and monitoring more complex. A multidisciplinary team approach to assessment of the needs of the patient and family is desirable and necessary for optimal outcome.

A recent landmark study, the “Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatment (SUPPORT),” documented the limitations of current end-of-life care in major hospitals in the United States. This study showed that physicians were unaware of patient preferences for no resuscitation and that they often wrote “Do not resuscitate” orders only within 2 days of death; that patients often spent their last days in an ICU; and that at least 50% of patients had severe pain before death. A detailed intervention designed to improve physician–patient communication regarding preferences for end-of-life care and to educate physicians on a continuing basis regarding patients' poor prognosis failed to improve these outcomes.<sup>37 SUPPORT Investigational Group Controlled trial to improve care for seriously ill patients JAMA 1995 ;  274 : 1591-1598

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Many explanations have been provided for the poor end-of-life care documented in the SUPPORT study, but perhaps the most significant are the overall societal ambivalence regarding death and dying and the poor education of physicians in palliative and hospice medicine.<sup>2 Billingsley M. Does mandating continuing education mandate competence? Nursing Connections 1998 ;  11 : 25-27

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The following list includes core competencies required of physicians to practice high-quality palliative and end-of-life care:<sup>2 Blank L.L., Cassel C.K., Foley K.M. American Board of Internal Medicine End of Life Patient Care Project  : American Board of Internal Medicine (1996). 

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The ability to work in a multidisciplinary team is a major core competency. The patient and medical staff often expect the physician to lead the team, but he or she must do so in a collegial fashion, respecting the expertise of nurses, social workers, clergy, and other allied health professionals.

Although there is a growing recognition of the benefits to be derived by implementation of a team approach to the provision of end-of-life care, existing health care systems do not always foster team development. Traditionally, physicians have not been trained to collaborate in a team approach, and, in many instances, have not been exposed extensively in their hospital training to hospice or home care issues.<sup>10 Coyle N. Interdisciplinary collaboration in hospital palliative care: Chimera or goal? Palliat Med 1997 ;  11 : 265-266  [cross-ref]

Haga clic aquí para ir a la sección de Referencias</sup> An awareness by physicians of the key components of palliative care is essential in the process of optimizing health care for patients who are nearing the end of life. Although many patients benefit from the input of a specialty-trained palliative care physician, it is vital that the primary physician, regardless of his or her area of specialty practice, has an understanding of the issues involved in the care of this group of patients.