The recent and rapidly growing emphasis on optimizing quality of life throughout the course of chronic progressive illness reflects a rededication to humanistic principles in the health care professions. This modern movement can be traced to several converging initiatives in the latter decades of the 20th century that recognized that “good medicine” requires attention to the burden of disease for the patient and family in addition to disease-specific, biomedically focused treatments. The global hospice movement, the World Health Organization (WHO) cancer pain relief program, and the worldwide emergence of pain medicine as a differentiated specialty that recognizes the importance of interdisciplinary care for complex pain-related disorders all contributed to this still-evolving shift in thinking. In economically developed nations, a major force driving this paradigm change is the substantial economic impact of contemporary medical and public health efforts. Such efforts have increased not only life expectancy but also costs of care to the point where such costs consume a significant and rising portion of the gross domestic product. For example, advancing rates of hospitalization during progressive illness result in almost a third of the total $100 billion U.S. Medicare budget spent on health care costs in the last year of life, and one-sixth of the total spent in the last 2 months of life, even though significant deficiencies continue to be documented for outcomes such as pain control or adherence to advance directives (1,2). These topics are described in greater detail in other chapters of this volume, such as Chapter 28 by Gallagher and Fishman on the emergence of pain medicine as a specialty, and Chapter 29 by Loeser on socioeconomic factors in pain management.

Hygiene and medical technology have together not only prolonged life, but extended the process of dying. In the face of accumulated comorbid conditions, the burdens of illness are numerous and, without due attention and skillful intervention, these can lead to tremendous unnecessary suffering and despair, and financial hardship. These burdens increase with advancing age, as described by Helme and Fleming in the preceding chapter on the treatment of pain in older people. Optimizing quality of life for the patient and family throughout the entire disease trajectory, including bereavement, has become the province of the current palliative care movement. Notwithstanding the limited curative and disease-modifying therapies available at the time, in retrospect, Sir William Osler was uncannily prescient when he stated a century ago, “Care more particularly for the individual patient than for the special features of the disease. To accept a great group of maladies, against which we have never had and can scarcely ever hope to have curative measures, makes some men as sensitive as though we were ourselves responsible for their existence. These very cases are ‘rocks of offence’ to many good fellows whose moral decline dates from the rash promise to cure. We work by wit and not by witchcraft, and while patients have our tenderest care, and we must do what is best for the relief of their sufferings, we should not bring the art of medicine into disrepute by quack-like promises to heal, or by wire-drawn attempts at cure, adding ‘continuate and inexorable maladies’” (3).

Although the substance of the present chapter is relevant across medical disciplines and specialties, it is intended to capture the collective wisdom and imagination of anesthesiologists in particular. Anesthesiologists—especially those with additional training and credentials in pain management—may be called upon as consultants to help relieve pain and related forms of suffering. Far too few anesthesiologists, however, have entered palliative care practice (including hospice as an end-of-life domain of palliative care) as integrated members of a palliative care or hospice team. This gap is unfortunate because the knowledge and skills acquired during anesthesiology postgraduate training and clinical practice well prepare anesthesiologists to relieve many of the burdens associated with advanced illness. The unique combination of expertise in neural blockade, analgesic pharmacology, and sedation (based on experience and skill in safe, effective, goal-directed drug titration that is a hallmark of anesthesiology) and the carefully cultivated ability to create an environment of calm among seriously ill, anxious, and agitated patients and their families, together create an invaluable foundation from which to contribute to palliative care teams (4).