In ancient cultures, physicians did not have central roles in caring for the dying. Physician skills were focused on caring for those for whom a cure was possible. From medieval times on through to the Reformation, religious organizations were important providers of care for the dying. The role of the physician remained peripheral. Much of the care of the dying through many centuries, including the ancient hospice movement, involved family and community members and those with nursing/religious training as the central figures in care.
In a world that now has embraced scientific medicine, the role of the physician as a skilled clinician has accelerated and the role of the physician as a care provider with capacities to relieve suffering in the seriously ill and dying has emerged.
Prominence of the role of the physician in care of the dying was heightened in the second half of the 19th century with the creation of sanatoriums and the realization that tuberculosis was an infectious disease. The result was institutionalization and medicalization of seriously ill and dying patients. The circle of care shifted to involve the physician as a central figure, often in a position of gatekeeping the role that family and community could or should play in care for these patients.
The role of the physician in palliative and end-of-life care is rooted in the genesis of the modern hospice movement. In the late 19th century, Christian-based residential care of the dying became prominent. With the development of the modern hospice movement some 30 years ago and the increasing focus on pain and symptom management, the role of the physician as a key skilled clinician in care of the dying has rapidly developed.
According to Lewis, sociologists describe three prevalent death typologies: traditional, modern, and late modern. “Traditional” is described as deaths from infectious diseases or trauma, where these rather sudden deaths evoke robust death rituals and the need to connect the dead person to the collective group from which they came. “Modern” is described as the cancer death, one that is managed by physicians and involves death in institutions. “Late modern” is described as death from chronic illnesses or degenerative diseases and a new focus on ways to search for meaning and quality of life during a long trajectory. Indeed, advances in life-prolonging medical knowledge over the last century, combined with the rise in illnesses with a longer period of morbidity before death such as cancer and heart disease, have resulted in a dying trajectory that can most appropriately be described as a phase of life. Comorbid conditions, complex syndromes, and medication regimens, as well as an aging population, have necessitated the development of physicians with adequate knowledge, attitudes, and skills to meet the demands of increasingly complex dying patients.
Thus, the role of the physician in palliative/end-of-life care very much mirrors the development of the modern death typology, the rise in scientific medicine, and the genesis of the modern hospice movement.
The Role of the Family Physician in Palliative Care
The essence of the physician–patient relationship makes family physicians ideally suited to provide palliative/end-of-life care. Cassell has said that this relationship is the very means to help relieve suffering. An in-depth understanding of suffering of those who are seriously ill, and responding to it, is a fundamental role of family medicine. When asked, patients consistently speak to the desire for continuity of care both in terms of the physician’s expertise and also in terms of maintaining the physician–patient relationship, as essential to their sense of nonabandonment at the end of life. They also describe the need for closure with the physician, with whom they have had an ongoing relationship. The family physician’s role allows him or her to be able to attend to the patient holistically, in the context of the patient’s family and friends, by virtue of his or her longstanding relationship with the patient. Family physicians have the capacity to stay available and involved in care in a way that is reassuring to patients and alleviates patient suffering. Patients repeatedly emphasize the importance of the role of a family physician with whom they have had close ties over the years, and for this role to continue through the palliative stages of life. The family physician is also well positioned to address the concerns of the patient’s loved ones and assist in coping with grief, as these persons are often patients in the physicians’ practice.
The Role of the Specialist Physician in Palliative Care
Although family physicians are ideally suited to roles in palliative/end-of-life care by virtue of their training and vocational calling—in essence, the “core business” of being a family physician—palliative/end-of-life care is not the exclusive focus of their practice. They need to be excellent providers of basic palliative care but not necessarily expert providers of palliative medicine. Expert providers of palliative medicine are needed as opinion leaders and experts in end-of-life care who have the breadth of skills to inform knowledge generation, acquisition, and translation. Thus, there is a need for physicians engaged in this pursuit full time and for physician experts who do so in relationship with academic medicine.
Palliative medicine meets the criteria of a specialty within the discipline of medicine. The area of practice for palliative medicine specialists encompasses practicing with knowledge of many different disease states and the ability to assess and manage a wide range of symptoms in physical, psychological, spiritual, and social realms. The physician specialist must be adept at dealing with ethical dilemmas, advanced care planning, decision making, family conflict, and issues regarding physician-assisted suicide and euthanasia.
The role of the expert palliative care physician can also be described in terms of a physician subspecialist. Palliative medicine is a subspecialty in the United States, Australia, New Zealand, the United Kingdom, Ireland, and multiple other European countries. Subspecialty status in medicine requires that an in-depth body of knowledge exists, that the area has identifiable competencies, that there is evidence of need for this status, and that there is adequate infrastructure, including professional organization and recognition, to sustain the specialty/subspecialty. Palliative medicine meets the criteria for subspecialty in Canada, and much like Australia, the United States, and the United Kingdom, this subspecialty designation can meet the standard for entry and eligibility from both family medicine and specialty colleges and boards.
The Role of the Physician and Models of Care
Family physicians express the wish to remain active in the care of their dying patients but find it challenging to address the complexity of physical and psychosocial issues at end of life. This is described as primarily the result of time and funding pressures, lack of education and experience, and lack of familiarity with the modern and postmodern dying trajectories. They also may experience difficulty in accessing interprofessional specialist resources to support them in providing comprehensive palliative home care. Sustainable models of palliative care that support optimal care and death at home can be achieved when family physicians work in collaborative, integrated ways with interprofessional specialist palliative medicine physicians and teams. Throughout the United Kingdom, the United States, Australia, Canada, and other countries, models of care that support family physicians through facilitated practice with specialists and enhanced care coordination through nurse case managers demonstrated improvement in all parameters of community-based care.
Specific Skills and Competencies
The field of palliative medicine is concerned with quality of life, value of life, and meaning of life. Healing requires competency in scientific diagnosis and treatment but also compassion as demonstrated through solidarity with the patient. Physicians who make an open-ended, long-term caring commitment to joint problem solving demonstrate the concept of nonabandonment in care. This is seen as the very essence of medical practice. Morrison and Meier articulate five broad areas of skills that form the core of palliative medicine: physician–patient communication; assessment and treatment of symptoms; psychosocial, spiritual, and bereavement care; and coordination of care. This involves defining practice standards, responsibility for educational development and implementation, research in partnership with the academy, and program and systems needs. The American Board of Hospice and Palliative Medicine describes roles for palliative medicine physicians that correspond well to Morrison’s and Meier’s categories. A compilation of these can be found in Table 46-1 .
| Physician Skills (Morrison & Meier, 2004) | Physician Roles (American Board of Hospice and Palliative Medicine [ABHPM]) |
|---|---|
| Patient–Physician Communication | Care for Patients |
|
|
| Assessment and Treatment of Pain and Other Symptoms | Care for Family Members
|
Psychosocial, Spiritual, and Bereavement Support
| Care for Self
|
| Coordination of Care | Care for the Team |
|
|
| Care for the Organization | |
|
Related posts:
Full access? Get Clinical Tree
