Prevent and Relieve Suffering: Professional Palliative Care

The development of a pain and palliative care service at the NIH deserves special notice. I'd like to put its development into the context of medical progress in general, and the evolution of professional palliative care in particular.

The prevention and relief of suffering have been important goals of medicine throughout the recorded history of health care. The development of the field of palliative care over the last 50 years is the contemporary manifestation of medical progress in meeting those goals. Never before in the history of medicine has there been more ability to relieve suffering and improve quality of life throughout the spectrum of illness. The development of a Pain and Palliative Care Service by Dr. Berger and her colleagues at the Warren Grant Magnuson Clinical Center at the National Institutes of Health represents a milestone in the professional development of palliative care in the United States. Just as in the other subspecialties of medicine and oncology, it is through the provision of subspecialist expertise that new knowledge is made practically available in the clinical setting. As Dr. Berger and her colleagues make explicit, palliative care expertise is as needed in a preeminent research center as it is other clinical settings in this country.

The advent of clinical palliative care at the NIH signals two important messages to the public and to the medical profession. First, it signals that there need not be conflict between the search for advances in curing disease and advances in providing comfort to the patient experiencing the disease and his or her family. Both are legitimate, and necessary, aims of scientific medicine. Any health care system striving for excellence must now acknowledge the importance of including expert and effective palliative care within its reach. Second, it signals that palliative care is a legitimate discipline, a discipline that employs the tools of modern clinical research to continue to develop new knowledge and more effective techniques for comfort care.

The development of academic palliative care have been slow but steady.[[1]] The first modern academic hospice, St. Christopher's Hospice, was developed by Dr. Cicely Saunders and opened in 1967. Its purpose was not just to care for those with advanced cancer but also to combine research and education with medical care in accord with the finest academic traditions. Those who studied with Dr. Saunders and her colleagues developed similar academic programs at Oxford University, McGill University, and in conjunction with Yale University. T. Declan Walsh developed the first academic palliative care service as part of a comprehensive cancer center in 1987 at the Cleveland Clinic. Other academic units and services in the United States followed. Now, many hospice programs and palliative care services in hospitals and health systems in the United States participate in the education of medical students, resident physicians, nursing students, and other health professionals.[[2]] Curricula on the core competencies in palliative care have been developed and broadly disseminated.[[3]][[4]] Certifying boards recognizing subspecialists in hospice and palliative medicine have been established both for physicians and for nurses.[[5]] There are seven subspecialty peer-reviewed journals serving the field. Chapters in general medical textbooks and subspecialty textbooks have been published. Fellowship programs are developing to train physicians who wish to subspecialize.[[6]]

For the oncologist this should be welcome news. Such professionalisation and subspecialization is the appropriate response to the expanding knowledge base in health care. Although oncologists need and use basic skills (primary palliative care), they will want to be able to turn to a subspecialist for consultation about difficult cases (secondary palliative care). There is also a need for tertiary palliative care where new knowledge is discovered and where clinicians are educated in the field. We should all be delighted to know that this level of care is now available in the research hospital of the NIH. It won't be long before every hospital and cancer center that claims comprehensive status will have a similar service for its physicians, patients, families, and staff.