Palliative Care and the Lost Art of Communication

The following is Part 2 in a series about end-of-life care. For Part 1, see here. This article addresses my own experience on a Palliative Medicine elective in my fourth year of medical school.

Despite the growing number of U.S. hospitals with Palliative Care teams, there remains a real lack of understanding about the benefit that specialized Palliative Care providers can bring for patients with advanced illness. This form of care is especially valuable in patients with end-stage illness (and has even been shown to extend life by several months), but it can also help any patient at any stage of illness (regardless of prognosis). Indeed, even prescribing an NSAID for headache can be considered a form of palliation. The focus is about improving quality of life now instead of later.

Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2941669/pdf/jpm.2008.0053.pdf

This relatively new field aims to fulfill three essential roles:

1. Symptom control and relief for patients, such as shortness of breath, pain, poor appetite, nausea, constipation
2. Communication with the patient and family about what makes life meaningful for the patient and what amount of pain or discomfort the patient is willing to go through to achieve it
3. Care coordination between the patient’s often numerous specialists and consultants, so that all are working toward the same coordinated effort.

I have seen Palliative Care teams work magic. I have seen distressed patients and families, struggling to cope with a new terminal diagnosis, or an advancement of an old diagnosis, or just difficult-to-treat pain symptoms. The team (usually comprised of at least an MD, an NP, and a social worker) works passionately and tirelessly to understand the fears and concerns of the patient, navigate family dynamics, and address miscommunications between the patient and the primary medical teams.

My attending once said to me, before embarking on that day’s rounds, “Pay attention to how bad we all are at communication.” And he was right. Doctors, nurses, patients, family members: nobody said what they meant, everybody made assumptions about what the other meant, and much was left unsaid.

If medicine is supposed to be an art, then Palliative Care practitioners are nothing short of virtuosos. For all the lip service rendered to “patient-centered care” in the medical world, Palliative Care providers actually center their practice around the patient. It was the first time that seeing the “whole patient” was modeled in practice for me (versus my experience on other services, where patients were simply the sum of their medical histories). For once, detailed social and family histories were just as important – if not more important – and it completely guided our thinking and planning as we worked with the patient.

I would love to see more of this kind of training in medical school and beyond. Every health care provider who works with patients needs to be able to see healthcare from the patient’s point of view – a perspective that rarely is reinforced outside of the classroom.