Blog Opens Window Into the World of Palliative Medicine

Colin T. Son

Disclosures

October 21, 2008

Drs. Drew Rosielle and Christian Sinclair see parts of life that few do: They practice palliative medicine, and they approach it with courage and compassion. They also help other healthcare professionals who treat patients at the end of life by reviewing relevant research and discussing hot topics at their blog, Pallimed . Along with their nurse blog partner, Thomas Quinn, Drs. Rosielle and Sinclair manage to make accessible a medical specialty that is often confusing and even frightening.

In a recent conversation, they laid out the basics of palliative medicine and discussed why they practice it and why they write about it.

Colin Son: Let's start with something simple: Can you define palliative medicine?

Christian Sinclair: Palliative medicine is a medical specialty dedicated to good symptom control for patients with life-threatening illness regardless of the goals of care (curative, restorative, comfort). In addition to symptom control, palliative medicine specializes in communication and the psychosocial support for patients and their families. Some wonder about the difference between palliative care and palliative medicine. Palliative medicine is a more narrow description highlighting the role of the physician, whereas palliative care involves multiple disciplines. Hospice is a type of palliative medicine, as palliative medicine can be involved much further upstream from acute end-of-life issues.

Pallimed hosts Grand Rounds
October 21, 2008

Colin Son: Okay, indulge the readers (and myself), and explain when and how each of you got attracted to palliative medicine?

Drew Rosielle: I am not entirely sure. It started in medical school -- I had not heard of palliative care but found myself with an interest in end-of-life care and created for myself a month-long hospice rotation, which I loved. I toyed with doing geriatrics, oncology, and even critical care during my medicine residency but realized my real interest in those was because I wanted to take care of patients who were dying. I was lucky enough to have a good mentor who convinced me that palliative care was a viable career option, as that wasn't really apparent where I did my residency.

I don't have great insight into why I like caring for dying patients -- I just do, and I find it tremendously rewarding. I consider myself lucky all the time that someone actually pays me to do what I do. What I can say is that when I was in residency, what I really enjoyed, really found personally meaningful, were the rare times that I could sit down with my patients and talk with them about what was going on, about the future, what they were afraid of, about the choices I was facing, etc. That, and not choosing the right antibiotics for community-acquired pneumonia, or pushing a patient's Hgb A1c from 8 to 7, etc., felt like good work to me.

Christian Sinclair: For me it was during my second year of internal medicine residency, enjoying the acuity of my ICU/CCU rotations, but also getting somewhat demoralized that I had technical skills and knowledge to ward off disease, but I was realizing that despite all my efforts, I was never being thanked by patients or families for my role.

I know this sounds somewhat selfish, but bear with me. The same week I had this demoralizing thought, I had an intense family conference in the CCU about the goals of care for a dying man. The family got angry, sad, but at the end thanked me for helping them over 90 minutes to realize that the patriarch of the family was dying and not just "sick." From that moment on, I asked my peers and attendings about caring for dying people in the hospital and how we identify dying patients and have honest conversations about outcomes, goals, and values. I was referred to the local hospice medical director and went on to do a palliative medicine fellowship.

Thomas Quinn: I became interested in oncology nursing through a mentor, Joan Piemme, an early leader in oncology nursing. That was still in the days when most people who had cancer died of cancer in a relatively short period of time. Chemotherapy and radiation therapy were quite toxic, and many of the supportive care agents we take for granted today weren't available yet. So, I developed an early interest in symptom management, end-of-life care, and quality of life. Hospice was a new concept, and "palliative care" was not yet in our lexicon, but it just seemed logical, natural even, to be interested in comfort care for both patients receiving cancer treatments and those with progressive and advanced disease.

Colin Son: Pallimed seems to have started as a venue to post on hospice and palliative medicine literature for palliative medicine professionals. Has the blog evolved at all over the years?

Christian Sinclair: In June 2005, Drew, as the founder, wanted a place to post interesting articles in non-core palliative medicine journals for his own reference and for maybe a few people that may be interested in the academic side of palliative medicine. The initial goal for the blog was very small in scope. But he was onto something amazing, since sharing good articles is usually done among your local peers, not on an international level. As a new field, we are still building our evidence base, so disseminating this information to other providers using blogs as a new form of collaboration was really an experiment on his part.

I stumbled across the blog while doing a Web search and immediately saw it as a great resource for my clinical care. He was posting prolifically with over 90 posts in the first 4 months (during his palliative medicine fellowship). I posted a few comments and emailed him asking if I could help contribute with original posts. For whatever reason, I must have convinced him that I was a sane person, and in November I started posting.

Thomas was a frequent commenter and gave us tips on good articles. We thought the addition of a nurse practitioner's viewpoint would add some diversity, and we asked him to join in July of 2007. Drew and Thomas typically take an in-depth approach to articles, whereas I am usually blogging about news and broader topics applicable to our field.

Colin Son: Every once in a while you turn attention to the intersection of health policy and palliative medicine. What is going on in Washington right now concerning end-of-life healthcare?

Christian Sinclair: Obviously, cases like Terry Schiavo are going to be important for Pallimed to comment on, and this obviously affects policy and healthcare legislation. Often our approach is not to necessarily take sides, but to add some rational, logical understanding of the complex issues that palliative care professionals handle daily. For example, the recent legislation for legalizing physician-assisted suicide in Washington State has received little press nationally or in medical blogs, but this could have big implications for palliative medicine and all of medicine, so we feel it is our duty to help share this information so we get a well-informed medical community.

In addition, we act as another source for advocating for hospice-oriented legislation such as postponing the recently enacted Medicare Hospice Benefit rate cuts.

Colin Son: On October 21, 2008, Pallimed will not only highlight the latest in palliative medicine, but will also feature posts from other bloggers with Grand Rounds. Grand Rounds is the weekly compilation of favorite posts from writers across the medical blogosphere, offering a host of different perspectives on healthcare, disease, healing, and more.

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