The Art of Medicine at the End of Life

Colin T. Son, MD


October 06, 2009

There's a big, bright banner at the top of the Pallimed Website that announces, "Welcome First Time Visitors!"

It's an important introduction. Palliative care is an aspect of medicine that can be difficult to describe. It often conjures up strong images of end-of-life care, pain control, and hospice, but in many ways it is more than that.

The World Health Organization describes palliative care this way:

Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.

Pallimed is a group blog covering the evolving world of palliative care.

Pallimed hosts Grand Rounds
on October 6, 2009

Founded in 2005 by Drew Rosielle, MD, Pallimed offers best practices in palliative care based on reviews of current palliative-medicine, hospice-, and end-of-life research. Christian Sinclair, MD; Thomas Quinn, APRN; and Dr. Rosielle post most of the content, but they encourage reader comments and other contributions.

One certainly gets the sense that palliative care is an area of medicine that everyone involved in the delivery of patient care should be exposed to, but I know from experience that beyond trying to instill some sort of humanism into end-of-life situations, there was very little opportunity in medical school to witness palliative care. This is undoubtedly a reason why I'm attracted to Pallimed.

Tuning into Pallimed drops you right into the heat of what palliative-care providers are talking about and the issues that they confront. One example is a lengthy and detailed post about the evidence for feeding tubes in patients with end-stage dementia:

[S]urvival is poor - and clearly FT [feeding tubes] are commonly placed in dying patients. Until there's actually a well-designed, large, prospective study on FT we're really not going to know confidently if they impact survival; even if they do however this is further indication that (in advanced dementia) overall survival is terrible anyway. When I was a fellow I was a little obsessed about this and spent several months carefully combing through the data on survival in dementia & FT to 'figure it out.' I didn't, there is no definitive data, although pretty much any way it has been looked at no one has shown a survival benefit. My own conclusion is that if it's there, it's small, at least on a population level - there are probably some patients whose lives are dramatically shortened by FT placement, and some whose are greatly lengthened.

Another provocative post, Onsolis and FDA Opioid REMS: Is This the Future of Opioid Prescribing?, offers commentary on the US Food and Drug Administration's new Risk Evaluation and Mitigation Strategy (REMS) for powerful opioid pain medications:

So we can now add bureaucracy to the possible barriers to prescribing opioids. I am not sure how these steps reduce any risk with opioids, with overdose and diversion being the two big ones I would assume the FDA is trying to reduce. I think the goal is laudable and one I think the hospice and palliative care community has not given the full attention I think it deserves, but the method to me just seems to add red tape without effect. Has the FDA tested this in opioids in a RCT to see if it reduces any risks? It would be nice to see an evidence based approach to this important problem. Thank goodness the law that gave the FDA this power also stipulates review of the REMS program for each drug at 18 months, 3 years and 7 years.

Physicians, nurses, pharmacists, and social workers who manage palliative-care patients should find Pallimed an incredible resource. For the rest of us with limited exposure to palliative care, Pallimed may offer the best tool for learning about this aspect of medicine.

This week a few more people will get a healthy exposure to palliative medicine at Pallimed when it plays host to Grand Rounds, the best of online medical writing.


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