Dr. Eduardo Bruera. Professor
Division of Palliative Medicine
Dept. of Oncology
University of Alberta
Edmonton, Alberta

Modern palliative care evolved in the U.K. during the 1960's as a response to the unmet needs of the terminally ill and their families. The initially British Hospice movement soon expanded to the rest of the world. While most palliative care groups developed out of mainstream academic health care, during the last 10 years an increasing number of academic groups have focused on end of life research. As a result, there have been major advances in the assessment and management of physical and psychosocial symptoms of the terminally ill. These include the development of simple and reliable tools for the regular assessment of physical and psychosocial symptoms, new types and routes of opioids and antiemetics, new adjuvant analgesic drugs, and increasing evidence for the effectiveness of radiation therapy, antibiotics, hydration, oxygen, or blood tests in selected patient groups.

Some palliative care groups have rapidly adopted these innovations. While other groups have expressed concern that some of these interventions, particularly the most invasive ones, could blur or eliminate the palliative nature of care.

Many aspects of this debate are due to our lack of solid evidence on the role of different palliative interventions. For example, the ethical dilemma regarding artificial nutrition of the terminally ill was resolved by the findings of randomized, controlled trials showing no significant advantages for artificial nutrition on the effectiveness or toxicity of antineoplastic interventions or overall survival.

The current debate regarding the role of different diagnostic and therapeutic interventions will be greatly assisted by less emphasis on rhetoric and more emphasis on solid evidence generated by clinical research. The main outcomes of this research should be those required by the Palliative Care Community for decision making such as symptom control, psychosocial distress, quality of life and satisfaction with care. The patient population in these studies should be that of the terminally ill and their families so that the results can be applicable to their care. It is a major responsibility of the Palliative Care Community to ensure that this body of knowledge evolves.

The success of palliative care with patients, families and the overall community does no reside on any specific interventions, but rather, on its ability to address the physical and psychosocial needs of the terminally ill. An increased body of knowledge and changing interventions are the hallmark of vibrant and effective areas of health care. New and better diagnostic and therapeutic options can only assist the Palliative Care Community in better serving the terminally ill.