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Peter Lawlor, MB
Consultant Regional Palliative Care Program
The steady flow of European and other
international visitors to the Edmonton Program has prompted
many queries concerning differences in the way palliative
medicine is practiced in different centres. Furthermore, one
doesn't have to cross the pond (Atlantic) to discover striking
differences in practice patterns: significant differences
exist in the practice of palliative medicine across Canada.
Some of these differences are more apparent clinically and
further exploration of the underlying factors is warranted.
Transatlantic differences in the practice
of palliative medicine have been documented [1]. One of the
biggest errors made in comparing practices, research studies
and other epidemiological data such as some of the outcome
measures, is failure to appreciate the biases that operate
in the selection of study samples. Many of the research studies
that have emanated from the Edmonton program were conducted
on a study sample of patients referred to a tertiary palliative
care unit, reflecting poorer prognosis in terms of symptom
management, particularly in relation to pain control. This
parameter has been recognized in the Edmonton Staging System[2],
which is now quoted in most of the Edmonton studies. A high
percentage of patients admitted to the tertiary level palliative
care unit are classified as Stage III (poorer prognosis for
pain control), indicating that they have evidence of one or
more of the following: predominantly incidental pain, neuropathic
pain, opioid tolerance, somatization or depression, or a history
of alcohol or drug abuse. Hence, much of the studies and reports
concerning opioid toxicity and opioid rotation relate to a
relatively select population that is at greater risk of opioid
toxicity. Therefore, there is a great need to appreciate the
sociodemographic characteristics of our study populations
when we attempt to conduct practice comparisons between centres
at both a national and international level.
The traditional hospice model grew
out of a recognized need on the part of the terminally ill
and a willingness and desire to meet their needs in a compassionate
and caring way. In addition, there was a sense that the conventional
medical model was inadequate in meeting the needs of these
patients and their families. As a result there was a tendency
to reject the conventional medical model on the grounds that
it was primarily cure driven, invasive, cold, and excessively
technical. This historical dichotomy has changed with the
emergence of palliative medicine as a specialty with its own
knowledge base and philosophy. However, it is possible or
even probable the remnants of the traditional dichotomy still
persist and to some extent account for the practice differences
in various centres [4].
Other important reasons for practice
differences include cultural influence, fiscal constraints,
administrative and legal factors including drug availability.
Further exploration of these issues extends beyond the scope
of this editorial.
Where can we find some common ground?
Clearly, we all share the ultimate goal of patient comfort.
In addition, there are four objectives which we can share
in the pursuit of this goal.
- We can all share the challenge
to further develop evidence based palliative medicine. Pursuit
of evidence based practice can help bridge the philosophical
gap between therapeutic nihilism on the one hand, and on
the other hand, the imposition of high burden interventions
that contribute little to patient comfort. Our evidence
based practice must promote the use of validated outcome
measures [3] that incorporate the existential as well as
other demains.
- Informed decision-making at the
end of life requires the existence of structured and efficacious
patient education programs. The increased use of the internet
by our patients and their families carries the risks that
such vulnerable people constitute easy prey for unscrupulous
peddlers who pose uncensored advertisements in a multitude
of web sites. This presents an example of where we share
a communal duty to educate our patients in relation to this
risk.
- The ethical principle of respecting
patient autonomy is a shared core objective. Respect for
cultural differences is implicit in relation to this principle
and ironically might contribute to the exposition of practice
differences between centres.
- One of the most difficult, yet
most important challenges is to foster an openness to change
in our practices.
In conclusion, therefore, there are many
reasons for differences in practices in different centres. Primarily,
there exists an apparent difference in the frequency or intensity
of certain practices based on selection biases in study patient
populations. The historical remnants of the dichotomy between
the traditional hospice care and the conventional medical model
would appear to have a significant impact on practice differences.
Our common ground lies with the challenge to further develop
evidence-based palliative medicine which in essence will serve
to educate all palliative care practitioners. In addition, more
extensive patient education programs will facilitate informed
decision-making on the part of patients and their families.
The ethical principle of respecting patient autonomy should
be upheld in the decision making process concerning our various
therapeutic interventions. The pursuit of these "common
ground" objectives should assist us greatly in attaining
the ultimate goal of patient comfort. This will also facilitate
the development of care models that are evidence-based, holistic,
acceptable to patients and incorporate the empowering influence
of patient education. Finally, our common ground challenge also
includes a willingness to change our practices in accordance
with the weight of available evidence. Our models of care should
therefore be dynamic as opposed to static. Increased similarity
between our practices might occur as a result of pursuing these
objectives. The dynamic paradigm and sociodemographic differences
will prevent absolute similarity, which is arguably an unnecessary
or unreasonable goal.
References
- Sherry K, Bruera E, Welsh J. Training
abroad: a worthwhile experience. Palliative Medicine 1997;
11:319-320.
- Bruera E, Schoeller T, Wenk R,
et al. A prospective multi-center assessment of the Edmonton
Staging System for cancer pain. J Pain Symptom Manage 1995;
10(5):348-355.
- Hearn J, Higginson IJ. Outcome
measures in palliative care for advanced cancer patients:
a review. Journal of Public Health Medicine (1997) 19, 2,
193-199.
- Colburn K. Despite the continuum
of care, is hospice terminal? Am J of Hospice and Palliat
Care 1998; 15(2):71-73.
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