30 Mar Palliative Medicine and its Role in Patient-Centered Health Care
A BRIEF HISTORY OF PALLIATIVE MEDICINE
Palliative Care in the 1840’s
Up until the beginning of the 20th century almost all medical treatment was palliative, with few interventions capable of cure and only some that provided a degree of comfort. Few people lived long enough to develop diseases of aging. There was no anesthesia for surgical procedures and no medications to fight infection. “Childbed fever” took the lives of many women until doctors and nurses saw the connection between hand washing and infection prevention in the 1840’s, then it took another 20 years for Joseph Lister to use carbolic acid successfully to clean wounds and sterilize equipment.
Palliative Care in the Late 19th Century
Starting in the late 19th century, new and potentially curative options began to emerge. The 1890’s brought the tetanus vaccinations, x-rays, and aspirin. In 1906 vitamins were discovered and with treating deficiencies, diseases like scurvy and rickets became curable. Insulin was isolated and extracted in the 1920s and the prognosis for type one diabetes changed from a lethal diagnosis to a treatable condition. Penicillin came into use in 1930s. Diagnostic tools grew to include electrocardiograms, electroencephalograms, CT scans, ultrasound, magnetic resonance imaging, and subspecialties emerged: cardiology, endocrinology, gastroenterology, oncology, neurology, psychiatry and pulmonology,
By the 1950’s the lives of people with kidney failure could be extended with use of an artificial kidney in the form of a dialysis machine. A heart-lung machine invented in the same decade made it possible to stop and restart the heart so that open heart surgeries could be performed. CPR began to be administered routinely in the 1960’s. When CPR was combined with electroshocks (defibrillation) and adrenaline, hearts that were not beating could be restarted and kept beating with implanted pacemakers. Human organ transplants also became reality: the first kidney transplant between identical twins in 1954; lung and liver transplants in 1963; and the first human to human heart transplant in 1967.
Palliative Medicine Introduced
In the same year, another new subspecialty was established: Hospice and Palliative Medicine, with the first modern purpose-built hospice, St. Christopher’s Hospice, in England. Within 5 years the first hospice program in the United States was founded in Branford, Connecticut and in the same year the first legislation to provide federal funds for hospice care was introduced.
Not long thereafter a US Department of Health, Education, and Welfare task force stated that hospice services were a viable and cost-effective means of providing medical care for the terminally ill. In 1978, the Health Care Financing Administration (HCFA) initiated demonstration programs at 26 hospices across the country. This project led to the creation of the Medicare hospice benefit in 1982 and in 1986 Congress made it a permanent part of Medicare Part A.
Up to this point all palliative care had been hospice care, but that changed in the 1970’s when a surgical oncologist at the Royal Victoria Hospital at McGill University coined the term “palliative care” and introduced the wholistic, patient-centered concepts of the hospice approach earlier in the trajectory of illness.
As palliative medicine grew over the next decade, three major palliative care organizations emerged: The National Hospice and Palliative Care Organization (NHPCO) in 1978; the American Academy of Hospice and Palliative Medicine (AAHPM) in 1988; and the Center for the Advancement of Palliative Care (CAPC) in 1999. In 2006 palliative care was recognized as a medical subspecialty by the American Board of Medical Subspecialties (ABMS).
According to the CDC, 6 in 10 adults in the US have a chronic condition, and 4 in 10 have 2 or more conditions. There are approximately 6,000,000 people with serious illness in the United States that could benefit from palliative care, and that number is expected to more than double over the next 25 years.
More Treatment is no Necessarily Better Treatment
One of the lessons from the last 50 years of advances in health care is that more treatment is not necessarily better treatment. Even with exponential expansion of technology the capacity to cure remains limited, as most of the illnesses of modern life remain incurable, though treatable: Alzheimer’s disease, diabetes, stroke, heart failure, chronic pulmonary disease, and chronic kidney failure. These diseases are the leading drivers of the nation’s health care costs, and despite leading the world in healthcare costs the United States lags behind in life expectancy and other quality measures.
Palliative medicine is a relatively new medical subspecialty that is poised to have an important role in impacting health care costs and improving outcomes. Its practitioners strive to provide guidance for making informed healthcare choices so that people are not only living longer but living better quality lives as well.
Palliative Care Consult