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Editorials
A
few years ago, an editorial in Canadian Family Physician ended on a laconic note with this remark,“Maybe home palliative care is too important to be left in the hands of family physicians.”1 The question is still valid today, as Canadians demand that physicians provide terminally ill patients with even better care. In 2001, there were more than 219 000 deaths in Canada:
29% from cancer; 26% from cardiovascular disease; and 7% from strokes.2 In Quebec, 24% of deaths from cancer or non–cancer-related chronic diseases occur in long- term care facilities and only 9% occur while patients are being cared for at home.3 When patients are being cared for at home, family physicians are the primary, if not the only, medical professionals caring for them during the last few weeks of their lives. In the palliative care units with which we are familiar, average length of stay is less than 9 days,4 indicating that most palliative care is pro- vided in the community. The question is, are family physi- cians the physicians most adequately prepared to deliver this care?
What constitutes good palliative care?
Canadians want adequate management of pain and other symptoms that occur at the end of life; this includes a deeper understanding of the nature and mag- nitude of the suffering that comes with terminal illness.5 For example, to many practitioners, some symptoms that receive standard treatment in palliative care, such as constipation, are relatively straightforward and even trivial. Our experience with terminally ill patients sug- gests that this type of problem can cause a great deal of discomfort, resulting in family tensions which, all too often, degenerate into inappropriate hospitaliza- tion. Canadians also think they are entitled to be treated with dignity, in spite of loss of function and profound changes in every part of their lives.6 Informal caregiv- ers want health care professionals to be more aware of the burden they carry, particularly when patients are cared for at home, and they want physicians to be more involved. They want physicians to be available 24 hours a day, 365 days a year.7
The Association of Faculties of Medicine of Canada is also concerned about the scope of palliative care. It wants all physicians to have a basic grasp of what is involved. It is running a 2-day symposium in April 2006 to train future physicians in end-of-life care. Although needed in all parts of Canada, nowhere is the involve- ment of family physicians more important than in rural
areas, where family physicians are responsible for a greater share of all care, including, in some instances, chemotherapy.
Patients and their caregivers want their family phy- sicians to take time to listen and to make every pos- sible effort to relieve symptoms.8 The quality of care and availability of physicians are often criticized, especially in urban centres where most Canadians live. We fre- quently hear that physicians who have cared for patients for years will not make house calls and deliberately extri- cate themselves from caring for patients during the fi nal months of life—at the very moment when patients need their care the most. Sadly, this is both true and disturbing.
It is probably due to 3 factors. First, some physicians have not been trained to provide palliative care at home, and this appears to be one of the main reasons why the pain experienced by terminally ill patients is not adequately managed.9-11 Second, multidisciplinary teams supporting physicians in providing comprehensive care to patients at home are often not available.12 Last, the remuneration physicians receive for providing care at home is clearly not commensurate with the work they do.
For the few end-of-life symptoms that can be particu- larly diffi cult to treat, every community should have a consultant available to recommend the most appropri- ate form of care to attending physicians. In some cases, it might be appropriate for consultants and family phy- sicians to care for patients together. Consultants can provide support through telephone consultations; it is almost never necessary to move a patient just so he or she can see a consultant in person.
Some people fear it is diffi cult, if not impossible, to provide high-quality palliative care in remote regions.
This simply is not true. One of the authors had an oppor- tunity to work in a remote region of Quebec where phy- sicians share responsibility for regular palliative care and refer patients with hard-to-manage symptoms to one of their colleagues. The region’s hospital created protocols for managing certain symptoms seen in pal- liative care. As is true elsewhere, nurses in this setting were particularly sensitive to, and interested in, their palliative care patients’ quality of life during their stay in hospital, another reason why teamwork is so important in palliative care practice.
Training family physicians in Canada
For family physicians, inadequate management of end-of-life symptoms is often the result of inadequate
Palliative care
First and foremost the domain of family physicians
François Lehmann,
MDSerge Daneault,
MD,
PHDFOR PRESCRIBING INFORMATION SEE PAGE 514
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training in palliative care. Because of this, several uni- versities have taken the initiative to make a palliative care rotation compulsory for their family medicine resi- dents. They fi rmly believe that, with better training, more physicians will be comfortable assuming responsibility for care of terminally ill patients.
Palliative medicine is a branch of medicine that involves all of the systems; terminally ill patients can experience neurologic, respiratory, infection-related, digestive, and musculoskeletal symptoms all at the same time. Physicians must adopt a systemic vision, a vision that takes into account the effects that diseases are hav- ing not just on patients but also on patients’ caregivers and loved ones. Family physicians are the medical pro- fessionals best equipped to care for most terminally ill patients, as their training imparts the skills and knowl- edge needed to treat common problems associated with every system of the human body. Our professional title, family physician, indicates that we play a role not only for our patients but also for their families.
Our faculties of medicine are changing and invest- ing in training future physicians in end-of-life care.
Our departments of family medicine should be directly involved in this process. Some have already developed programs; others are in the process of doing so. We need to ensure that all future family physicians receive adequate training in palliative care during residency.
This training must include not only theoretical training with the acquisition of new knowledge but also ade- quate practical experience with patients and their fami- lies. In this way, future family physicians will realize that, in spite of moments of deep sadness, caring for termi- nally ill patients can be gratifying and that their contact with these patients can be fi lled more with laughter than with tears.
Conclusion
To improve the quality and quantity of palliative care across Canada, all family physicians need to be actively involved on an ongoing basis. In answer to the question
raised at the beginning of this editorial as to whether palliative care is too important to be left in the hands of family physicians, it is precisely because palliative care is so important that it is the domain of family physi- cians—provided they are adequately prepared and con- tinually supported in this undertaking.
Dr Lehmann is an Associate Clinical Professor, Faculty Advisor on palliative care, and Head of the Department of Family Medicine at the University of Montreal in Quebec.
Dr Daneault is an Assistant Professor of Family Medicine.
He works in the Palliative Care Unit at the Hôpital Notre Dame in the Centre Hospitalier de l’Université de Montréal.
Correspondence to:Dr Lehmann, Département de méde- cine familiale, Faculté de médecine, Université de Montréal, CP 6128, succ. Centre Ville, Montréal QC H3C 3J7
The opinions expressed in editorials are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.
References
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5. Daneault S, Lussier V, Mongeau S, Paille P, Hudon E, Dion D, et al. The nature of suffering and its relief in the terminally ill: a qualitative study. J Palliat Care 2004;20(1):7-11.
6. Hack TF, Chochinov HM, Hassard T, Kristjanson LJ, McClement S, Harlos M. Defi ning dignity in terminally ill cancer patients: a factor-analytic approach. Psychooncology 2004;13(10):700-8.
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BMJ 1993;306(6872):249-51.
8. Mitchell GK. How well do general practitioners deliver palliative care? A systematic review. Palliat Med 2002;16(6):457-64.
9. Oneschuk D, Fainsinger R, Hanson J, Bruera E. Assessment and knowledge in pal- liative care in second-year family medicine residents. J Pain Symptom Manage 1997;14(5):265-73.
10. Haines A, Booroff A. Terminal care at home: perspective from general practice. BMJ 1986;292(6527):1051-3.
11. Sloan PA, Donnelly MB, Vanderveer B, Delomas M, Schwartz RW, Sloan DA. Cancer pain education among family physicians. J Pain Symptom Manage 1997;14(2):74-81.
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