Biren Saraiya, MD

In past entries of this column, we have written a lot about what palliative care is, the skills that are required to deliver it and the specific symptom-management guidelines associated with it.

The July issue of Palliative Medicine features22 systemic reviews of topics relating to opioid treatment in cancer pain. This was done as part of updating the European Association for Palliative Care guidelines. As the editorial by Drs. Kassa and Haugen suggests, even with the advances in pain research in recent years, there is still a great need for systematic research in pain.

In the Aug. 19 issue of The New England Journal of Medicine, investigators from Massachusetts General Hospital reported that early palliative care interventions in patients with advanced lung cancer had better quality of life and mood, received less aggressive care at the end of life and had improved survival.

Recently, I received a compliment on my “listening skills” from a family member of a patient.

Last month, in her Palliative Care column, Stephanie Harman, MD, wrote about communications at the end of life. Communication at the end of life requires handling patient’s emotions. In my column this month, I want to share a recent patient encounter to highlight some skills in dealing with difficult conversations.

All medical school curriculums teach students anatomy, physiology, pathophysiology and pharmacology. The processes and explanations for each of the subjects start from birth and ends … well with disease management. The normal process of death is rarely, if ever discussed. Many times patients with cancer and their families wonder and ask about death and physicians should be able to answer their questions.

In 2006, Weiner and Roth discussed potential iatrogenic harms of goals of care discussions at the end of life. They reported five behaviors that can produce harm to patients and families because of the intertwined nature of decisions regarding therapy, including end-of-life care and patients’ and families’ loss and grief. These behaviors include:

In the past month, I have been attending on the Leukemia and Lymphoma Service at our hospital. During our rounds, I made a comment to the residents that the leukemia service is the most aggressive palliative care service in the hospital. They looked puzzled until I explained what I meant.

During my busy clinic last week, I received a call to sign a death certificate for a patient who had died over the weekend. It brought back the memories of the previous night where I had felt that I had failed this patient and his family.

In a recent column, I discussed caring for the whole patient and recommended the use of a tool such as the NCCN’s Distress Thermometer to assess for distress and its cause. The other aspect of caring for patients is discussing end-of-life care.