Are We Making Progress?

I time the beginning of my work in palliative medicine to my first exposure to patients enrolled in hospice care in the United States in 1988. That is 29 years ago. There are days when I think we have not made any sustained progress. Attitudes and patterns of prescribing behavior for opioids are one example. ¹ Some will observe that a whole generation has come and gone during the time I have been in practice. The science of opioid prescribing and the education on which it was based seem to have been swept away and discarded simply because it is “old.” Yet, there is also evidence that we are making progress. On reading this issue of Journal of Palliative Medicine, my enthusiasm and optimism for a better future for patient care are renewed.

The area of symptom control that, in my mind, is so frequently mixed up and confused with pain control is that of delirium. That issue is laid out clearly in a report of delirium's relationship to other symptoms (De La Cruz et al., this issue). Of all those reports of “screaming in pain” that got our field started, I wonder how much was really (and remains) unrecognized and unmanaged delirium.

Measuring the quality of what we do is of paramount importance as we move forward, not just about ourselves, but about the larger healthcare systems in which we work. We have moved beyond, “the nurse who trained me did it this way” to a series of quality measures. The major objection has been the burden of the measurement—to patients, families, and staff. Of interest is to move beyond process measures to patient-centered measures that are not burdensome. To that end, the report in this issue of evidence for the validity of a single item approach is of real interest (Conrad et al., this issue). Although more work needs to be done, I take heart that this takes work from the research realm to something that could be of utility in daily practice.

One of my pet peeves is the report by a healthcare provider that the patient “wants everything done” versus “comfort care only” as if there were just two flavors of ice cream: vanilla and chocolate. The report that preferences for aggressive medical treatment are not associated with healthcare utilization in the very old is heartening (Albert et al., this issue). It suggests that patients, families, and their healthcare professionals are able and willing to engage in nuanced discussion and planning to achieve the right treatments for the patient at the time. In other words, we can move away from slogans toward patient-centered care with confidence.

With the rapid growth of hospice and palliative care worldwide, a significant area of interest is the workforce. I remember reading that, when a new program, or a new field, is small, there is a rich pool of potential workers. However, with time and growth, that rich pool is depleted and there is a need to recruit from the larger world of people who are less equipped to do the work than the “pioneers.” To that end, in addition to all of the education and training research, the focus on self-care research is an important one (Mills et al., this issue).