The Landscape is Changing

The previous three decades in our field of palliative care have been in many ways dedicated to building programs, structures, teams, guidelines, and organizations. We have been good builders, seeking solid blueprints and strong structures. We were on somewhat of a direct course, and we most certainly have been industrious builders, massively extending the number of hospice programs and moving from 0 palliative care programs to 1800 programs in record time.

But the landscape is changing and the blueprints are fading into unclear directions. The perfect storm of an overburdened healthcare system, an aging society, prolonged survival for children and adults with serious illness, and certainly not the least of the factors is the chaos in current healthcare policy, all which have created a serious pause for we who build palliative care.

There is a new skyline in the architecture of palliative care, and in many ways, it is based on new angles, new designs, and perhaps on even leveling some old structures to make room for the new. This change in building palliative care is good news. In the words of Warren Buffet, “In a chronically leaking boat, energy devoted to changing vessels is more productive than energy devoted to patching leaks.”

This issue of the journal represents the changes in our field. We, and our colleagues at City of Hope Medical Center and Johns Hopkins Cancer Center, share an article reporting on a randomized trial in progress related to integrating palliative care for patients on phase 1 clinical trials. Other articles in this issue address topics such as shifting positions on physician-assisted suicide and an article comparing nurse practitioner-only care with the interdisciplinary team standard. These topics are not exactly what the building industry would consider a midlife home remodel of a few bedrooms and new marble counter tops. These changes are better classified as the bulldozer approach to remodeling the house.

Maybe it is the right time for reconstruction and rethinking. Buckminster Fuller is quoted as saying, “You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete.”

If you read the articles in this issue of the journal carefully, you will find a healthy dose of both cynicism and critique. Authors in this issue ask pertinent questions about feasibility and limitations of quality measurement, the real challenges of integrating palliative care in community settings, and the extent to which end-of-life care really represents patients' values. Building a community for our ever increasing diverse society will require a new blueprint and will result in a new skyline.

As two professionals who have spent entire careers in the bastion of death-denying oncology, tackling the world of clinical trials is in the bulldozer category of home remodeling.

We hope this issue of the journal and the wisdom of our colleagues whose work appears in these pages inspire you to pick up a hammer and rip something apart.