Growing Every Which Way

One of the cool things about medicine is something discovered to help one condition is subsequently discovered to help other conditions that never occurred to the group initiating the new approach. For example, sildenafil, developed for erectile dysfunction, was later discovered to help people with pulmonary hypertension. I clearly remember my first interdisciplinary team meeting where an incensed member wanted to know why we were giving sildenafil to a patient—and didn't that represent a misuse of our pharmacy budget! A vivid example of the need to “keep up” with an advancing body of knowledge. Similarly, anti-HIV drugs were developed to control, but not cure, HIV infection. Later, they were demonstrated to be able to cure chronic hepatitis C infection most of the time. There is always something new popping up where one did not expect it.

Our field is no different. Cicely Saunders wanted to do something about the uncontrolled pain of adults dying of cancer on the surgical wards in the academic teaching hospital where she was working as a social worker. She tried out her ideas in a facility built as a demonstration project. She was only trying to improve care for patients with cancer and motor neuron disease. It took others to demonstrate that her approach worked with other diseases. Still others demonstrated her approach worked as a consultation service in acute care hospitals, as a home visiting service, and in care homes. Then it was shown that it worked for people who are not dying, and even improves the cure rate! Saunders would probably be surprised, but pleased.

A key issue is fidelity of the intervention. In this issue, Ferrell and colleagues publish the fourth edition of the National Consensus Guidelines for Quality Palliative Care. One of the things that can happen in the enthusiasm to apply new approaches to new groups of patients is that the intervention changes. A major difference between our intervention and drug treatment is that it involves a team of people. It is difficult enough to standardize a drug for wide distribution; it is even harder to standardize a team of people.

The data demonstrating the improved quality of a team addressing multidimensional needs of their families are incontrovertible. Yet, in the absence of standards, many have observed that someone can say they are “doing” palliative care without really providing it. This is not different from those offering comprehensive stroke, cardiovascular, or cancer care in hospitals, nursing homes, surgical centers, and other aspects of the health care industry. Without standards, we are no better than caveat emptor in the business world. The degree to which these palliative care guidelines are used as the touchstone for quality palliative care is directly related to the degree to which patients and families can reliably get good care. The fact that we are in the fourth edition reflects the maturing of our field, and the demand for this document.

Other articles in this issue reflect the directions in which this one field is going. Yennurajalingam and colleagues report on embedded palliative care rather than stand-alone outpatient palliative clinics. Button and colleagues push the boundaries into hematological malignancies—an area that has only recently been reached by palliative care.

Evaluating what is in the “black box” of the palliative care intervention—what is in the “syringe” that delivers the outcomes—is a high priority research objective. The technological advances to measure “silence” as a communication tool have been a barrier. Two articles from the same group point the way to pulling back this curtain in a measurable way. The clinical pharmacist as an additional member of the core palliative care team is also a new innovation and is only beginning to be described as an addition to the core team of physician, nurse, social worker, and chaplain first hypothesized by Saunders in the 1950s.

In short, our field is growing every which way. That is exciting, and a bit frightening as well. It is all of our professional responsibility to ensure that the growth includes both the enthusiasm of discovery and the commitment to professionalism.