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Palliative Care Perspectives : Chapter 1: Death and Dying in Modern Times : Palliative Care and Palliative Medicine

The root word for palliation in Latin, palliare, means to cloak or shield. At a simple level we can imagine that palliation protects people from the ravages of illness. Palliative care means different things to different people, and modern definitions are rapidly evolving.

The modern use of the term palliative care is usually attributed to Dr. Balfour Mount, one of the founders of the North American hospice/palliative care movement. Working in French-speaking Montreal, Mount felt the need to coin a new term for hospice, as the French equivalent meant almshouse for the poor and elderly. Cicely Saunders reports that he borrowed the term from palliative radiation therapy.

The World Health Organization (WHO) has defined palliative care as care that "affirms life and regards dying as a normal process,... neither hastens nor postpones death,... [and] provides relief from pain and other distressing symptoms."15 The emphasis is on symptom management in the dying, with no effort to prolong or hasten death. This definition appears to be synonymous with a reasonable definition of hospice care, but others may define it differently. Much "palliative" chemotherapy, for example, seems to have as a goal of care tumor response or improved survival, not symptom management. A few years ago I did a Medline search for articles with keywords referring to palliation and non-small cell lung cancer. What were the outcome measures examined in these studies? Without exception, all looked at survival rates and tumor response rates. None examined symptomatic relief. (Oncologists are beginning to push at least for inclusion of subjective patient responses, positive and negative, as legitimate outcome measures to be reported in clinical trials.) The oncologic meaning of palliative care appears to mean simply noncurative, life-prolonging care. While no one has a patent on this word, the WHO and the oncologic meanings are antithetical in nature; one deals with quality and the other with quantity of life.

A third meaning appears to be evolving. Palliative care attempts to alleviate the misery associated with illness, and not exclusively terminal illness. The emphasis remains on patients with serious, life-limiting, usually chronic illnesses. The American Academy of Hospice and Palliative Medicine [ www.aahpm.org ] provides this definition: "The term palliative care originally referred to the care of patients with terminal illnesses, but now refers to the care of patients with life-limiting illnesses, whether or not they are imminently dying."16 Palliative medicine has a somewhat more formal ring to it and is very similar in meaning. It suggests that aspect that is the domain of physicians or the more "medical" aspects of palliative care.17 In its core curriculum the American Academy of Hospice and Palliative Medicine [ www.aahpm.org ] defines palliative medicine as "the study and management of patients with active, progressive, far advanced disease for whom the prognosis is limited and the focus of care is quality of life."16 The main palliative care group for physicians in the United States is the American Academy of Hospice and Palliative Medicine [ www.aahpm.org ] . The broader National Hospice Organization (NHO) recently changed its name to the National Hospice and Palliative Care Organization [ www.nhpco.org ]. Many have described modern hospice care as being a subset of palliative care, even though hospice as a social institution predated palliative care.18

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Palliative Care Perspectives

James L. Hallenbeck, M.D.

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Copyright 2003 by Oxford University Press, Inc.

The online version of this book is used with permission of the publisher and author on web sites affiliated with the Inter-Institutional Collaborating Network on End-of-life Care (IICN), sponsored by Growth House, Inc.