| Ch 15 | Page 2 / 13 | |
| Palliative care | Continuous and palliative care | |
We are unable to cure around 60% of cancer patients. However, caregivers (physician, nurse, technician) should endeavour to offer the best possible care to patients who have faith in them , up to the very end.
In reality, relatively soon before the patient's situation becomes tragic leading to what is known as the 'terminal' stage, caregivers know that treatment will not offer cure, but may lengthen the patient's life, improve quality of life and prepare him/her for a dignified death. Remission periods, that can last years, may be observed.
Such apparent failure requires personal psychological preparation for each caregiver: it is easier and far more comfortable to treat with a curative intent than to be faced with an incurable person to care for.
Most oncologists and caregivers prefer not to entrust their patient to any specialised palliative team. They believe that patients feel better if they remain in the care network within which they were actively treated.
Many patients, however, express their desire to end their life at home. For this reason, many home care teams, mobile units and various external care groups have been set up, with specifically designed systems, which may slightly differ from one location to another.
In fact, the desire to return home is not always quite as clear as it often appears: many patients express this wish when they are still in relatively good health. In acute or preterminal phases (dyspnea, hemorrhage, anxiety, death proximity) or because they are aware of their family's disarray, they often ask to be brought back to hospital and then feel more secure within a professional team. Families should always be comforted since they often feel they have failed in their duty of keeping their patient at home: the most important thing to bear in mind is that they tried and that they should respect, every day and as best they can, the patient's personal comfort and wishes.
Therefore, more and more, genuine care networks (associating hospital and home care) are the most appropriate structures to assume care continuity.
Nevertheless, for those patients desiring to stay or to return home, the main actor will be the general practitioner who will ensure terminal care together with the district nursing team.
The general practitioner completely fulfils the duty of human medicine towards the sick person by offering adapted palliative care, taking into account not only the medical but also the social, psychological and spiritual aspects.
When able to bear the burden, the patient's family will turn out even stronger and more united when dignified death at home is made possible. There are many discussions with the dying person that can only be broached within the context of usual daily life. The assumed difficulties lead to a more serene bereavement.
Good home care organisation is mandatory to help the family to assume and fully invest in the care of the beloved person. Caregivers often experience intense care periods and good personal self-confidence is necessary for providing the best care every day. Work within a team and participation in discussion groups (even in private city practice) are essential in the prevention of caregiver burn-out (cf. chapter on psychological aspects).
Wherever palliative care is to be provided, it constitutes complete and genuinely satisfactory medicine.
Precise diagnosis (requiring excellent knowledge on the symptoms or syndromes generally encountered during the palliative care phase) is mandatory for instituting appropriate treatment.
Cooperation is generally necessary with a number of other specialists (radiotherapist, nutritionist, pain specialist but sometimes also surgeon, medical oncologist and other carers). Failing to call upon such specialists can place patients in dead-end situations, every added delay bringing new iatrogenic events.
Precise use of analgesic medications but also of other palliative drugs can transform the patient's life from a lengthy and painful "cul-de-sac", with a vision limited to pain and symptoms, into an enlightened appeased end of life, allowing intense dialogue, rich affective life and a profound spiritual (potentially religious) experience.
Offering a 'beautiful death' requires a genuine dialogue with the patient but also, for the caregiver, profound self knowledge on one's own reactions. Prior personal and team work can help each caregiver in this specific context.
Therefore, palliative medicine is an intellectually, technically and spiritually rich medical practice.
Unfortunately, such medicine is not always taught by universities (neither from a theoretical point of view nor in daily patient practice). Therefore, many physicians and nurses train themselves within post-graduate teaching programmes
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