Palliative Care: An Historical Perspective

Palliative care began with a focus on the care of the dying. Dr. Cicely Saunders first articulated her ideas about modern hospice care in the late 1950s based on the careful observation of dying patients. She advocated that only an interdisciplinary team could relieve the “total pain” of a dying person in the context of his or her family, and the team concept is still at the core of palliative care. In the 1960s, a psychiatrist in the United States, Elisabeth Kubler-Ross, confronted fierce resistance to treating people at the end of life with respect, openness and honest communication. Her groundbreaking book, On Death and Dying, and charismatic presentations revolutionized and humanized how dying patients were acknowledged and cared for. In 1974, Dr. Balfour Mount, a surgical oncologist at The Royal Victoria Hospital of McGill University in Montreal, Canada, coined the term palliative care to avoid the negative connotations of the word hospice in French culture, and introduced Dr. Saunders’ innovations into academic teaching hospitals. He first demonstrated what it meant to provide holistic care for people with chronic or life-limiting diseases and their families who were experiencing physical, psychological, social, or spiritual distress. In 1997, the Institute of Medicine report, “Approaching Death: improving care at the end of life” (M.I. Field and C.K. Cassel, editors) documented glaring deficiencies in end-of-life care in the United States. With the support of the Robert Wood Johnson Foundation and George Soros’ Open Society Institute, a major effort to bring palliative care into mainstream medicine and nursing was launched. There were clinical demonstration projects, reviews of palliative and end-of-life care content of core textbooks, consumer awareness through Last Acts and the Bill Moyer’s Series, “On Our Own Terms” (2000), funding of palliative care faculty scholars, and an NIH State of the Science conference. Clinical Practice Guidelines for Quality Palliative Care were first released in 2004, expanding the focus of palliative care to include not just dying patients, but also patients diagnosed with life-limiting illnesses. By 2006, there were 57 palliative medicine fellowship programs with approximately 100 trainees. In 2006, the American Board of Medical Specialties (ABMS) and the Accreditation Council for Graduate Medical Education recognized the subspecialty of Hospice and Palliative Medicine. Reflecting the roots of palliative medicine in many specialty fields, the boards of 10 specialties are cosponsoring the ABMS certification examination, given for the first time in 2008, and there are over 3000 members of the American Academy of Hospice and Palliative Medicine. Palliative medicine is the continuation of the long struggle to accept life on its own terms, honestly and openly. Taking its place in academic medicine, this new subspecialty will enable future generations of physicians to gain generalist-level palliative medicine skills while advancing knowledge in the field and fulfilling our promise to patients and their families that we will not abandon them when our treatments fail and that, at all times, we will do all we can to relieve their suffering.

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