A Brief History of Palliative Care

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A Brief History ofPalliative Care

• David L. Sharp, M.D.
• Grand Rapids Medical Education Partners
• Hospice of Michigan Grand Rapids

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David L. Sharp, M.D. brief bio

• B.S./M.D. - University of Pittsburgh
• pilot program - Family Medicine, Flemington, NJ
• moved to Grand Rapids in 1986 when daughter
  Martie matriculated at Hope College
• Board Certified in Family Medicine and Hospice
  and Palliative Care
• spiritual gift mercy
• Inpatient Physician Trillium Woods - 2007-2009
• Medical Director Hospice of Michigan Grand
  Rapids - 2010 to present

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our goals today

• reach a better understanding of
• how far back palliative care reaches
• some historical landmarks along the way
• recent history compassion pushes back against
  technology
• palliative care today Economics 301 - the
  future of palliative care
• meet the art of Deidre Scherer

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one of the ironies of life

• By the time youre old enough to know your way
  around, youre not going anywhere.

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Palliative Care is not exactly a new concept

• Cure sometimes,
• treat often,
• comfort always.
• Hippocrates
• 460-357 B.C.

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Ancient China

• special houses death houses
• destitute people were allowed to go there to live
  and die

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New Zealand

• Maoris tribe
• family of dead person is given support in all
  possible ways
• entire tribe joins in mourning

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East Africa

• Tribal elders offer spiritual and practical
  support to the dying person and their family

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a rest along the way

• During the Crusades in the Middle Ages,
  monasteries provided care for
• the sick and dying
• the hungry wayfarer
• the woman in labor
• the needy poor
• the orphan
• the leper

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Middle Ages

• Religious orders established hospices at key
  crossroads on the way to religious shrines
• Santiago de Compostela (Spain)
• Chartres (France)
• Rome (Italy)
• ironically, people died in these shelters while
  on pilgrimages seeking cures for their diseases

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16th 18th centuries

• religious orders offered care of the sick and
  dying in local or regional institutions
• but most people died at home, care for by the
  women in their families

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17th Century

• A young priest, St. Vincent de Paul, founded the
  holy order of Sisters of Charity in Paris, 1633
• They, in turn, opened more than 40 houses for the
  poor, the sick, the dying
• motto The charity of Christ impels us

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1800s

• Madame Garnier of Lyon, France, opened a
  calvaire to care for dying
• 1879 Our Ladys Hospice Dublin cares only
  for the dying
• By late 19th century, increase in municipal or
  charitably-financed infirmaries, almshouses and
  hospitals begins the medicalizing of dying

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1900

• Five of the Irish Sisters of Charity founded St.
  Josephs Convent, London
• Began visiting the sick in their homes

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1935

• Interest grows in the psycho-social aspects of
  dying and bereavement, sparked by the work of
  Worcester, Bowlby, Lindemann, Hinton,
  Kubler-Ross, Raphael, Worden and others

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Europe and USA

• Up until 19th century, belief was that the family
  and church should be responsible for the dying
  person and also help loved ones cope with
  situation

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Mid-20th century

• The expansion of medical knowledge, fueled by
  wartime experiences, results in almost 80 of
  people dying in hospitals or a nursing home

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1957 - 1967

• Cicely Saunders first a social worker, then a
  nurse and finally a physician
• Works at St. Josephs Hospice studying pain
  control in advanced cancer patients
• Pioneered concept of opioids given by the clock
  instead of as prn pain control

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Dame Cicely Saunders 1918-2005

• nurse, physician, founder of St. Christophers
  Hospice, Sydenham, south London, 1967
• No human life, now matter how wretched, should
  be denied dignity and love.

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Dr. Cicely Saunders

• We need to help the dying to live until they die
  and their families to live on
• Author of three books on hospice care
• Care of the Dying, 1960
• The Management of Terminal Disease, 1978
• Living with Dying, 1983

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1967

• Dr. Saunders opens St. Christophers Hospice in
  London
• Emphasized multi-disciplinary approach to caring
  for dying
• Regular use of opioids
• Careful attention to social, spiritual and
  psychological suffering of patients and their
  families

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1974 - New Haven, Connecticut

• Nurses carry the banner from London to America
  and begin teaching Dr. Saunders principles
• New Haven Hospice in Branford begins caring for
  patients with cancer, A.L.S. and other fatal
  illnesses

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Canada -1975

• Dr. Balfour Mount founds hospice and palliative
  care work in two North American hospital
  facilities
• St. Boniface Hospital - Winnipeg
• Royal Victoria Hospital - Montreal

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British Columbia - 1978

• Victoria Hospice founded as The Victoria
  Association for Care of the Dying
• pilot program successful became Hospice
  Victoria 1982
• began with 7 acute-care beds in Royal Jubilee
  Hospital

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1975 - 1978

• Hospices and palliative care units open across
  USA
• California
• Support team at St. Lukes in NYC
• Church Hospice Baltimore
• Cleveland Clinic
• Medical College of Wisconsin

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1984

• Congress adds Hospice Benefit

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2009

• Most recent financial data shows
• 11,633 home health agencies
• 3,533 hospices
• Center for Medicare Medicaid Services, OSCAR
  data, April, 2011

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2009 USA hospice care

• USA stats
• 1,123,495 covered patients
• 77,822,892 covered days of care
• 12 billion reimbursement
• (12,085,785,062.15)
• Source CMS OSCAR data, April, 2011

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2009 Michigan

• 607 home health agencies
• 104 hospices
• 41,918 total hospice patients
• 2,477,382 covered hospice days
• 378,947,823.67 hospice reimbursement
• CMS OCSAR data, April, 2011

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Philosophy before function

• Palliative care (symptomatic and supportive care)
  is generally withheld until all attempts to treat
  the underlying disease and other medical problems
  are exhausted many times palliative care is
  offered with little time left for living.

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Philosophy before function 2

• Palliative care should be considered in
  conjunction with active treatment, and, as death
  nears, palliative care becomes more important as
  active treatment, while cure becomes less
  important

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Philosophy before function 2

• Palliative care should be considered in
  conjunction with active treatment, and, as death
  nears, palliative care becomes more important as
  active treatment, while cure becomes less
  important

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Modern definition

• Advanced knowledge/skills to prevent and relieve
  suffering experienced by patients with
  life-limiting, life-threatening and terminal
  illnesses.
• Expertise in assessment of patients with advanced
  disease and catastrophic injury

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Modern definition 2

• Coordination of interdisciplinary patient and
  family-centered care in diverse settings
• Use of specialized care systems including
  hospice, management of the imminently dying
  patient and legal and ethical decision making in
  end-of-life care

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Modern definition 3

• Work with an interdisciplinary hospice or
  palliative care team to maximize quality of life
  while addressing physical, psychological, social
  and spiritual needs of both patients and family
  members thru illness, dying and bereavement

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Drivers of palliative care

• Sheer demographics growth of elder population
  with diseases of senescence
• Conventional medicine enabling younger patients
  with previously-fatal diseases to survive longer
• Emerging infectious diseases (HIV-AIDS, hep C,
  resurgent tbc, etc.)

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U.S.A. Demographics I

• over-65 age group will double between 2000 and
  2030
• over 70 million gtage 65 by 2030
• gtage 85 4.2 million in 2000 to 8.9 million in
  2030
• by 2050 we will may well have 834,000 persons
  over 100 years old

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U.S.A. Demographics II

• we post-moderns tend to think of death as an
  option rather than a reality however
• roughly 100 of Americans are expected to die at
  the end of their lifetimes.

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What is Futile care?

• use of expensive technology to prolong the
  natural dying process of terminally ill persons,
  with no realistic expectation of longer survival,
  clinical improvement or better quality of life

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An artists rendering of futility
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Sisyphus, by Tiziano Vecelli, 1490-1576

• In Greek mythology, Sisyphus was doomed by
  Zeus to forever carry a huge rock uphill, only to
  have it roll back down again this went on day
  after day for eternity.

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So How will we know.?

• patients are often the first to know when its
  bad news
• a sensing of body language, non-verbal
  communication, insight into ones own body and
  destiny
• innate sense of the timing of life
• importance of the will to live

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But, how will we know.?

• consensus on futility is reached between
• the patient
• the family (or best friends as family
• surrogate)
• the spiritual advisor (pastor, priest, rabbi,
• etc.)
• the patients personal physician

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Politics of palliative care

• Hospitals held accountable for 30-day
  re-admissions
• DRG-type comprehensive reimbursement schemes
• Need to reduce ER visits and un-necessary
  hospitalizations
• Discussions of futility mandatory or simply
  essential?

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Allen Stewart Konigsberg 1935-????
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Woody Allen

• Im not afraid to die. I just dont want to be
  there when it happens.

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History of Palliative CareYour Questions
Please

• David L. Sharp, M.D.
• Grand Rapids Medical Education Partners
• Hospice of Michigan
• 989 Spaulding SE
• Ada, Michigan 49301