As far as we’ve come in the 50 years since Balfour Mount and Sue Britton opened the first palliative care at the Royal Victoria Hospital in Quebec, have we lost something along the way?

In today’s podcast we welcome some of the early pioneers in palliative care to talk about the roots of palliative care. Sue Britton was the first nurse hired on that palliative care unit. Michael Kearney on a transformational meeting in Cicely Saunders’s office, with Balfour Mount at her side and a glass of sherry. Justin Sanders wants to be sure the newer generations of palliative care clinicians understand the early principles and problems that animated the founders of hospice and palliative care, including:

• Origins of the word “palliative” - it’s not what I thought! Yes, it means “to cloak,” but there’s more…

• Whole-person-care

• Total pain

• Healing as a process distinct from the deterioration of the body

• Sympomatologists

• The patient and family as the unit of care

Our guests referenced many articles on this podcast, linked above and below. If you read just one, read Palliative Medicine - Just Another Specialty? by Kearney. I promise it’s short. 2 pages. Here’s a taste:

…While there is an abusive and useless dimension to illness, pain and suffering which needs to be removed if at all possible, there is also potential in such experience…If we in palliative medicine fail to accept this view, a view which allows that there may also be a potential in the suffering of the dying process, if we sell out completely to the literalism of the medical model with its view that such suffering is only a problem, we will be in danger of following a pattern which could significantly limit our scope for development and lead to our becoming ’symptomatologists’, within just another specialty.

And love that Jim Croce choice. What’s in a name? I’ve got a name.

Enjoy!

-Alex Smith

Links

• Link to the McGill National Grand Rounds Series on Palliative Care, Michael Kearney as initial presenter, and registration for future events. No, you don’t need to be Canadian. Canadians are welcoming.
• Palliative Medicine - Just Another Specialty? In Palliative Medicine By Kearney
• Joe Wood’s book on Total Pain
• Balfour Mount’s memoir Ten Thousand Crossroads paper on Healing Connections in JPSM and Healing and Palliative Care in Palliative Medicine
• Cicely Saunders: A Life and Legacy, by David Clark
• Self-Care of Physicians Caring for Patients at the End of Life, by Michael Kearney and colleagues in JAMA Perspectives on Care at the Close of Life series
• Twycross on Readdressing Balance in Hospice

Much like deprescribing, we plan to revisit certain high impact and dynamic topics frequently. Substance use disorder is one of those complex issues in which clinical practice is changing rapidly. You can listen to our prior podcasts on substance use disorder here, here, here, and here.

Today we talk with experts Janet Ho, Sach Kale, and Julie Childers about opioid use disorder and serious illness. We address:

• Why is caring for patients with this overlap so hard? Inspired by Dani Chammas’s paper in Annals of Internal Medicine titled, “Wishing for a no show” we talk about countertransference: start by asking yourself, “Why am I having difficulty? What is making this hard for me?”

• Sach Kale set up an outpatient clinic focused on substance use disorder for patients with cancer. Why? How? What do they do? Do you need to be an addiction medicine trained physician to start such a clinic (no: Sach is not). See Sach’s write up about setting up this clinic in JPSM.

• What is harm reduction and how can we implement it in practice? One key tenet of harm reduction we return to multiple times on this podcast: Accountability without termination (or, in more familiar language, without abandonment).

• When to consider bupenorphine vs methadone? Why the field is moving away from prescribing methadone to bupenorphine; how to manage patients prescribed methadone for opioid use disorder who then develop serious and painful illness - should we/can we split up the once daily dosing to achieve better pain control?

• Who follows the patient once the cancer goes into remission? Who will prescribe the buprenorphine then? Or when it progresses - will hospice pay?

• And so much more: maybe not the oxycodone for breakthrough; when the IV dilaudid is the only thing that works; pill counts and urine drug tests; the 3 Ps approach (pain, pattern, prognosis); stimulant use disorder; a forthcoming VitalTalk section…

Thanks to the many questions that came in on social media from listeners in advance of this podcast. We all have questions. We addressed as many of your listener questions as we could. We could have talked for 4 hours and will definitely revisit this issue!

Sometimes the drugs don’t work.

-Alex: @alexsmithmd.bsky.social