The postgraduate degree attached with my training goes by the name of MD Palliative Medicine. While, I have decried the absence of inpatient beds during my tenure as a particular impediment to quality postgraduate training, there exists a need to understand that service development has specific local, country and culture specific requirements. Palliative Medicine has developed as a subspecialty of Internal Medicine, and I have written earlier about how a sound foundation is required to understand nuances related to decision making and more specifically, those related to treatment planning and limitation. Palliative Care on the other hand, is not necessarily a subject, but an all-encompassing approach towards care in advanced disease.

Understanding the origins of the terminology Palliative and Supportive Care has seemed perplexing, to say the least. Coming to the origins of the term Palliative and Supportive care, Why is there a need to separate Palliative care from Supportive care? Supportive care by virtue of its ambit is expected to contain Palliative Care within its scope. Why should there be a need to mention it separately?

Despite the fact that the postgraduate curriculum and specifically the Palliative Care formulary contain more than a mention of management of medical issues, their extrapolation to decision making at the bedside is still hindered by the reality of working in a multidisciplinary environment. The super-specialty team remains the preferred team to manage complex medical issues at the end of life and advice about rationalizing management is less well understood and faces various challenges in its implementation. I have been forced to take recourse to the fact that this information resides within the Palliative Care Formulary in order to justify my engagement with these issues. Of course my continued engagement with gaining proficiency in Internal Medicine might also work in my favor, in order to justify this necessary incursion. However the truth remains that specialization in Palliative and Internal medicine risks getting read as one done at the exclusion of the other rather than the continuum that it is expected to represent.

Having struggled with the idea of extrapolating outcome indicators linked to mainstream Internal Medicine to contemporary Palliative medicine practice, I recently came across a thesis project by Dr Irene Higginson, about the development of the Support Team Assessment Schedule, which appears to have functioned as the basis for Integrated Palliative Outcome Scale. While going through the Thesis, a host of items caught my attention, foremost among them being the descriptor of support teams.

These teams may be based out of Hospices, Hospitals or Community. They are expected to visit and advice on patients admitted to the hospital and may not have beds for admissions under them. They are expected to achieve referrals from both specialist physicians and general practitioners. They provide home visits after seeking agreement from general practitioners. Teams provide additional support, in addition to that provided by the general practitioner and community nurses, along with a 24-hour on-call service.

The fact that an outcome measure intended to measure the effectiveness of a palliative care service has been labelled as a Support Team Assessment Schedule might also say something about the origins and the evolution of the terminology. The author mentions that it is to be used for audit of care by the support team in the community setting.

This descriptor differs substantially from the usual terminology of Supportive Care which has come to include the following
Treatment and management of chemotherapy related-adverse effects,
Component transfusions,
Infusion of immunoglobulins, human albumin, antibiotics, antifungals and antivirals, iron, electrolytes, analgesics, diuretics, steroids, octreotide, anti-emetics or anti-histamines,
Infusion of bone modifying agents,
Hydration following high dose chemotherapy,
Hydration for acute and chronic renal failure,
Provision of parenteral nutrition all of which have come to characterize supportive care provision (as defined by the criteria for certification of designated centres of excellence for supportive care provision in cancer laid out in the Multinational Association of Supportive Care in Cancer document).

While the original document, envisages the support care team as a link between the patient in the community and their primary teams, the terminology of supportive care in the present remains quite distinct and shines a light on the evolution of the discipline. One could argue that these developed separately, and that Higginson’s Support teams have a different purpose. However it remains difficult to ignore that these terms are used to define closely linked services in the same patient population. The original use of the term Support care team is more in line with the contemporary palliative philosophy of providing an extra layer of care rather than taking the lead in care provision. Its evolution into supportive care and the distinct emphasis on correction of medical issues (by way of management of cancer-treatment related adverse effects) once again points to the central value of Internal medicine in modern supportive care (including palliative care) provision. The work of Support teams might have been taken over by community palliative care services, delivering home care, in the present, but the first use of the term and the descriptor, tells a lot about its origins. One cannot deny the fact that most complex interventions to be carried out in the community setting such as continuous subcutaneous administration of drugs including furosemide require expertise and knowledge in internal medicine, perhaps shining an important light on why these are yet to take off, in this setting and pointing towards the perils of mislabeling palliation as a broad specialty.

“No wonder the Impostor syndrome remains hard to shake off”.

References

Higginson, I. J. (1992). The development, validity, reliability and practicality of a new measure of palliative care: The Support Team Assessment Schedule [Doctoral dissertation, University of London].
Multinational Association of Supportive Care in Cancer. (n.d.). Designated centers of excellence in supportive care in cancer: Certification program.