"Comfort Care"

Some people see palliative care and intensive care as two ends of a spectrum. Palliation is the idea that all interventions are simply for comfort; we treat pain, discomfort, anxiety, shortness of breath, nausea, diarrhea, constipation, dry eyes. We don't necessarily pursue treatments that are curative of the patient's disease. But some things are borderline; sometimes, patients on hospice getting palliative care can still get chemotherapy because treatment of their cancer will relieve their symptoms. But for the most part, the focus is on comfort. On the other hand, intensive care has a reputation of pushing people to their limits, making decisions that incur short-term discomfort or harm for the possibility of long-term benefit, and pursuing invasive and aggressive intervention.

To some degree, these characterizations are true. But what I hope will happen in the next decade is a cultural shift to finding a more reasonable medium. Today, we had a patient who is on maximal life support with no hope of recovery. In morning rounds, our decision was to "continue full aggressive treatment unless the family decides to withdraw care." Is this appropriate? It's not up to me to say what is futile care or not. And it's not my call about what sort of life is worth living. And it's not my place to comment on whether resources are better spent here than elsewhere. But I want to venture a suggestion that we not look at this in such a black-and-white harsh manner. It is not that we can only pursue runaway intensive care without any recourse to palliation. Even if we don't know what intensive care measures to pull back, we can at least get the palliative care specialists to weigh in. And indeed, there was a recent study of lung cancer which showed that patients who were enrolled in hospice lived longer than patients who had aggressive chemotherapy. In any case, this is something I'm more and more interested in, and I think that it would not be odd or inappropriate to do a fellowship in both intensive care and palliative care medicine.