It is clear that palliative care principles have been acknowl-edged by surgeons and are being integrated into basic and postgraduate training and practice, and that both disci-plines could ‘benefit by coming together . . . [to] . . . reclaim the lost ground of the surgeon–patient relation-ship’ 39 . The prevailing bias towards separating care into a curative and then a palliative phase (‘cure, then comfort’) is not acceptable. Provision of palliative care alongside comprehensive, possibly curative care should be available to every patient at an early stage 48 . This would represent a shift towards patient-centered care 1 ( Figure 6.4 ).
The integration of a palliative care approach into gen-eral hospital practice has demonstrated improved termi-nal care 49 , 50 . Such practice centers on outcomes that are meaningful to the patient and thus may be a focus for further research. Some work into quality of life in surgical oncology has been undertaken 2 , 51 , a relatively new focus in palliative surgery 52 . This increased interest in quality of life should be welcomed and developed further, and may help surgeons to identify appropriate procedures for patients with advanced disease 2 and reflect goals impor-tant to patients themselves 9 .
In palliative surgery there is a lack of evidence-based benefit and risk in many instances 40 . There can be a reluc-tance to involve palliative care patients in research, per-haps due to ethical concern or fear of creating false hope of cure. Such concern is largely unnecessary. Patients are often keen to be involved in clinical trials, if not for their own benefit, then for the ‘common good’ and researchers
should not avoid them through any such fears or thoughts that the trial would be weakened 1 .
CONCLUSION
It is encouraging to reflect on the origins of palliation in surgical oncology and recent developments towards further integration of the specialties. Important lessons
have been learned through the realization that quality of life, rather than patient prognosis or survival, is an appropriate focus for professional involvement in patients with advanced disease. A palliative care approach to patient care is within the capabilities of all professionals involved in patient care and can only serve to improve such care to the benefit of patients, families and professionals themselves.
‘. . . the closer to the bedside, the better 7 .’
Figure 6.4 Traditional and suggested place of palliative care in cancer management. Adapted from reference 14 . Cancer treatment
Cancer treatment
Diagnosis Death
Traditional model
Diagnosis Death
Suggested model Palliatine
care Palliatine care
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BACKGROUND
When confronted by cancer, patients may experience a sense of loss of control, fear and even anger. The principal concern with the psychological aspects of cancer is to alle-viate the emotional distress which affects patients. There is a current trend to view psychological care within the context of ‘supportive care’ in a multidisciplinary team approach 1 . Supportive care refers to a culture of care that has evolved from the palliative care ethos and focuses on generic cancer teams assisting the patient and their carers to cope with cancer and its treatments at all stages of the cancer journey. It helps the patient to maximize the ben-efits of treatment and to live as well as possible with the effects of the disease.
The key principles underpinning supportive care are 1 :
• A focus on quality of life
• A whole person approach
• Care to include the patient and those who matter to them
• Respect for patient autonomy and choice
• An emphasis on open and sensitive communication.
Communication that assists patients and their carers to express emotions and concerns can reduce fears and anxiety, and promote working together in the cancer experience.
An individualized approach to information can empower patients to be involved in decision making and exercise choice, resulting in a greater sense of control and self-esteem.
HISTORICAL PERSPECTIVE
Communication with, and the psychological response by patients to their cancer was barely investigated before the 1950s, when it was commonplace not to disclose a cancer diagnosis. Outcomes tended to be restricted to survival time and recurrence-free survival. Cancer surgeons
traditionally obtained consent for surgery without discuss-ing the definite diagnosis, or likelihood of a diagnosis, of cancer, and following surgery, cancer was not revealed as the diagnosis because it was considered as something that it was best for the patient not to know. At this time there was also a commonly believed assumption that because anxiety and depression were natural, inevitable reactions to cancer, psychological treatment was not feasible. Set against this model of care, systematic enquiry that included the patient perspective on how patients felt about their cancer, and their quality of life was simply not accessible.
Decades before this, many radical surgical procedures for the treatment of cancer had been developed and utilized, surgery being the main treatment approach for cancer.
Much of the seminal work had been undertaken at the Memorial Hospital in New York, USA. At this same unit, some of the first studies into the psychological aspects of cancer surgery were undertaken by Sutherland (a psychia-trist), who examined psychological adaptation to mastec-tomy and colosmastec-tomy 2 , 3 . However, Sutherland and others 4 struggled to have these psychological studies accepted as necessary, let alone, scientific, as psychology was not viewed as an important aspect of cancer patient management.
It was during the 1960s that a more enlightened view of the ethical issues surrounding disclosure of a cancer diagnosis to patients started to be acknowledged. Along-side this, the importance of the relationship between the psychological effects of cancer and cancer treatments such as surgery also began to develop and measurement of out-comes in cancer care began to include the psychological issues of quality of life of individuals affected by cancer.
In the USA, papers were presented by cancer surgeons at academic meetings 5 and published in recognized jour-nals 6 , resulting in an increased recognition of the psycho-logical needs in the management of the patient with cancer. Practical guidance was provided 6 , which is still very pertinent today and included how to:
• Establish rapport with the patient in the preoperative period
• Allay the patient's fears