The objectives of the medicine could be summarized into two: to preserve life and to relieve suffering. However, as the end of life gets closer, the alleviation of the suffering acquires more importance, as the preservation of life is no longer possible. At a certain point, terminally ill patients may decide not to continue treatment that has a goal of prolonging life, and to change to palliative treatment that has as its primary goal the treatment of pain and suffering.
Palliative medicine aims to provide the best quality of life to terminal patients in their remaining time. It affirms their life and accepts death as a natural process intending neither to delay nor to hasten it. Emphasis is placed not only on making the patient as comfortable as possible and managing pain and other symptoms, but also on caring for and assisting the patient’s family and friends and supporting them as they grieve. This means providing material and moral comfort for the patient in order to make the last moments of his life easier for him, his family and his friends.
The philosophy of palliative care has human dignity at its center, emphasizing solidarity between medical professionals and patients. Solidarity, rather than science, is the principle that directs the care of the patient. This relatively new kind of medicine has restored the most humane aspects of the profession, which had been set aside in search of technical and scientific progress. Humane care means “sometimes curing, usually relieving and always comforting.”[1]
The first objective of palliative care (apart from basic care like hygiene, nutrition, etc.) is to provide relief from pain and other distressing symptoms. Every person has the right to be offered all necessary pain relief medication, even if this medication could shorten life (in rare situations). This can be provided as long as it is needed for the comfort of the patient. If the standard medication is not enough to alleviate the pain, then palliative or terminal sedation could be used. This means to decrease the patient’s consciousness in order to palliate the suffering.
Doctors must seek everything that contributes to the wellness of the terminally ill, taking into account: the discomfort caused by the treatment, the quality of life obtained, the estimated survival and, of course, the desire of the patient. Doctors should not promote unnecessary interventions and disproportionate treatments with the only intention of delaying an inevitable death, but focus on what matters to the patient in how she lives out her remaining days. Measures as nasogastric tubes, intravenous infusions, cardiopulmonary resuscitation and artificial respiration might not be appropriate, since they could unnecessarily extend the life of a person who is already dying, adding discomfort caused by aggressive therapies. However, they might be appropriate in some specific situations.
For example, in the case of a patient to whom breathing takes an extreme effort or who is suffering from asphyxia, an endotracheal tube may be required to alleviate the anguish of this symptom. Nevertheless, when artificial respiration is just a life support treatment, its use may not be justified. Its risks, such as irritation of the airway, risk of pneumonia, etc., may outweigh the benefits.
Nutrition and hydration must be provided as long as it can be done in a painless way. We must not withhold food and water that can be taken naturally. However, sometimes there is not a clear line between natural and artificial nutrition. This was the case of Terry Schiavo, a disabled woman whose feeding tube, on which her life depended, was withdrawn. If the feeding tube is basic care and simply a mode of delivery of food and water it must be maintained. If it is life support treatment for a failed alimentary system, then there may be some justifications to remove it. These are difficult decisions that must be taken for the sake of the patient, deciding in each context what is more appropriate.
Non-physical aspects must be also taken into account. For example, the desire of a patient with anemia to play football with friends may necessitate a blood transfusion that would not be administered otherwise. On the other hand, a particular therapeutic device, such as a respiratory mask, may be a good measure for a patient, but it could make more difficult for him to talk with his family or friends. All these aspects must also be assessed.
Although medicine is a healing profession, in some circumstances can be care but no cure. Doctors should not try to delay the inevitable as long as possible, but focus instead on what matters most to the patients as they near death. Some interventions will not advance a medical goal, but will help the patient get the most out of the end of their lives.
The doctor must consider, in each particular case, which therapies are proportionate and will contribute to the comfort of the patient, and which ones are an unnecessary attempt to extend his life. In the latter case, death should be accepted as a natural process, and patients should be given all the means to go through it in the most humane way, affirming in all moment the infinite value of their lives, including when they are close to the end.
Palliative care is an excellent example of how science and technology must be put at the service of human dignity, and not the other way around. Here, patients are cared for in a holistic way, helping them to have the best quality of life until the very last moment. The objective is not to extend life, but to live better, respectful of their human dignity, until the last day. Life will be sustained as long as it is sustainable. During this time, it must be supported according to the infinite value of every human life. When it is no longer sustainable, it need not be supported by artificial means. Then, we will let nature take its course and death will take place calmly, in a very human way.
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Written by Ines Lobo Lozano, a World Youth Alliance Europe intern and medical student from Spain.
[1] Hippocrates
