A Brief History of
Palliative Care
David L. Sharp, M.D.
Grand Rapids Medical Education Partners
Hospice of Michigan – Grand Rapids
David L. Sharp, M.D. – brief bio
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B.S./M.D. - University of Pittsburgh
pilot program - Family Medicine, Flemington, NJ
moved to Grand Rapids in 1986 when daughter
Martie matriculated at Hope College
Board Certified in Family Medicine and Hospice and
Palliative Care
spiritual gift: mercy
Inpatient Physician – Trillium Woods - 2007-2009
Medical Director – Hospice of Michigan – Grand
Rapids - 2010 to present
our goals today…
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reach a better understanding of:
– how far back “palliative care” reaches
– some historical landmarks along the way
– recent history: compassion pushes back
against technology
– palliative care today – Economics 301 - the
future of palliative care
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meet the art of Deidre Scherer
one of the ironies of life:
By the time
you’re old
enough to
know your
way around,
you’re not
going
anywhere.
Palliative Care is not exactly
a new concept…
“Cure sometimes,
treat often,
comfort always.”
Hippocrates
460-357 B.C.
Ancient China
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special houses – “death houses”
destitute people were allowed to go
there to live and die
New Zealand
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Maoris tribe
family of dead person is given support
in all possible ways
entire tribe joins in mourning
East Africa
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Tribal elders offer spiritual and
practical support to the dying person
and their family
a rest along the way…
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During the Crusades in the Middle
Ages, monasteries provided care for
the sick and dying
the hungry wayfarer
the woman in labor
the needy poor
the orphan
the leper
Middle Ages
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Religious orders established “hospices” at
key crossroads on the way to religious
shrines
Santiago de Compostela (Spain)
Chartres (France)
Rome (Italy)
ironically, people died in these shelters
while on pilgrimages seeking cures for
their diseases
16th – 18th centuries
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religious orders offered care of the
sick and dying in local or regional
institutions
but – most people died at home, care
for by the women in their families
17th Century
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A young priest, St. Vincent de Paul,
founded the holy order of Sisters of
Charity in Paris, 1633
They, in turn, opened more than 40
houses for the poor, the sick, the
dying
motto: “The charity of Christ impels
us”
1800’s
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Madame Garnier of Lyon, France,
opened a “calvaire” to care for dying
1879 – Our Lady’s Hospice – Dublin –
cares only for the dying
By late 19th century, increase in
municipal or charitably-financed
infirmaries, almshouses and hospitals
begins the “medicalizing” of dying
1900
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Five of the Irish Sisters of Charity
founded St. Joseph’s Convent, London
Began visiting the sick in their homes
1935
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Interest grows in the psycho-social
aspects of dying and bereavement,
sparked by the work of Worcester,
Bowlby, Lindemann, Hinton, KublerRoss, Raphael, Worden and others
Europe and USA
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Up until 19th century, belief was that
the family and church should be
responsible for the dying person and
also help loved ones cope with
situation
Mid-20th century
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The expansion of medical knowledge,
fueled by wartime experiences, results
in almost 80% of people dying in
hospitals or a nursing home
1957 - 1967
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Cicely Saunders – first a social worker,
then a nurse and finally a physician
Works at St. Joseph’s Hospice studying
pain control in advanced cancer
patients
Pioneered concept of opioids “given by
the clock” instead of as “prn” pain
control
Dame Cicely Saunders
1918-2005
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nurse, physician,
founder of St.
Christopher’s Hospice,
Sydenham, south
London, 1967
“No human life,
now matter how
wretched, should
be denied dignity
and love.”
Dr. Cicely Saunders
“We need to help the dying to
live until they die and their
families to live on…”
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Author of three books on hospice care:
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“Care of the Dying,” 1960
“The Management of Terminal Disease,” 1978
“Living with Dying,” 1983
1967
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Dr. Saunders opens St. Christopher’s
Hospice in London
Emphasized multi-disciplinary
approach to caring for dying
Regular use of opioids
Careful attention to social, spiritual
and psychological suffering of patients
and their families
1974 - New Haven, Connecticut
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Nurses “carry the banner” from
London to America and begin teaching
Dr. Saunders’ principles
New Haven Hospice in Branford begins
caring for patients with cancer, A.L.S.
and other fatal illnesses
Canada -1975
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Dr. Balfour Mount – founds hospice
and palliative care work in two North
American hospital facilities
St. Boniface Hospital - Winnipeg
Royal Victoria Hospital - Montreal
British Columbia - 1978
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Victoria Hospice founded as “The
Victoria Association for Care of the
Dying”
pilot program successful – became
Hospice Victoria 1982
began with 7 acute-care beds in Royal
Jubilee Hospital
1975 - 1978
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Hospices and palliative care units open
across USA
California
Support team at St. Luke’s in NYC
Church Hospice – Baltimore
Cleveland Clinic
Medical College of Wisconsin
1984
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Congress adds Hospice Benefit
2009
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Most recent financial data shows:
11,633 home health agencies
3,533 hospices
Center for Medicare & Medicaid Services, OSCAR data,
April, 2011
2009 – USA hospice care
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USA stats
1,123,495 covered patients
77,822,892 covered days of care
$12 billion reimbursement
($12,085,785,062.15)
Source: CMS OSCAR data, April, 2011
2009 – Michigan
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607 home health agencies
104 hospices
41,918 total hospice patients
2,477,382 covered hospice days
$378,947,823.67 hospice
reimbursement
CMS OCSAR data, April, 2011
Philosophy before
function
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Palliative care (symptomatic and
supportive care) is generally withheld
until all attempts to treat the
underlying disease and other medical
problems are exhausted; many times
palliative care is offered with little time
left for living.
Philosophy before
function 2
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Palliative care should be considered in
conjunction with active treatment,
and, as death nears, palliative care
becomes more important as active
treatment, while cure becomes less
important
Philosophy before
function 2
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Palliative care should be considered in
conjunction with active treatment,
and, as death nears, palliative care
becomes more important as active
treatment, while cure becomes less
important
Modern definition
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Advanced knowledge/skills to prevent
and relieve suffering experienced by
patients with life-limiting, lifethreatening and terminal illnesses.
Expertise in assessment of patients
with advanced disease and
catastrophic injury
Modern definition 2
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Coordination of interdisciplinary
patient and family-centered care in
diverse settings
Use of specialized care systems
including hospice, management of the
imminently dying patient and legal and
ethical decision making in end-of-life
care
Modern definition 3
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Work with an interdisciplinary hospice
or palliative care team to maximize
quality of life while addressing
physical, psychological, social and
spiritual needs of both patients and
family members thru illness, dying and
bereavement
Drivers of palliative care
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Sheer demographics – growth of elder
population with diseases of
senescence
Conventional medicine – enabling
younger patients with previously-fatal
diseases to survive longer
Emerging infectious diseases (HIVAIDS, hep C, resurgent tbc, etc.)
U.S.A. Demographics I
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over-65 age group will double
between 2000 and 2030
over 70 million >age 65 by 2030
>age 85: 4.2 million in 2000 to 8.9
million in 2030
by 2050 we will may well have
834,000 persons over 100 years old
U.S.A. Demographics II
 we
post-moderns tend to
think of “death” as an
option rather than a
reality; however…
 roughly 100% of Americans
are expected to die at the
end of their lifetimes.
What is “Futile care?”
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use of expensive technology to
prolong the natural dying
process of terminally ill persons,
with no realistic expectation of
longer survival, clinical
improvement or better quality of
life
An artist’s rendering of
“futility…”
Sisyphus, by Tiziano Vecelli, 1490-1576
In Greek mythology,
Sisyphus was doomed
by Zeus to forever
carry a huge rock
uphill, only to have it
roll back down again;
this went on day after
day for eternity….
So … “How will we
know….?”
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patients are often the first to know
“when it’s bad news”
a sensing of body language, nonverbal communication, insight into
one’s own body and destiny
innate sense of the timing of life
importance of “the will to live”
“But, how will we
know….?”
consensus on futility is reached
between:
– the patient
– the family (or best friends as family
surrogate)
– the spiritual advisor (pastor, priest, rabbi,
etc.)
– the patient’s personal physician
Politics of palliative care
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Hospitals held accountable for 30-day
re-admissions
DRG-type “comprehensive”
reimbursement schemes
Need to reduce ER visits and “unnecessary” hospitalizations
Discussions of “futility” – mandatory or
simply essential?
Allen Stewart Konigsberg
1935-????
Woody Allen:
“I’m not afraid to die.
I just don’t want to
be there when it
happens.”
History of Palliative Care:
Your Questions Please…
David L. Sharp, M.D.
Grand Rapids Medical Education Partners
Hospice of Michigan
989 Spaulding SE
Ada, Michigan 49301