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Palliative Care
Case Two:
• Highlights common and special roles of primary and
consulting palliative care doctors.
• Demonstrates ethical challenges of surrogacy.
• Demonstrates the need to trust but verify; i.e. docu-
mentation of AD etc.
• Illustrates the danger of allowing concern for the sur-
rogate to over-shadow the patient.
• Demonstrates tremendous angst among the medical
teams (collectively and individually) consequential to
the care.
• Medical history: 90-year-old with severe dementia that
evolved into end stage dementia over four years.
Case Three:
• Highlights how lack of advance directive (AD) and
ACP creates care challenges and family distress.
• Demonstrates the use of a family conference as a tool
to discern “what matters most.”
• Demonstrates the children’s intrafamilial dynamics.
• Medical history: Reverend M’s condition: Nonage-
narian with stage IV colon cancer with relatively high
functional capacity.
• Mrs. M: Nonagenarian with advanced dementia (Func-
tional Assessment Screening Tool (FAST): Stage 6).
(Table 1)
• A crisis occurred when Mrs. M needed critical care;
Rev. M could not decide for his wife; the children were
equally divided based on diametrically opposing biblical
interpretations.
Palliative Care Defined:
The World Health Organization defines palliative care
as an approach that improves the quality of life of patients
and their families facing the problems associated with
life-threatening illness. This is through the prevention
Introduction
Many palliative principles are imbedded at the core of
primary care. In this article, the authors emphasize the
fundamental nature of caring “for our fellow creatures
in pain” from the perspective of a family physician/geri-
atrician, an internal medicine/pediatrics physician, and a
neurologist/palliativist in training.Though borrowed from
the traditions of hospice, the emphasis in this discussion
is on early introduction of palliative care in the pursuit of
“assessing, anticipating and alleviating suffering.”1
Here is a case-based introduction to principles of pallia-
tive care. All are real cases from the collective experiences
of the authors. Specific identifiers have been altered to
protect each patient’s identity. Additionally, we illustrate
the principles of primary palliative care and the facets of
specialty consultative palliative care.
Case Studies
Case One:
• Highlights the benefits of preparation of an Advance
Directive (AD) via Advance Care Planning (ACP).
• Demonstrates the ethical principle of autonomy.
• Acknowledges the important role of religious beliefs
and tolerance and respect thereof.
• Medical history: 83-year-old chronic “hurt all over,”
bone/joint pain, subacute pruritus, episodic epistaxis,
and dyspnea.
Palliative Care for Primary Care Providers:
Isn’t this what we all do?
By Robert P. Shannon, MD, FAAHPM1, Alva Roche’-Green, MD1 , Kristin M Scott, MD1
1 Departments of Family Medicine and Palliative Medicine, Mayo Clinic College of Medicine, Jacksonville, Florida
Address Correspondence to:
Robert P. Shannon, MD, FAAHPM
4500 San Pablo Road
Jacksonville, FL 32224
Tel: (904) 953-6722; Fax: (904) 953-0626