Dr. med. Matti Aapro has been a part of the supportive care discussion for years and finds that reorganizing the supportive and palliative care can be done without major implications on the budget. “We just need to gather the right people around the table”, he concludes.
Dr.med. Matti Aapro, FMH Internal Medicine and Oncology-Hematology, past-President of the Multi-national Association for Supportive Care in Cancer (MASSCC) and Honory President of the French-speaking Association for Oncological Suppoortive Care (AFSOS), past-editor-in-cheif of critical reviews in oncology/hematology
I helped write this definition of supportive care versus palliative care a long time ago, and this is still how I define it. To me the discussion of palliation versus supportive care is very much a big misunderstanding. Because there are two issues there; one is that as a doctor you want to offer the best you can for your patient, the other is that for historical reasons we use different denominations as discussed later. You should be able to understand the different areas – which doesn’t mean that you’ll be an expert in all areas. Every doctor should know the basics and when it gets complicated, you call the experts and ask them how to do it. That’s themedical perspective.
The other perspective is – which willmcertainly give me some very angry comments from my colleagues – that it is always a fight for budgets related to the names. So, when you are in an area you are defending a budget, you must convince those who have the hands on the budget to accept that you will benefit from this. And that adds a complicated aspect to the issue. Because there are many established, well run palliative care centres or units at the hospitals which are less so in the sense of supportive care. So, there is always a fight there. Some of my colleagues in palliative care tend to view their colleagues in supportive care as if they are pushing treatment too far. But I think that this is something we need to fight. Because the purpose is to do the best possible, and sometimes that is not just by giving up on everything not going too far, but it is by applying properly palliation and supportive care together with the active treatment when indicated.
Anywhere in the world there is always discussions of who is doing what, why is it being done. And I think the integration of those that are looking at the patient as a whole and not as a “I’m the expert of this surgery so that’s what I want to do and anything else, forget it” – is somewhat complex.
When we talk of palliative care there is a perception amongst patients, that “Oh God – you are sending me to those who are dealing with patients who are dying. So, I’m lost.” But that’s not what palliative care means. Many of the former palliative care units have therefore changed their name to supportive care units. Because the public perception is that palliative care is end of life. To me it is not – of course, it is one of the aspects, but it is also when you are not offering active anti- cancer-treatment that can change the ultimate outcome of the cancer for a significant length of time. But sometimes anti-cancer treatment can palliate a symptom, and that’s something that we have to understand. I see patients coming out from surgery – wonderful surgery – with terrible pain in their scar. And some surgeons don’t The whole issue is that we are not always facing the parts of palliation that are really just about the last few weeks of life. One of the aspects in the last few weeks of a life is pain control. But as a doctor I need pain control even from the beginning of the treatment.care much about that, because the patient is cured. So, for me dealing with that pain is also palliation. But it is palliation in a situation where the patient is cured.
Research has shown that the earlier you are looking at the whole perspective of the patient, the better it is. You’ll have less need for acute intervention, patients will have the support and be reassured what will be done to help them with their problems.
Really, it is holistic care – it is care of everything – and you don’t need an expert to help you being an expert there. But you’ll need to know some of the basics, and that is why all the medical societies now have the supportive- and palliative care sessions, so that all doctors know these basics that they are not taught anywhere else. In my opinion anything can be moved towards a more holistic approach, provided that you get the right people gathered around the table discussing how each one can contribute. We just need to get people together. Talk to each other. What’s the problem? It’s so simple. Once you get people to talk to each other they realise that there is a lot that can be done.
But anywhere in the world we have the budget issue. And people say “oh, but if you want to do this, we will have to increase the budget”. My answer to that is this: We have examples that reorganizing the supportive and palliative care can be done without major implications on the budget. And sometimes re-organizations can actually decrease the budget. So, it is important to say that this is not about asking for more money. I think, that if we talk to each other and organize ourselves better, we can save money and we will be able to offer more to the patients for the same amount.