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FPs should fill end-of-life care void
Ira Byock, M.D., wants family physicians to lead a dying revolution.
Byock, a family physician who directs the Palliative Care Service in Missoula, Mont., believes family physicians should play a significant role in helping their patients, their patients' families and their communities respond to dying people's needs.
"The dying process is more than a series of medical problems to be solved," said Byock. "Dying is fundamentally a part of life for every individual, so the personal aspects need to be treated as well as the medical. Dying also is a part of the life of every family, no matter how one defines family."
Joanne Lynn, M.D., president of Americans for Better Care of the Dying in Washington, D.C., said family physicians are at the front line of patient care and should accept the role of helping people experience the end of their lives in the best ways possible.
"We shouldn't aim for saying 'It wasn't awful,'" said Lynn. "Good palliative care certainly includes excellence in symptom management. But it also includes attention to family, psychosocial support and attention to spiritual and existential issues. A physician has to know how to get medicine out of the way so the human thing can happen."
Byock, author of the 1997 book Dying Well, said physicians who are trained to care for a patient from the cradle to the grave should realize the similarities between care for the newborn and care for someone at the end of life.
"We see our tiny patient with his or her family as a unit of care," said Byock. "We look at so much more than just the physical aspects of the child's discomfort or mucosal health or nutritional intake. We specifically attend to the quality of the dynamics within the family. We want to ensure that not only is any suffering being attended to, but also that the child has a chance to grow and develop."
Although it might seem ironic, family physicians should bring the same family focus to caring for a patient at the end of life.
"FPs are involved in many deaths because of the philosophy of family practice," said Lynn. "Even if an FP refers a patient to an oncologist and the patient dies in the oncologist's care, the FP is still on the background team and in the best position to support the family."
FPs are trained to take care of the patient and be in touch with the family, Byock said. They recognize the medical needs of the patient, and the emotional needs of the family.
"We can give anticipatory guidance during what we know is a difficult but absolutely critical stage in the life of this individual and family. Why wait for a crisis to occur? Learning to work well with a patient and family dealing with the end of life provides FPs with a chance to provide a high level of counseling and support. I think it's a natural fit," said Byock.
An FP can work with an interdisciplinary team and respond to suffering within a patient and the family unit. FPs can preserve opportunity for the dying person and the family to grow individually and together through the very end of life.
"That's what people have taught me through the years," Byock said. "As we focused on alleviating symptoms and making sure that the practical issues are addressed ... people have repeatedly taught me that this time we call dying, in addition to being extremely difficult, is often an inherently valuable time of life."
FP Report is published by the AAFP News Department. Copyright © 1998 by American Academy of Family Physicians.