1. Salcido, Richard MD, EdD

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Since the beginning of time, the patient and physician have been the main actors in managing acute and chronic medical care decisions. The evolving concepts of palliative and hospice care, however, have expanded the number of professionals who have influential roles in implementing the goals and expectations on behalf of the patient. The traditional patient-physician dyad has its origins in the ethical principles of benevolence, where "the doctor-patient relationship is characterized by power/knowledge inequalities and has been dominated by paternalism in Western societies."1

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More recently, the concept of the interprofessional team healthcare delivery model as promulgated by the Institute of Medicine's pivotal 2003 report, "Health Professions Education: A Bridge to Quality," called for students and working professionals to develop and maintain 5 core competencies, including "working in interdisciplinary teams and engaging in quality improvement principles."2


This month's continuing education activity (page 130) expands the dyad to a "circle of care," which includes many factors or points of influence focused on the patient's role in the management of his/her care. The goal of pain and palliative care is to maintain or improve the patient's dignity and quality of life in general and, in particular, as it relates to the amelioration of acute and chronic pain in the context of wound care.


The Patient: A Member of the Team

Evolving social constructs bring new concepts in shared decision making with evolving terms such as "empowerment." In my view, empowering the patient connotes giving the patient information (through knowledge transfer) to contribute to his/her well-being. In the interprofessional environment, healthcare professionals also transfer knowledge to each other about the patient's medical condition and communicate the patient's goals. Thus, conceptually, the patient in turn transfers the power for his/her care to the team through some directive and in many circumstances to the family or significant other; this concept is shared decision making.3 In the long-term/hospice/palliative care environment, the patient also empowers healthcare professionals and family members to act on his/her behalf through advance directives, living wills, and, most important, developing trust through oral communication.4


If indeed the patient is the "center of attention," it is important for the interprofessional team to have an empathetic understanding of the vulnerabilities felt by the patient, especially the patient with advanced age and "frailty."5 A vulnerable person has been described as one "who is in need of community care because of "mental health issues, physical disability, age, or illness and needing assistance to care for themselves or is unable to protect himself/herself against significant harm or exploitation."5 Frailty is defined as a "clinical syndrome encompassing diverse vulnerabilities, weaknesses, instabilities, and limitations of function."4 These descriptions are certainly apropos to patients in palliative or hospice care. Chronic conditions must be evaluated in the context of a "potentially harmful imbalance between the care needs and the care provided."5 In systems-based practice, there may be imbalances or gaps between the patient's needs and the resources available or our ability to provide effective treatments.


Pain, as a subjective symptom, remains the fundamental basis for treatment; however, pain analog scales are highly individualized. Therefore, clinicians must be highly sensitive to physical signs and symptoms of pain, including changes in vital signs, pupillary dilatation, and increased respirations or changes in pulse and blood pressure.6,7 In older adults, other signs and symptoms may include changes in physical function, cognition, nonrestorative sleep, restlessness, and changes in behavior. Interprofessional team meetings and communication rounds provide an excellent venue and space to communicate pain management issues on behalf of the patient.6,7


Eliciting pain symptom cues from the patient requires active listening skills. Too often, we "talk to" the patient or family member when we should be "talking with" them. On average, the first interruption by a physician in consultation is between 18 and 20 seconds after the start of the contextual narrative communicated by the patient.8 Given the absence of objective pain measurement techniques to guide us, we must remember to listen to the patient first and foremost!


"Nothing about me without me." -Valerie Billingham, Through the Patient's Eyes, Salzburg Seminar Session 356, 1998.


Richard "Sal" Salcido, MD, EdD

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