Family medicine and palliative care: is there a missing link?

Kenny Kung 龔敬樂

HK Pract 2013;35:33-34

Malignancies, heart diseases, cerebrovascular diseases, chronic lower respiratory tract diseases and dementia comprise the large majority of annual deaths in Hong Kong.¹ Death is much more than an outcome: before it comes the process of dying; and after it the loss and sadness in families and among friends. It appears that despite all our efforts to improve care and saving lives, palliative care remains to be neglected. As Friedrich Nietzsche, a German philosopher, once wrote: "one should die proudly when it is no longer possible to live proudly" – have we been letting our patients die proudly?

The principles of palliative care include integration of psychological and spiritual aspects of care, offering a support system to help patients live as actively a life as possible until death, as well as help patients' families cope with the patient's illness and then in their own bereavement.² These are very much congruent with the principles of family medicine, which emphasises a holistic approach that considers patients' psychosocial backgrounds as well as being the central coordinator in patient care. Indeed our comprehensive vocational training programme includes palliative care. However, the degree to which it is included is a subject for discussion. Readers dissecting our logbooks will certainly note its relative scarcity. For basic training,² palliative care is grouped within internal medicine, where pain control is the only concept that is required. During higher training,³ palliative care is structured under "caring for those with special needs", where trainees should be competent in breaking bad news, coordinating palliative care services and possessing counselling skills. Although this is not a platform for reviewing our training programme, it does beg a question of whether our discipline is training our specialists adequately for helping patients and their families with terminal illness. If opportunities for training in palliative care are not made available (whether training in the private or public sectors) our doctors will not be able to provide services that are on par with those overseas.

Papers in this issue highlight the problems with Hong Kong's palliative care services. Some authorities have impl ement ed new me a sur e s wi th an a im to improve such care.⁴ Challenges continue to exist which cannot be addressed unless there is a concerted effort from various different parties.⁵

Family physicians form the backbone of healthcare services and therefore should be central in care provision no matter what disease stage the patient is at. Countries where family medicine has been well developed coincidentally also have higher proportions of palliative care provided at home. Over the last few years primary care has blossomed through efforts from our College and its members, leadership from our previous Secretary of Health resulting in the establishment of the Primary Care Office, trials for public-private partnership, as well as more funding in public health services to improve quality of care. Will this momentum continue?

This issue identifies gaps not only in palliative care, but also in the practice of family medicine in Hong Kong. Various parties need to work together so that primary care can be provided by a discipline that has been proven to work. In this way, palliative care will improve too.

I conclude with a quote from William Wordsworth: "Life is divided into three terms - that which was, which is, and which will be. Let us learn from the past to profit by the present, and from the present, to live better in the future." It is time for us to progress from past experiences, and build a stronger primary care for our future.