The Power of a Palliative Perspective in Dermatology

Christopher S. Yang; Victor L. Quan; Alexandra Charrow

doi:10.1001/jamadermatol.2022.1298

Viewpoint

May 11, 2022

The Power of a Palliative Perspective in Dermatology

Christopher S. Yang, BA¹; Victor L. Quan, MD¹; Alexandra Charrow, MD, MBE²

Author Affiliations Article Information

¹Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
²Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts

JAMA Dermatol. 2022;158(6):609-610. doi:10.1001/jamadermatol.2022.1298

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In the essay “Letting Go: What Should Medicine Do When It Can’t Save You?,”¹ Atul Gawande demonstrates the need for all physicians to confront the difficult conversations with patients from a place of honesty and humility. While dermatology and palliative care are rarely mentioned together, dermatologists grapple with questions of palliation daily as we encounter illnesses that we can help, but not cure. How do we help elderly patients with countless skin cancers? Or younger patients with newly metastatic melanoma? How do we consider pain management for patients with hidradenitis suppurativa? How can we help patients with intractable alopecia cope? Gawande’s essay called for a shift in mindset to include a palliative approach to medical care, and although it may not seem self-evident, dermatology is a prime specialty to answer the call. In this Viewpoint, we consider several opportunities for the integration of palliative care and dermatology.

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June 12, 2022

The perspective with rheumatology for advancing palliative dermatology

Kwok Ying CHAN, MD | Palliative Medical Unit, Grantham Hospital, Hong Kong; Department of Medicine, University of Hong Kong

We read the Viewpoint by CS Yang et al with great interest.1 As many severe skin conditions are associated with systemic rheumatic diseases, more attention should be drawn to the rheumatological perspective in palliative dermatology.
According to WHO, patients suffering from the systemic rheumatic diseases should be considered for Palliative Care (PC) management, especially in advanced stages of the disease or in multi-systemic autoimmune disorders that run can cause significant damage accrual such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), systemic sclerosis (SS), dermatomyositis and vasculitides.2 In fact, extra-articular involvement (e.g., skin, eye, lung, heart, kidney) of most rheumatic diseases is a marker of severe disease and is associated with increased morbidity and mortality.3 In this context, a significant proportion of patients require both rheumatological and dermatological inputs for their end-of-life care, and hence have ample room of collaboration in skill transfer, training and development of respective PC services.
Patients with systemic rheumatic diseases (whether neoplastic, inflammatory or autoimmune cause) will eventually require PC, including symptom control, psychosocial and spiritual care during end-of-life care.2 Moreover, elderly patients with multiple co-morbidities or frequent admissions have higher symptom burden. Like in other chronic diseases, late referral and lack of advance care planning (ACP) remain major gaps for PC service in rheumatology patients. One recent study reported that rheumatologists have acquired more general PC skill and knowledge (68% had training for symptom management/ACP/communication skills).4 This generalist plus specialist PC model5 may represent a more sustainable approach and therefore should be seriously considered in future development of palliative dermatology.
A stepwise approach may help promulgate engagement in palliative dermatology. Establishing national/territory-wide palliative dermatology network in partnership with rheumatology can provide more opportunities for advocacy and education.
References
1. Yang CS, Quan VL, Charrow A. The Power of a Palliative Perspective in Dermatology. JAMA dermatology online on 11 May 2022.
2. Cho J, Zhou J, Lo, D, et al. Palliative and end-of-life care in rheumatology: high symptom prevalence and unmet needs. In Seminars in Arthritis and Rheumatism 2019; 49(1): 156-161.
3. Turesson, Carl, et al. "Occurrence of extraarticular disease manifestations is associated with excess mortality in a community based cohort of patients with rheumatoid arthritis." The Journal of rheumatology 2002; 29(1): 62-67.
4. Saltman A, McGuinty C, Chandhoke G, et al. Rheumatologists’ Attitudes Toward Palliative Care and Medical Assistance in Dying [abstract]. Arthritis Rheumatol. 2020; 72 (suppl 10). https://acrabstracts.org/abstract/rheumatologists-attitudes-toward-palliative-care-and-medical-assistance-in-dying/. Accessed May 27, 2022.
5. Quill T E, Abernethy A P. Generalist plus specialist palliative care—creating a more sustainable model. New England Journal of Medicine 2013: 368(13): 1173-1175.
Dr CHAN, Kwok Ying, MD (1), Dr YAP, Desmond Y. H., MD (2), Dr CHUNG, Ho Yin, MD (3)
(1 ) Palliative Medical Unit, Grantham Hospital, Hong Kong.
(2) Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong.
(3) Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong.

CONFLICT OF INTEREST: None Reported

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