Volume 24, Number 2: February 2023
Why I Moved from Anesthesiology to Palliative Care
By Roberto Wenk, MD
IAHPC Board Member
I am a physician in Argentina whose base discipline is anesthesiology, but half of my time as a clinician was dedicated exclusively to palliative care. This is the story of how—and especially why—I made this transition.
I worked as an anesthesiologist from 1976 to 1978 in a large hospital in a university town. Between 1975 and 1980 the anesthesiology service implemented chronic pain control—oncologic and non-oncologic—with neurolytic blocks and anti-inflammatory drugs. I was amazed: with a syringe and needle I was able to relieve most patients! I knew that alcohol or phenol solutions prepared by a pharmacist were injected, but did not know of any undesirable effects.
In the 1980s I moved to a smaller city and became interested in chronic pain management. But several unknowns about the neurolytic blocks emerged:
- What were the appropriate concentrations of phenol or alcohol?
- What undesirable effects might occur?
- Did patients know their diagnoses and prognoses?
- Besides pain control, what did patients and families need?
I read articles, visited major clinics in Argentina, and learned a variety of “effective" techniques. They all involved pain blocks and, in case of failure, IV infusions that produced sedation until the patient died. I started offering pain control to patients with severe lumbar, pelvic, or lower limb oncologic pain, using subarachnoid neurolytic blocks with alcohol or phenol with glycerin.
These were my results:
- Acceptable: When evaluating only pain control, analgesia of variable quality and duration (hours, days, or weeks) was achieved in almost all patients.
- Poor: When evaluating the whole outcome, serious ill effects were noted. They included dysesthesias and loss of muscle function of the blocked region, sphincter function disturbances, hypotension, neuropathic pain due to aggregated nerve injury, etc.
My opinion was that results were bad and sad, and therefore unacceptable. While patients don't use the word "sad" to describe the outcome of an intervention, I was sad because patients and families accepted undesirable, sometimes severe, effects in exchange for temporary pain reduction.
Vulnerable people in our care
These vulnerable people, who knew neither their diagnosis nor prognosis, peacefully accepted what was offered without knowing what possible consequences could result. Unacceptable and brutal.
Two cases marked the beginning of the end of this stage, which I define as iatrogenic (unintentional) brutal practices.
The first was an adult with lumbar pain due to prostate cancer. I periodically performed blocks that prevented him from walking for one or two weeks. He arrived walking and knew that he would leave in a wheelchair, but was happy to accept each block because it temporarily reduced his pain.
The second was a teenager with advanced facial fibrosarcoma. He was in a public hospital with unbearable uncontrolled pain, and I was invited to collaborate. I performed a transoral gasserian ganglion block. The practice was traumatic, and the result was additional neuropathic pain controlled only with deep sedation.
Life-changing advice
Dr. Kathleen Foley, Professor Vittorio Ventafridda, Dr. Eduardo Bruera, and Dr. Robert Twycross. All photos used with permission.
A change was needed. It happened about two years later, thanks to the help I received from the IAHPC and the advice of Liliana De Lima. Many others helped me during my new training in palliative care, including:
- Dr. Kathleen Foley, who described the structure and results of the World Health Organization’s analgesic ladder and invited me learn by the bedside.
- Professor Vittorio Ventafridda, who convinced me to use the term “palliative care,” not "pain management.” He said, "Roberto, in 2000, patients with severe symptoms due to potentially malignant diseases should have the right to receive the same care as those who are born." This concept is my guiding light.
- I worked with Dr. Eduardo Bruera in the development of subcutaneous infusion sets, and on two occasions performed bedside training on his service.
- Dr. Robert Twycross allowed me to visit his department twice, where I learned the basics and importance of communication with the patient and family.
My move to palliative care was not quick or easy...but it was a positive change. I would never go back. My message is this: invest in resources in learning how to provide quality palliative care.
Roberto Wenk, MD, retired from clinical activity in 2017, but continues to perform administrative tasks and palliative care teaching. He is responsible for the creation and continued management of Pallipedia.