A doctor for the dying
Dr. Balfour Mount is widely considered the father of palliative medicine in Canada. Originally a McGill-trained urologic surgical oncologist, he found a new calling in the early seventies. In 1973, he founded a palliative care ward at the Royal Victoria Hospital, the first of its kind in Canada. He later founded Palliative Care McGill in 1990 and the McGill Program in Integrated Whole Person Care in 1999. Mount retired in 2007, after surviving esophageal cancer and a heart attack. But he remains active; he has just finished writing a biography of his parents, neurosurgeon Harry Mount and teacher and nurse Maude Henry, and has started work on an autobiography. On August 24, Mount received
the 2011 Canadian Medical Association’s Medal of Service in recognition of his exceptional contributions to the advancement of health care in Canada.
McGill News contributor Sylvain Comeau recently spoke to Dr. Mount.
How did you first get involved in palliative care?
In 1973, I helped conduct a study on how people die at the Royal Vic. We had anticipated finding unmet psycho-social needs; what we hadn’t anticipated were the unmet physical needs. There was poor control of pain and other symptoms, and a general lack of understanding about just how poor the care was.
Looking for options, I came across the writings of Dame Cicely Saunders, who had really started the modern hospice movement. I visited her hospice in London, England and was extremely impressed.
But I realized that the hospice model was not practical or cost-effective for Canada. My solution was to try to duplicate it in a hospital.
When you say there was a neglect of patients’ physical as well as psychosocial needs, does that mean there was a lack of compassion?
No, the doctors certainly were compassionate, but they were aimed in another direction. We just didn’t see the needs, because we were trained to treat, prolong and cure. And those goals are irrelevant for terminal patients. Parodoxically, it was not from a lack of caring, but a lack of being present to the patients’ real needs.
You were already a cancer survivor in your 20s (Mount survived a bout with testicular cancer). How did your own health issues affect your work?
I experienced firsthand what it’s like to have cancer. And at the time, I was 24, and that form of cancer had a cure rate of about 33 percent. So it did have a huge influence, but I wasn’t aware of that at the time.
You had an advantage over other doctors; you knew what it was like to deal with what the patients are facing.
I agree. I’m always fascinated — but no longer surprised — when I meet someone who has been through a terrible situation, and they say that it has been pretty rough, but they wouldn’t change it. Because in some way, they’ve become better for having gone through it.
How do you feel the field of palliative medicine has changed over the years, and what progress would you like to see in the future?
The most evident change is in the medicines available, and in the studies that have helped tease out what we can do for the real problems and issues. In the future, I’d like to see palliative medicine become a recognized discipline by the Royal College of Physicians and Surgeons in Canada, as it was in England in 1987. So we are far behind in that regard.
[Terminal patients] are the sickest people in the health care system, so they have important needs. It is too bad that quality, organized whole-person palliative care is still only available to a very small minority in Canada. There are not enough palliative care programs, and standards are not consistent across the country. There is very unequal distribution [of services] between urban and rural areas.
What is your take on the debate over euthanasia?
I have great sympathy for the notion that one can feel that “my time has come” or “if it continues like this much longer, I wouldn’t want to go on.” I also sympathize with people who would want to help end the suffering of their loved ones.
That being said, I am strongly opposed to euthanasia. Legalizing it would require a radical change in legislation. It would be very difficult, if not impossible, to set up guidelines that safeguard the rights of the most needy and vulnerable people.
Why is it that [organizations for the disabled] are always the first to oppose legalization? I would submit it’s because, once we put a value on other people’s lives, we’ve stepped over a line. I see great dangers there.
What have you learned through years of interactions with dying patients and their families?
I’ve learned that life is an existential experience; we are meaning-seeking creatures. In one study I conducted with [former McGill professor of oncology] Patricia Boston, we compared people who are anguished at the end of life to those with the same symptoms, but have gained a sense of inner peace. We found that the difference was largely due to what we call ‘healing connections’ — a capacity to find meaning and connection to something greater and more enduring than the self.
This isn’t necessarily a religious or spiritual thing; it is anything that gives an individual a sense of meaning.
What kind of advice would you offer to colleagues starting a career in palliative medicine?
Learn to listen, to the whole person. Listen to what is being said, and what isn’t being said. Strive to learn, with the patient, where quality of life might exist at this time, and for this individual.
One patient I remember had always found meaning in European soccer leagues — watching games, keeping track of the score. For another, it was his garden. Meaning is a highly individual thing.
You’ve said in the past that doctors aren’t well equipped to deal with fatal diseases. They’re trained to defeat disease, not to ensure a dignified and comfortable end. Are healthcare practitioners getting better on that front?
I think so. But, again, the full benefit from that improvement, from what we’ve learned in the past 40 years, is still only available to a very few.
Do you feel that compassion is becoming a stronger force in medicine, or is there less room for it today, considering factors like overcrowding and understaffing of hospitals?
Those factors do work against the capacity of care givers to have a healing connection and bond with the patient. But the really skilled care giver can still make that connection; it doesn’t take more time to be present for the patient, in a way that is healing. It’s simply a different quality of presence, with no distractions.
Palliative medicine is a very demanding profession, but you have also often described it as very rewarding.
Yes, because there is so much that we can do to radically change the situation of dying people. Paradoxically, these were the people about whom doctors would say: “there’s nothing more we can do.” That’s what’s always been said, but the truth is that there is everything that we can do.