Palliative Medicine: 10 years as an area of medical practice in Brazil

 

The World Health Organization (WHO) first defined Palliative Care (PC) in 1990, involving the practice as one of the focuses of cancer care (prevention, diagnosis, treatment, and PC). Since then, the concept was broadened in 2002 to include any life-threatening disease throughout its entire course, especially, but not only, in advanced and terminal diseases and end-of-life care ¹ .

In 2014, WHO qualified this practice so that its principles of action should be guiding for any good health practice ² , leading to a new definition in 2017 ³ . Since then, the concept has been broadened even more, involving aspects of human care in situations of suffering related to social vulnerability conditions and pandemics ⁴ . In 2020, a group of experts gathered by the International Association of Hospice and Palliative Care (IAHPC) formulated the most recent and comprehensive definition involving this practice ³ .

Despite the successive and recent reformulations of its definition and the large increase in the number of scientific publications in the field, PC has not been recognized as a medical specialization in several countries around the world in spite of the UK and other countries’ recognition since 1987 ⁵ .

Development in the Brazilian context

In Brazil, the practice of PC is described from individual initiatives and in a punctual way since the 1980s ⁶ .

In 1997, with the creation of the Brazilian Palliative Care Association (ABCP), an entity with a multiprofessional character, the professionals involved in the practice started to organize themselves. They discussed their actions and preliminary aspects of the so-called “Brazilian Palliativist Movement”, holding the first National Congress in the field in 2004 at the headquarters of the National Cancer Institute, in Rio de Janeiro.

Then, a group of professionals, understanding that the regulation of this practice was necessary and that this depended on articulation with the medical entities in the country, founded the National Academy of Palliative Care (ANCP) on February 26, 2005. The association was composed of multiple health professionals but directed only by physicians, a mandatory requirement for this articulation at the time.

This allowed greater visibility and insertion in the then recently created Technical Chamber of Terminality of Life and Palliative Care of the Federal Council of Medicine (CFM), active in the preparation of important documents such as the resolution 1.805/2006 ⁷ and the first version of the New Code of Medical Ethics (2009/2010), which was the first to textually mention the term “Palliative Care” in the Fundamental Principle number XXII and the articles 36 and 41. The text was maintained in its entirety in the most recent edition of the Code of Medical Ethics ⁸ .

Palliative Medicine: a new area of medical practice

In Brazil, the inclusion of an area of knowledge as a recognized specialization is a process that involves specific rules and prerequisites regulated by competent medical bodies, especially the CFM.

In the context of the growing practice and gradual representation in decisive medical regulatory boards in the country, it was time, in mid-2010, for the official recognition of Palliative Medicine as an area of medical practice.

As a first step, the National Commission on Palliative Medicine was created by the Brazilian Medical Association (AMB). The first meeting of the commission took place on March 30, 2010 with the representation of the medical specialties who understood that Palliative Medicine was an area of practice related to their practice, after an open consultation, by letter, made by the AMB to the boards of all medical specialties. On this occasion, the societies that initially manifested themselves were Oncology, Internal Medicine, Geriatrics, Family and Community Medicine, and Pediatrics, besides ANCP itself. Later, the Anesthesiology Society started to compose the group of specialties considered prerequisites to obtain the title of Palliative Medicine as an area of practice.

This Commission was responsible for requesting to the Mixed Committee of Specialties, constituted by the CFM and AMB, the approval, in August 2011, of the request so that Palliative Medicine could integrate the list of recognized areas of practice in Brazil, which, according to the recent update, resolution 2221/2018 that ratifies the CME 01/2018 ordinance, lists the existence of 57 areas of medical practice in the country ⁹ .

On May 18, 2012, by the letter OF/AMB/0117/2012, the AMB informed the six societies of the first call for the selection of candidates, by curriculum analysis, requiring that the candidates had documented experience in Palliative Medicine for at least 5 years and that they were certified by the AMB in one of the areas listed as prerequisites at the time. In this initial selection process, 45 physicians (20 anesthesiologists, 9 pediatricians, 7 geriatricians, 7 internists, and 2 family physicians) were qualified.

From 2013, upon request to the AMB, the ANCP became part, with two representatives, of the board responsible for preparing the exam for new candidates, now by written test and curriculum analysis, along with the other six societies that had participated in the previous selection process. That year, the National Commission of Palliative Medicine decided to hold the sufficiency exams for the area of Pediatrics separately from the other areas.

From that moment, the exam started to be held periodically by the AMB in a place predefined by the entity or during the ANCP Palliative Care Congresses, according to the entity's calendar.

The number of medical specialties considered prerequisites to obtain the title has increased progressively, so that it currently amounts 12 (Anesthesiology, Internal Medicine, Head and Neck Surgery, Oncological Surgery, Geriatrics, Mastology, Family and Community Medicine, Intensive Care Medicine, Nephrology, Neurology, Clinical Oncology, and Pediatrics). In the year 2021, Brazil had 389 medical professionals certified by the AMB in this area of practice ¹⁰ .

Medical residency in Palliative Medicine: a requirement

As part of the providences required for the regulation of a new area of medical practice in Brazil, guidelines were elaborated for the registration of Medical Residency Programs in Palliative Medicine with the duration of one additional year to the residencies in the prerequisite areas previously listed ¹¹ . These guidelines oriented the characteristics of the programs and the distribution of the workload among the different assistance modalities of Palliative Medicine in diverse scenarios of medical practice.

Based on this regulation, the registration of the programs with the Ministry of Education and Culture (MEC) began in 2012. Currently, there are 17 active residency programs in Brazil (only one in Pediatric Palliative Medicine) having already trained around 200 physicians in 2022 ¹² .

Palliative Medicine as a specialty in Brazil: the state of the art

Palliative Medicine refers only to the body of knowledge concerning the medical doctor. By concept, the adequate and competent application of PC practice requires an appropriate organization and training of all health care professionals. In this sense, some representative councils of different health professions are already beginning to recognize, from their criteria, that their professionals may be considered specialists or have an area of practice in PC.

Nevertheless, regarding medical doctors, one cannot, by force of concept, speak of a professional specialty.

Palliative Medicine is an area of practice for which, in Brazil, the candidate for the so-called “title” has only two options: either to undergo a written test prepared by the AMB or to complete 1 year of Medical Residency in Palliative Medicine in one of the programs duly registered and recognized by the MEC in the country.

However, with the increasing visibility and growth of the area in the country, following the MEC norms ¹¹ , a training alternative for any health professional has been configured with the emergence of lato sensu postgraduation courses in the area. The norms refer to on-site training with a minimum of 360 h and certified by a Higher Education Institution (HEI) registered with the MEC. In times of the COVID-19 pandemic, the transition to online training modalities, whether in hybrid-live format or distance learning with recorded classes, is being considered valid by the MEC as long as the minimum workload is respected and duly certified by a registered HEI.

In the lato sensu postgraduation modality, there are a rapidly increasing number of Medical and Multiprofessional Specialization courses in Brazil. However, it is fundamental to understand that these courses confer to the professional the title of Academic Specialist, which is not recognized by the AMB and, therefore, is not equivalent to the title of Professional Specialist.

More recently, the AMB has recognized that these specialization courses and other education courses (for physicians), with a minimum length of 1 year, may be computed in a more expressive way among the prerequisites to register for the sufficiency exam for obtaining the title of area of practice in Palliative Medicine.

Palliative Medicine as a medical specialty: perspectives

Considering the reality of Palliative Medicine as an area of medical practice in the country, there is an open perspective for the recognition of the area as a medical specialty.

Although this is already a reality for several countries in the world, this process is still under discussion in Brazil. In this aspect, it is worth clarifying that Palliative Medicine comprehends a set of competencies and skills that all physicians must carry, as occurs with all other medical specialties, in graduation.

However, the advances in technical and scientific knowledge in the area, the increasing number of publications and scientific events worldwide, and the already existing Brazilian medical ethic normative ⁸ regarding that PC must be offered in the context of advanced and terminal diseases highlight Palliative Medicine as an area of its own and with demands for a large number of specific technical and attitudinal competencies, which were recently recognized in Brazil ¹³ .

The recognition of this situation and a compilation of specific competencies required of the physician in this practice, which cannot be contemplated in only 1 year of residency, are essential for the acknowledgment that Palliative Medicine has the requirements for its establishment as a new medical specialty in Brazil. Contributing to that are the recent establishment of the Ministerial Resolution 41/2018, of October 31, 2018 ¹⁴ and four State Laws ^15-18 that begin to provide the basis for the development of specific Health Policies aimed at the adequate provision of PC in Brazil, especially in the public context. In this sense, it was necessary to re-register all residency programs and to elaborate new pedagogical projects in order to start, in 2023, the already expanded 2-year residencies.

CONCLUSION

The process of increasing the organization of Palliative Medicine in Brazil is accelerated. However, the inclusion of PC training in the graduation of future health professionals, as well as the development of National Health Policies with universal access to PC are challenges of vital importance for the upcoming years.